Every finding on record at New Horizons Limestone

Based on observations, interviews, record reviews, and review of the facility policy titled Oxygen Administration, Transport and Storage - Patient Care, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for two residents (R) (R9 and R180) of 27 residents reviewed for oxygen use. The deficient practice had the potential to increase the residents' risk of respiratory complications and adverse clinical outcomes. Findings Include: Review of the facility's undated policy titled Oxygen Administration, Transport and Storage – Patient Care, documented in section for oxygen administration A physician or advanced practice professional (APP) order is required prior to administering oxygen. The policy specifies that the order must include: a. The oxygen delivery device b. The liter flow and/or oxygen concentration (percentage). 1. Record review of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to atrial fibrillation, asthma, disorder of the lung, and heart failure. Review of R9's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, indicating severe cognitive impairment. Section GG (functional status), revealed R9 was dependent on staff for all other activities of daily living, including wheelchair mobility. Section O (special treatments and procedures) revealed no oxygen therapy or other treatments during the assessment period, as None of the above was coded. Review of R9's care plan updated 03/11/2026 revealed oxygen use was not addressed. Review of the Physician's Order for R9 included but were not limited to: Order dated 02/13/2025 for Oxygen Therapy Nasal Cannula; 2; 2; 0; Target 02 Sat: Other; as needed for SOB as needed for SOB. Initial start rate L/min: 2, max rate L/min: 2 {two liters per minute as needed for shortness of breath.} Observation made on 03/10/2026 at 11:14 AM revealed R9 was wearing her oxygen via nasal cannula (NC), and the oxygen (O2) concentrator was running at the setting of 3 liters per minute (LPM). Observation made on 03/11/2026 at 11:10 am revealed R9 was wearing her oxygen via NC and the O2 concentrator was running at the setting of 3 LPM. Observation and interview on 03/11/2026 at 11:27 am with Licensed Practical Nurse (LPN) JJ in R9's room, revealed R9's O2 concentrator remained at a setting of 3 LPM. The nurse confirmed the setting, exited the room to review the physician orders, and identified an order for O2 at 2 LPM. Upon returning, LPN JJ adjusted the O2 concentrator to 2 LPM. The nurse acknowledged she had not yet verified the setting during the current shift Interview on 03/11/2026 at 12:00 PM with the Director of Nursing (DON) GG revealed nursing staff are expected to check oxygen concentrator settings during medication administration and ensure the setting matches physician orders. 2. Record review of the electronic medical record (EMR) revealed R180 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to COPD (chronic obstructive pulmonary disease), OSA (obstructive sleep apnea), history of pulmonary embolus, edema. Review of R180's Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 which indicates little to no cognitive impairment. Review of R180's care plan started 01/10/2025 revealed a problem: oxygen and interventions included but not limited to administer oxygen as ordered. Review of the Physician's Order for R180 included but were not limited to: Order dated 03/02/2026 for Nursing oxygen orders / instructions 3L {liters per minute} via nasal cannula as needed and tolerated. Observation on 03/10/2026 at 1:20 PM revealed R180 was receiving oxygen via nasal cannula at 2 liters per minute (LPM). Observation on 03/12/2026 at 10:34 AM revealed R180 was receiving oxygen via nasal cannula at 5 LPM. Observation on 03/12/2026 at 1:05 PM revealed R180 continued to receive oxygen via nasal cannula at 5 LPM. Interview and observation with RN QQ confirmed that R180's oxygen setting was at 5 LPM and the physician's order was for oxygen administration at 3 LPM. During an interview on 03/12/2026 at 2:25 PM, DON FF stated it is her expectation that nursing staff ensure oxygen is administered by physician orders and that oxygen equipment, including tubing and filters, is maintained clean and properly functioning.

Based on observation, staff interview, review of manufacturer package inserts, and facility policy titled Medication Storage, the facility failed to ensure proper medication labeling, expiration dating, discard procedures, and secure storage for one of eight medication carts. This deficient practice had the potential to place residents at risk for administration of expired, improperly labeled, or unsecured medications, which could compromise resident health and safety. Findings Include: Review of the facility's policy titled Medication Storage, dated 8/22/2023, documented All medication storage areas will inspected. to ensure that all medications are being properly and safely stored in accordance with manufacturer's instructions. IN addition, documented in section Procedures III. All expired. medications are segregated until they are removed from the organization. Outdated. medications will be kept in a designated area until they are returned to the supplier. and Item XVI. B. Medications stored throughout the center must be stored in accordance with manufacturer's instructions.to assure their integrity, stability, and effectiveness. Item H. All outdated, damaged, and discontinued medications will be disposed, returned, or held for disposal. Finally, documented under Procedure: 4. Medication Carts: a) Must be kept locked at all times unless in nurses' direct eyesight. Review of the Lantus (insulin glargine injection) package insert, page 21, item 16.2 Storage After Lantus vials have been opened (in-use), vial must be discarded 28 days after opening, whether stored refrigerated or at room temperature. 1. Observation conducted on 03/10/2026 at 11:10 AM revealed a medication cart was unlocked and positioned near the nurses' station with no nurse present or in the immediate area. The Director of Nursing (DON) was observed walking past the unlocked medication cart without addressing the issue. Interview and observation conducted on 03/10/2026 at 11:12 AM with the Director of Nursing (DON) revealed the medication cart belonged to Licensed Practical Nurse (LPN) CC. The DON stated the nurse was performing a blood sugar check at the time. The DON stated medication carts are not supposed to be left unlocked. The expectation is that any time staff step away from the cart or it is outside of their direct line of sight, the cart must be locked and the keys kept on the staff member's person. Interview conducted on 03/10/2026 at 11:16 AM with LPN CC revealed she was not aware she had left the medication cart unlocked. Interview conducted on 03/12/2026 at 9:33 AM with the Administrator revealed medication carts are not supposed to be left unlocked or unattended. The Administrator stated the expectation for staff is that medication carts are to be secured. 2. Observation and interview on 03/11/2026 at 9:55 AM of the 1-South medication cart with Licensed Practical Nurse (LPN) KK revealed the following: Expired Medication: Calcium Carbonate (antacid) tablets bottle with an expiration date of 12/2025 was present on the cart. Unlabeled/Undated Medication: One Lantus insulin pen was stored unlabeled and undated. Incorrect Discard Date: One Lantus insulin vial had an incorrect discard date of 03/30/2026 instead of 03/29/2026 per manufacturer guidance (28 days after opening on 03/01/2026.) Interview on 03/11/2026 at 9:55 AM with LPN KK revealed that she planned to discard the expired antacid, was unsure of the owner and opening date of the unlabeled insulin pen, and corrected the insulin vial discard date to 03/29/2026, confirming the original dating error. Observation on o3/11/2026 at 10:08 AM revealed that LPN KK consulted Registered Nurse (RN) BB regarding the expired antacid and unlabeled/undated insulin pen. RN BB discarded the expired antacid, provided a new bottle for storage on the cart, and instructed LPN KK to dispose of the unlabeled insulin pen in the sharps container. Interview on 03/11/2026 at 12:03 PM with the Director of Nursing (DON) revealed that staff are responsible for checking medication carts weekly to ensure expired medications are removed and replaced as needed. The DON stated that the facility expects no expired medications to be present on the medication carts. He further explained that insulin must be labeled with the date it is opened and assigned a discard date 28 days later, and that nurses are responsible for accurately calculating and documenting this discard date. Additionally, insulin pens must be labeled by the pharmacy with the resident's name, open date, and discard date to ensure safe administration.

Based on observations, record review, staff interviews, and review of facility policy titled, Self-Administration of Medications, the facility failed to ensure two residents (R) (R130 and R57) could safely self-administration medications by leaving medications at the bedside unsupervised. This deficient practice had the potential to increase the risk of clinical complications. Findings include: Record review of the facility's policy titled, Self-Administration of Medications, revealed under section titled, III Policy, if a resident requests to self-administer medication (s) it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right. The policy further states that, A resident may only self-administer medications after the IDT has determined medications may be self-administered. The policy requires consideration of the resident's cognitive status, ability to follow directions, understanding of medications, and ability to ensure medications are stored safely and securely. 1. A review of the electronic health record (EHR) for R130 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, hypertension, depression, mood disorder, chronic kidney disease, and unsteadiness. A review of the Annual Minimum Data Set (MDS), dated [DATE], documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Additional MDS findings revealed the resident required extensive assistance with activities of daily living (ADLs), including dependency for toileting, bathing, dressing, and personal hygiene. Record review of the care plan for R130 with a start date of 01/03/2024, documented focus areas including cognition (mild impairment), behaviors (episodes of refusing care and meals), mood related to grief and loss, and dementia-related interventions. Interventions included staff explaining care, allowing the resident to express concerns, monitoring for changes in mental status, providing simple explanations of risks and consequences, and observing for behavioral responses during care. Record review on 03/10/2026 of physician orders revealed no order for triple antibiotic ointment. A record review on 03/10/2026 of the EHR revealed no documentation that R130 was assessed for the ability to safely self-administer medications. Observations conducted on 03/10/2026 at 11:00 AM, 03/11/2026 at 10:45 AM and 03/11/2026 at 12:34 PM revealed a tube of triple antibiotic ointment on R130's bedside table. Interview and observation conducted on 03/11/2026 at 12:39 PM with Certified Nursing Assistant (CNA) AA, revealed she has worked at the facility for two years. She stated that if medication is found at the bedside, she immediately gives it to the nurse. CNA AA stated she has not encountered any residents who self-administer medications. During observation of R130's room, she stated she had not seen the triple antibiotic ointment earlier that morning and that the resident could have had it in her purse. CNA AA stated a potential negative outcome could include the resident ingesting the medication. Interview and observation conducted on 03/11/2026 at 12:44 PM with Unit Manager Registered Nurse (RN) BB, revealed the facility performs daily room checks due to increased items being brought in by families. RN BB stated that if medications are found at the bedside, staff remove them, notify the family, and store them for retrieval. During observation, she observed the triple antibiotic ointment on R130's bedside table. RN BB stated staff are expected to remain vigilant when entering resident rooms. She stated a potential negative outcome could include ingestion or adverse reaction if accessed by a resident. Interview conducted on 03/11/2026 at 12:51 PM with the Director of Nursing (DON) revealed the facility's expectation is that staff report medications found at the bedside, and nursing staff will remove and secure them. The DON stated residents who self-administer medications are typically assessed for their ability to do so. The DON stated potential negative outcomes could include medication interactions or overdose. Interview conducted on 03/12/2026 at 9:33 AM with the Administrator revealed the facility's protocol is to immediately remove medications found at the bedside. She stated staff conduct routine sweeps and have educated families that over-the-counter items are considered medications. She confirmed awareness of the antibiotic ointment found at Resident #130's bedside. She stated potential negative outcomes include medications getting into the wrong hands or being used improperly. 2. R57 was admitted to the facility on [DATE] with diagnoses including, but not limited to, history of cerebrovascular accident (CVA) with residual deficit, expressive aphasia, debility, abdominal distention, abdominal pain, and gastroparesis. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the following: Section A (Identification Information) indicated the resident's preferred language is Spanish and that an interpreter is needed to communicate with a doctor or health care staff. Section B (Hearing, Speech, and Vision) indicated the resident's hearing was adequate and no hearing aid was used. The resident's speech was documented as unclear, the resident rarely made himself understood and usually understood by others. Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the care plan dated 03/07/2025 identified a problem related to cognitive and communication impairment, with a goal that the resident will be able to make simple decisions and communicate needs. Interventions included staff asking simple, direct questions, providing clear information, and assisting the resident with communication. The care plan indicated the resident's primary language is Spanish and that an interpreter pad may be used at times to aid communication. Documentation noted the interpreter confirmed the resident's speech in his native language is often mostly incomprehensible. Review of the physician's note dated 02/25/2025 documented, Patient is minimally verbal but gives yes and no and short responses. Review of current medications revealed orders for metoclopramide (Reglan) 10 mg four times daily and simethicone (Mylicon) chewable tablet 80 mg four times daily as needed for flatulence. On 03/10/2026 at 11:21 AM, R57 was observed in his room in a wheelchair leaving the room and entering the hallway. During the observation, two white pills with the imprint G-103 were noted in a medication cup at the resident's bedside. A photograph was taken. The resident was unable to communicate verbally with the surveyor and communicated by pointing to objects and making sounds. Restorative Certified Nursing Assistant (CNA) DD stated the resident typically points to what he needs and staff can understand his needs through gestures. She further stated staff may also use an interpretive pad if needed. At 3:45 PM, the resident was still not in his room; however, the medications remained at the bedside. At 5:43 PM, the resident returned to his room. The surveyor pointed to the pills and asked the resident what was in the cup. The resident's response was non-comprehensible; he opened his mouth, pointed to his mouth, and repeatedly said, no, no, no. In an interview with RN EE, who was caring for the resident on 03/10/2026 at 5:44 PM, the RN stated she was not aware of medications left at R57's bedside and did not know what the white pills were. She stated medications should not be left at the bedside and further indicated the resident is not able to self-administer medications. RN EE removed the pills and identified them through an online search of the white round tablet imprint G-103, which indicated the medication was Simethicone 80 mg. RN EE then reviewed the Medication Administration Record (MAR) with the surveyor, which revealed R57 had an as-needed order for Simethicone 80 mg, with the last documented administration on 12/06/2025. The RN stated it was unlikely the medication had been sitting there since that time but did not know who left the medication at the bedside. In an interview with the Director of Nursing (DON) FF on 03/11/2026 at 10:15 AM, she stated R57 had not been assessed for self-administration of medications due to impaired cognition. She further stated her expectation is that nursing staff do not leave medications at the resident's bedside and that medications should be observed being taken by the resident. In an interview with the Licensed Practical Nurse (LPN)SS (AM Assessment Nurse) on 03/12/2026 at 1:00 PM, she stated that residents must be assessed prior to self-administering medications. She further stated that nursing staff are frequently educated that if medications are seen in residents' rooms, staff should notify the nurse and remove the medication.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Care Plan - LTC - Patient Care, the facility failed to develop and implement comprehensive, person-centered care plan for one resident (R) (R9) of 60 sampled residents. Specifically, the facility failed to develop and implement care plan interventions related to oxygen administration. This deficient practice had the potential to result in inadequate monitoring and improper oxygen administration, which could compromise the resident's health and safety.Findings include:Review of the undated facility policy titled Care Plan - LTC - Patient Care, documented in Section III Policy Do not leave blanks or incomplete sections. Further review revealed that Complete the . Care Plan based on . provider orders and .documents the resident's immediate problems that require nursing care interventions and will guide the delivery of nursing care.Record review of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to atrial fibrillation, asthma, disorder of the lung, and heart failure.Review of R9's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section GG: (functional status), revealed R9 was dependent on staff for all other activities of daily living, including wheelchair mobility. Section O: (special treatments and procedures), revealed oxygen therapy or other treatments were coded during the assessment period, as None of the above.Review of R9's care plan updated 03/11/2026, revealed that oxygen use was not addressed in the care plan. Review of the Physician's Order for R9 included but were not limited to:Order dated 02/13/2025 for Oxygen Therapy Nasal Cannula; 2; 2; 0; Target 02 Sat: Other; as needed for SOB as needed for SOB. Initial start rate L/min: 2, max rate L/min: 2 {liters per minute.}Observation made on 03/10/2026 at 11:14 AM revealed R9 was wearing her oxygen via nasal cannula (NC) and the oxygen (O2) concentrator was running at the setting of 3 liters per minute (LPM).Observation made on 03/11/2026 at 11:10 AM revealed R9 was wearing her oxygen via NC and the O2 concentrator was running at the setting of 3 LPM.Observation and interview on 03/11/2026 at 11:27 AM, with Licensed Practical Nurse (LPN) JJ in R9's room, revealed R9's O2 concentrator remained at a setting of 3 LPM. The nurse confirmed the setting, exited the room to review the physician orders, and identified an order for O2 at 2 LPM. Upon returning, LPN JJ adjusted the O2 concentrator to 2 LPM. The nurse acknowledged she had not yet verified the setting during the current shift.Interview on 03/12/2026 at 10:06 AM with LPN-MDS LL confirmed that oxygen use was only added to the care plan on 03/11/2026, although the oxygen order dated back to 02/13/2026. MDS LL explained that capturing oxygen use for PRN orders on the MDS is challenging and acknowledged that the care plan update regarding oxygen was missed.Interview on 03/12/2026 at 10:47 AM with the Director of Nursing (DON) GG revealed that the MDS nurse is responsible for updating the care plan promptly, ideally within 24 hours, as new orders are discussed during daily clinical meetings. The DON emphasized that timely care plan updates are critical for staff safety, as the care plan serves as a reference for nursing interventions, for example, confirming oxygen orders if a resident shows shortness of breath.

Based on observations, staff interviews, record review, and review of facility's policy titled, Nutrition Food and Supply Storage Procedures, Facility A failed to properly discard expired food items, label food items with expiration dates, and properly refrigerate opened food items. This deficient practice had the potential to result in foodborne illness affecting 77 out of 82 residents who receive food orally at Facility A. Findings include: Record review of facilities policy titled, Nutrition Food and Supply Storage Procedures dated [DATE], under section titled, Purpose revealed, All food, non-food items and supplies used in food preparation shall be stored in such manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. (A.) General Storage .2. The use-by date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by date should be discarded. 3. Cover, label and date unused portions and open packages. Use the [NAME] orange label; complete all sections on the label. (B.) Dry Storage .7. Date and rotate items; first in, first out (FIFO). 8. Remove from storage any items for which the expiration date has expired. Return for credit if possible. (C.) Refrigerated Storage .4. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date. (D.) Frozen Storage .9. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date. An observation was conducted on [DATE] at 9:00 am with the Executive Chef (EC) and continued at 9:10 am with the Dietary Kitchen Manager (DKM) and the following expired items were found in the pantry: -There were 44 bottles of [Name] compact therapeutic shake (vanilla) with an expiration date of [DATE]. -There were 16 bottles of [Name] therapeutic nutrition (chocolate) with an expiration date of [DATE]. -There was one bag of [Name] flour tortillas with an expiration date of [DATE]. -There were four cans of [Name] coconut milk, all of which expired on [DATE]. -There were three bags of [Name] oats and honey granola cereal, all of which had an expiration date of [DATE]. The following unlabeled and unrefrigerated items were also observed in the pantry: -There were three loaves of opened bread, which were unlabeled and not dated. -There was one bag of croutons, which was opened and not labeled or dated. -There was one bag of [Name] pecan pieces, which was opened and not labeled or dated. -There was one bag of vanilla wafers with no expiration date. -There was one bottle of pancake & waffle syrup [Name] with an expiration date of [DATE]. -There was one bottle of light unsulfured molasses with an expiration date of [DATE]. -There was one bottle of [Name] jelly, which was opened and found unrefrigerated in the pantry. An observation was conducted on [DATE] at 9:51 am with the DKM and the following items were observed in the freezer: -There were four packets of [Name] flour tortillas, which had an expiration date of [DATE]. -There were two packets of burgers, which were unlabeled or dated. -There was one bag of whipped cream with an expiration date of [DATE]. -There was one bag of blue cheese with an expiration date of [DATE]. An observation was conducted on [DATE] at 9:45 am with the DKM and the following items were observed in the cooler: -There was one bottle of [Name] (chocolate) with an expiration date of [DATE]. -There was one container of [Name] cottage cheese with an expiration date of [DATE]. An interview was conducted on [DATE] at 9:54 pm with the EC, and he revealed when asked who oversees checking for expired foods and labeling and dating items, he stated that the freezer might have been neglected but the pantry was checked often. The EC further stated that all staff have assignments, and each shift comes in and checks for cleanliness, organization, and the dating and labeling of items in the cooler, pantry, and freezer. The EC also mentioned that his expectations was for the staff to be more diligent, and that maybe they need to be micromanaged. The EC highlighted that one negative outcome of expired food and unlabeled items was that expired foods could be served to residents. An interview was conducted on [DATE] at 11:27 am with the DKM, revealed her expectations for staff members are for more training and increased accountability from staff. DKM stated that there was currently too much inventory, which becomes confusing, and emphasized the need for more training on the first in, first out method. DKM also mentioned that both she and the EC were responsible for checking employees to ensure they were fulfilling their assignments. DKM further stated that a possible negative outcome of expired or improperly labeled food was the risk of foodborne illness spreading to the floor, potentially affecting every resident. An interview was conducted on [DATE] at 11:33 am with the Administrator, who expect staff to follow guidelines for refrigerating, labeling, and checking expired items. The Administrator also emphasized that improper refrigeration and expired food could lead to foodborne illness, posing a significant risk to the residents' health.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, Facility A failed to adequately assess one out of 60 sampled residents (R) (R71) for self-administration of medication. This had the potential to result in serious health complications, including medication misuse or overdose, and compromise the safety and well-being of the resident. Findings include: A review of the facility's policy titled Resident Self-Administration of Medication, dated 7/1/2023 under section titled Purpose revealed, The purpose of the Self-Administration of Medication Policy is to develop guidelines about facility staff expectations in the nursing home to honor resident's request for Self-Administration of Medications whenever assessed as appropriate to keep resident at their highest level of functioning. Under the section titled Policy revealed, If a resident requests to self-administer medication(s), it is the responsibility of the interdisciplinary team (IDT) (as defined in S483.21(b), F657, Comprehensive Care Plans) to determine that it is safe before the resident exercises that right. A resident may only self-administer medications after the IDT has determined which medications may be self-administered .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT, based on changes in the resident's medical and decision-making status .If self-administration is determined not to be safe, the IDT should consider, based on the assessment of the resident's abilities, options that allow the resident to actively participate in the administration of their medications to the extent that is safe (i.e., the resident may be assessed as not able to self-administer their medications because they are not able to manage a locked box in their room, but they may be able to get the medications from the nurse at a designated location and then safely self-administer them). A review of electronic health record (EHR) for R71 revealed she was admitted to the facility with diagnoses including but not limited to peripheral neuropathy, mood and anxiety disorder. A review of R71's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. A review of R71's care plan with a start date of 10/24/2024 revealed, there was no care plan for self-administration of medication. A review of R71's physician orders revealed, there was no order for self-administration of medications. During an interview and observation on 2/11/2025 at 11:34 am with the R71, two [name] inhalers (used to treat or prevent bronchospasms) was observed at R71's bedside table. R71 revealed that she had them for [AGE] years and had been at the facility for about four months. She stated, the inhalers had been brought in with her upon admission. R71 further stated that the staff was aware of the inhalers and did not tell her she couldn't have them. An observation on 2/12/2025 at 10:21 am in R71's room revealed, two [name] inhalers was observed at R71's bedside table. R71 stated, that she used them when she needed them. An interview and observation on 2/12/2025 at 10:26 am with Certified Nursing Assistant (CNA) DD revealed that this was her first time seeing the inhalers at the resident's bedside table. CNA DD explained that if she notices medication at the bedside, she must inform the floor nurse, and the nurse would take the medication. An interview and observation on 2/12/2025 at 10:37 am with Licensed Practical Nurse (LPN) EE revealed that the resident was not allowed to have the inhalers at the bedside. LPN DD explained that if the resident needed them, they would typically keep the inhalers in the cart. She stated that a physician's order would be required to keep medications at bedside. LPN DD further mentioned that a self-administration assessment would be needed for the resident to self-administer medication. An interview on 2/12/2025 at 10:41 am with Registered Nurse (RN)/ Unit Manager CC revealed, that residents who self-administer medication must be assessed and demonstrate proper usage. RN CC stated that they also require the medication order to include a notation for self-administration. RN CC further clarified that residents were not supposed to have medication at the bedside, and over-the-counter medications were discouraged due to the potential for drug interactions. An interview on 2/13/2025 at 11:14 am with the Director of Nursing (DON) revealed, that if medication was found at the bedside, the nurse or unit manager must be notified, and the attending physician would be contacted. The DON stated the physician would determine if the resident was allowed to self-administer the medication. If approved, the nurse and unit manager would provide patient education to ensure the resident understands and follows the medication directions. The family would also be notified, and an order would be written. DON confirmed R71 should not have had the inhalers at the bedside, as there was no diagnosis for the medication at the time of admission, and it was not communicated to the staff. The DON stated some possible negative outcomes include contraindications, drug interactions, potential overdose, or over-sedation, especially if the resident was already receiving similar medication. The DON stated his expectation was that staff should immediately notify the nurse or unit manager if any medication was found at the bedside.

Based on staff interview, record review, review of the facility's document titled, [Name] Bed Hold Notice Facility B failed to provide a written bed hold notices for one out of two residents (R) (R179) reviewed for hospitalization . This failure had the potential to place R179 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital. The sample size was 60 residents. Findings include: Review of the facility's document titled, [Name] Bed Hold Notice dated 2/10/2025 under the section titled Please provide to the Resident or Representative revealed, Please review the information provided below to understand the financial obligations related to your decision to hold or release your bed at [Name of facility] Under the section titled Bed Hold Details revealed, Medicaid will provide payment for residents for up to seven nights of bed hold during hospitalization . Medicaid residents are provided up to eight days per year of Therapeutic leave (other than hospitalization ). If a hospital stays or therapeutic leave extends beyond the time limitation for Medicaid residents, payment arrangements can be made for continuing to hold a resident's bed by contacting the [NAME] Office. If arrangements are not made and hospitalization or therapeutic leave exceeds the Medicaid guideline discharge will occur. An opportunity for readmission will be provided pending availability if they require services provided by the facility and care needs can be met. Review of R179's Discharge Minimum Data Set (MDS) dated [DATE] revealed, Section A (Identification Information) documented R179 was discharged to a short-term hospital with an anticipated return. Review of R179's Discharge MDS dated [DATE] revealed, Section A (Identification Information) documented R179 was discharged to a short-term hospital with an anticipated return. Review of Progress Notes dated 10/3/2024 revealed, R179's Case Manager (CM) communicated to the Transitional Team Coordinator (TTC) a request for a bed hold. Review of Progress Note dated 10/18/2024 revealed, R179 had a seven-day bed hold beginning at midnight. Review of R179's electronic health records (EHR) revealed no evidence of bed hold notices provided to the resident or representative upon transfers. Interview on 2/12/2025 at 12:27 pm with the Administrator confirmed they did not have a bed hold notice for R179 nor did they provide any written bed hold notices for resident that goes out to the hospital. He stated that the Bed Hold Policy was in the admission packet. He continued to state the nurses would contact the family representative via phone and inform them about the resident being sent out and reinstate the bed hold policy to see if they would like to pay after the seven days. From there they can accept or deny the responsibility of the payment that exceeds seven days. If the resident does not have a bed hold the facility will offer the next available bed to the resident. Interview on 2/12/2025 at 4:35 pm with Licensed Practical Nurse (LPN) EE stated she was responsible for completing the bed hold notice when a resident was being sent out. She stated that the family was presented with the bed hold policy on admission and given a form to sign for consent for bed holds. She stated, she was not aware it needed to be signed at the time of transfer to the hospital.

Based on observations, staff interviews and record review, Facility B failed to ensure that one of 14 residents (R) (R150) receiving respiratory therapy, nebulizer mask was covered or properly stored. This deficient practice had the potential to put R150 at risk for increased respiratory infections. Findings include: Review of the electronic health records (EHR) revealed, R150 was admitted to the facility with diagnoses of chronic obstruction pulmonary disease (COPD), chronic respiratory failure with hypoxia (reduced oxygen in the blood), acid reflex, and chest congestions. Review of R150's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 14 which indicated his cognition was intact; Section O (Special Treatments and Programs) revealed, R64 received oxygen therapy. Review of R150's physicians orders revealed, orders for albuterol (Proventil) 2.5 milligrams (mg)/ 3 milliliters (mL) (0.083 percent) nebulizer solution 2.5 mg; albuterol (HFA) (ProAir/Proventil/Ventolin HFA) 90 microgram (mcg)/arcuation inhaler one puff and fluticasone-vilanterol 100-25 mcg/dose Diskus inhaler one puff. During an observation on 2/11/2025 at 11:45 am revealed R150's nebulizer mask was not covered or properly stored. During an observation on 2/11/2024 at 8:25 am revealed R150's nebulizer mask was in his dresser not covered or properly stored. During an interview and observation on 2/12/2025 at 5:07 pm with the Unit Manager (UM) AA revealed that the Saturday supervisor and Certified Nurse Assistants (CNAs) were responsible for doing spot check on items to ensure that they were properly covered, labeled and dated. UM AA confirmed R150's nebulizer mask was not covered or properly stored.

Based on observations, staff interviews, and a review of the facility's policy titled Laboratory Services-,d+[DATE]-POC Glucose Testing with [Name] Glucometer, Facility A failed to discard expired Glucometer Control Solution Level 3, that was stored in one of four medication carts (Hall 300 medication cart). This deficiency created a risk of the expired solution being used, potentially compromising the accuracy and functionality of the glucometer, which could lead to unreliable blood glucose readings. Review of the undated facility policy Laboratory Services-,d+[DATE]-POC Glucose Testing with [Name] Glucometer under the section titled III. Equipment and Supplies revealed, D. [Name] glucose control solutions: Levels 1 and 3 .2. Unopened reagent bottles are good until the expiration dated printed on the container. 3. When opened, the bottles are good for 90 days or until the manufacturer's expiration date, whichever comes first. MUST BE LABELED WITH NEW EXPIRATION DATE. An observation on [DATE] 8:20 am of the medication cart on Hall 300 revealed, an expired unopened Glucometer Control Solution Level 3 with an expiration date of [DATE] was found on the medication cart right upper drawer with other diabetic related supplies. When the surveyor asked Licensed Practical Nurse (LPN) AA about it, she stated that it was still acceptable to use because if it were no longer effective, the glucometer would display an error message and prevent testing. In an interview on [DATE] at 9:06 am, with the Unit Manager for Hall 300, Registered Nurse (RN) BB, she revealed that expired control solution must be discarded. In an interview on [DATE] at 9:30 am, with Unit Manager for Hall 100, RN, CC she stated that expired control solutions should not be used. In an interview on [DATE] at 10:44 am, with the Director of Nursing (DON), he confirmed that expired control solutions must be discarded, as they may compromise the accuracy and proper functioning of the glucometer, leading to unreliable blood glucose readings. In an interview on [DATE] at 1:45 pm, the DON showed the surveyor the medication cart and the carrying case for the [Name] Glucometer that was stored on the side of the medication cart. The case contained all the control testing supplies, with control bottles labeled with expiration dates. The DON stated he was unsure why the expired control solution #3 was kept in the medication cart drawer, even though he assured the surveyor that it would not be used.

Based on observations, record review, and interviews, the facility failed to ensure that activities of daily living (ADL) care was provided for two dependent residents (R) (R#482 and R#60) related to baths/showers. R#482 and R#60 resided in Facility B. The sample size was 70. Findings include: 1. Review of the medical record revealed R#482 was admitted to the facility 12/15/21, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/30/22 at 11:24 a.m., R#482 revealed that she had not received a shower in the last two weeks. Review of the shower log and electronic documentation revealed that R#482 received a bath/shower on 5/31/22, 6/9/22, 6/16/22, 6/28/22, 7/5/22, 7/12/22, 7/16/22, 7/26/22, 7/28/22, 8/2/22, 8/9/22 and refusal on 8/30/22. Further review of records revealed that R#482 was admitted to the hospital on 6/10/22 and returned to the facility on [DATE]. R#482 was also admitted to the hospital on 8/12/22 and returned to the facility on [DATE]. Review of a shower log revealed that R#482 bath days are Tuesday, Thursday, and Saturday. Interview on 9/1/22 at 11:24 a.m. the Director of Nursing (DON) confirmed that baths or showers was given on these dates. Further interview with the DON revealed that her expectation is to honor resident's preferences related to receiving baths. The DON further revealed that the Certified Nursing Assistant (CNA) that is responsible for bathing R#482 failed to document bathing as required and failed to document refusals of baths. 2. Review of the medical record revealed R#60 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review the most recent MDS quarterly assessment dated [DATE] revealed R#60 has a Brief Interview Mental Status (BIMS) score of 15, which indicates that R#60 was cognitively intact. Rejection of Care on the MDS revealed no behaviors documented. R#60 required extensive assistance with ADL's. During initial screening on 8/30/22 at R#60 revealed that she has not had a shower for one month. Review of the shower logs for R#60 revealed no evidence that R#60 was offered a shower on 7/5/22, 7/12/22, 7/14/22, 7/16/22, 7/19/22, 7/21/22, 7/26/22, 8/9/22, and 8/30/22. R#60 refused a shower on 7/26/22. Review of the progress notes revealed that there was no documentation indicating R#60 was offered a shower. During an interview on 8/31/22 10:05 a.m., CNA AA revealed that R#60 was offered shower on the following days, 7/5/22, 7/12/22, 7/14/22, 7/16/22, 7/19/22, 7/28/22, 8/2/22, 8/9/22, 8/2/22, 8/13/22, 8/18/22, 8/23/22, and 8/30/22. Interview on 9/1/22 at 9:23 a.m., Unit Manager (UM) BB, revealed that his expectation from the shower team is to provide showers/baths for residents on their scheduled shower days and that it is documented on the shower log. Interview on 9/1/22 at 10:40 a.m. the DON revealed her expectation from the shower team is to give baths/showers as scheduled. She stated that residents are scheduled to receive showers two to three days a week and documentation should reflect that. She stated the process is to notify the unit manager if a resident refuses a bath/shower, who will then talk to the resident. She revealed that the facility does not have a shower policy or procedures.

Based on observations, record review, and interviews, the facility failed to provide evidence that restorative nursing services were provided for passive range of motion (PROM) and active range of motion (AROM) as recommended by Physical Therapy (PT) and Occupational Therapy (OT) for bilateral upper extremities (BUE) and for splint or brace for one Resident (R) (R#113) of one reviewed for restorative nursing. R#113 resided in Facility B. The sample size was 70. Findings include: Review of the medical record revealed that R#113 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that R#113 is cognitively intact. The MDS revealed he is totally dependent requiring two person plus assist for bed mobility and transfers and has limited range of motion in bilateral upper and lower extremities. Further review revealed R#113 received restorative nursing for passive and active range of motion (ROM) two of seven days during the assessment period. Review of the care plan updated 5/20/22 revealed activities of daily living (ADLs) deficit with interventions that include certified nursing assistant (CNA) to provide restorative nursing as ordered and CNA to apply splints, rolls, slings, ROM as ordered. Review of PT and OT notes for R#113 revealed that on 2/8/21 (PT) and (OT) referred R#113 to the Restorative Nursing Program and provided recommended activities. Updated recommendations by PT dated 5/19/22 include active and passive ROM, splint or brace assist and wheelchair mobility and use of an OmniCycle. Review of Restorative Program form from PT dated 4/4/22 and OT dated 5/19/22 revealed goals are to maintain current ROM and strength, prevent contractures of joints in bilateral upper extremities (BUEs), improve independence and endurance for wheelchair mobility. Documented R#113 was to receive two activities from a provided list every day and to be sure all activities were completed at least once a week. The list of activities include: 1. Provide ROM exercises to both arms and legs in all joints, all ranges 10 repetitions each. 2. Bring resident to the rehabilitation gym to use the OmniCycle with his arms on the Neuro setting, level four resistance, with use of ace wraps to secure hands to handlebars as instructed. Can complete this activity for 15 minutes. 3. Provide assist as needed for resident to propel wheelchair both forward and backward for 75-100 feet each direction. 4. Apply bilateral resting hand splints at night for 6-8 hours (on in PM/off in AM). Review of the documented Restorative Care Flowsheet Data in the electronic medical record (EMR) dated 5/28/22 through 8/28/22, revealed documentation that R#113 received restorative nursing services for active and passive ROM exercises, splint and/or brace assistance, transfers, chair mobility and OmniCycle use on some days, but not on all days, with some days having only removal of BUE splints documented. Observation of and interview on 8/30/22 at 10:05 a.m., R#113 was sitting in a wheelchair and observed to have limited ROM and contractures in BUE. He was not wearing splints or any other devices, nor were their handrolls in his hands. He stated he is scheduled to receive restorative nursing services daily but added that he does not receive it every day. He revealed some weeks he only receives restorative nursing one day a week. He stated that he would like to receive restorative nursing daily and he believe that therapy ordered daily restorative nursing services. He revealed he usually wears upper extremity splints at nighttime only. Observation of and interview on 8/31/22 at 10:58 a.m., R#113 was sitting in a wheelchair. He was observed to have limited ROM and contractures in BUE. He did not have handrolls in his hands nor was he wearing splints. R#113 revealed he does not receive restorative nursing daily and has not gone to use the OmniCycle in weeks. He revealed he does roll his wheelchair very short distances in his room daily and requires assist with more than minimal movement of wheelchair. Interview on 8/31/22 at 10:20 a.m., CNA EE revealed she normally does restorative nursing services at the facility, but revealed other CNAs are trained to provide restorative nursing services in her absence. She revealed she follows recommendations from the therapy departments for restorative nursing services. She revealed that she maintains a notebook with restorative nursing recommendation and orders from therapy departments. During further interview, she stated she documents restorative nursing services in the electronic medical record (EMR). She further revealed she is often assigned a different assignment due to staffing shortages. Interview on 8/31/22 at 11:05 a.m., Registered Nurse (RN) Unit Manager (UM) CC revealed OT and PT will screen residents and provide written recommendations for restorative nursing care and restorative nursing staff follows the recommendations. She stated there is one restorative CNA for each unit (two units in facility) and every effort is made to avoid re-assigning the restorative CNAs to other areas, but that there are times when they are re-assigned. Interview on 8/31/22 at 11:15 a.m., Licensed Practical Nurse (LPN) DD revealed that she is the supervisor for the restorative CNAs. She stated that other CNAs are trained to provide restorative nursing services in the absence of the regular restorative CNAs. She stated the facility does not have a restorative nursing policy. She further stated that monthly team meetings with herself, and restorative CNAs are held to discuss resident progress, participation, and their needs. She also revealed that if the residents' needs change, she requests an evaluation from the therapy departments. Interview on 9/1/22 at 9:00a.m., LPN DD stated that the other CNAs are trained to provide restorative nursing services as needed. She stated that the two designated restorative nursing CNAs are sometimes re-assigned to other duties depending on the needs of the facility. She revealed she and the CNAs meet monthly to discuss resident status and determine if any changes are needed to be recommended to therapies. She revealed the CNAs and any staff providing restorative nursing services are to document services that were provided in the EMR under the Restorative Care Flowsheet Data flowsheet section for restorative nursing. Record review of the Restorative Care Flowsheet Data flowsheet section for restorative nursing documentation for the past 3 months was reviewed with LPN DD at this time. She verified services were not documented as being provided per therapies recommendations. Interview on 9/1/22 at 11:10 a.m., Director of Nursing (DON) revealed the facility does not have a restorative nursing policy or procedure. She revealed PT and OT evaluate and provide a written individualized program for each resident that needs restorative nursing services. She stated that she requests assistance from therapists or LPN's if restorative CNAs are unavailable to provide restorative nursing services. She revealed the LPN supervisor, and the restorative CNAs meet monthly to discuss resident needs. She revealed it is her expectation that restorative nursing services are provided as recommended by PT and OT and that services are documented in the restorative nursing flowsheet in the EMR.

Based on observation, policy reviews, and interviews, the facility staff failed to appropriately use Personal Protective Equipment (PPE), while providing care on a COVID-19 unit. The failure to appropriately wear PPE on a long-term care COVID-19 unit increased the risk of exposure and/or infection for staff, residents, and potentially increased the risk of community spread of the COVID-19 virus. The census was 113. Findings include Review of the facility's policy titled, Infection Prevention-Guidelines for Isolation Precautions, undated revealed, .Applying Standard Precautions for all patients.Droplet-For patient with suspected or confirmed influenza, pneumonia.or other infectious agents that are spread by droplets generated from coughing, sneezing.Mask with eye protection required when working within 6 feet of a patient. An additional undated facility policy titled, .Procedures for COVID-19, revealed, .If the COVID-19 test is performed and it is positive, then.All employees must.Use standard, contact, and droplet precautions with eye protection when caring for residents with undiagnosed respiratory infection. During a tour of the facility's COVID-19 unit on 6/17/20 at 2:10 PM the Unit Manager (UM HH) was observed with a hair restraint, goggles, N95 along with a surgical mask that covered the N95, and gloves. Also observed were several resident rooms in which the doors were closed to the hallway. Each door had a posted sign that revealed, .In addition to Standard/Universal Precautions: Long Term Care Enhanced Droplet.Facial Shield (within 6 feet of patient) . A random observation on 6/17/20 at 2:15 PM, when a Certified Nursing Assistant (CNA II) came out of Resident (#6)'s room. CNA II failed to have a face shield or goggles on. CNA II confirmed she had completed personal care for the resident. CNA II stated she did not wear a face shield since it made her too hot. Immediately after this observation, CNA JJ came out room [ROOM NUMBER]. CNA JJ did not have a face shield or goggles donned (to put on). CNA JJ stated she typically has her googles on and thought they were on her head. The UM HH was present during these observations and interviews. The UM HH stated it was the expectation for caregiving staff to don a gown, N95 and a surgical mask that covered the N95, and to wear either a face shield or goggles when providing care to residents on the COVID-19 unit. An interview was conducted with Licensed Practical Nurse (LPN LL) on 7/17/20 at 2:33 PM and she said that she had seen the two CNAS with googles and a face shield on previously, and was unsure why they did not have them on currently. LPN LL stated the expectation was for caregiving staff to wear googles or a face shield in addition to the gown, N95, surgical mask, and gloves. Immediately after this interview, CNA JJ had her goggles on and said she had previously cleaned them and inadvertently left them at the nursing station. On 7/17/20 at 2:35 PM, CNA II was observed to re-enter the COVID-19 unit, and while walking down the hallway, placed her hair under a hair restraint and attempted to place her face shield on. The top part of the face shield was observed to be shoved under her hair restraint and the bottom part of the face shield stuck out from the lower part of her face, approximately three inches from the bottom of CNA II's chin. CNA II stated her face shield was broken and she would typically request a new face shield from the Infection Control Preventionist (ICP KK) and then walked away. An interview was conducted with the Administrator, Director of Nursing (DON), and ICP KK, on 7/17/20 at 3:01 PM. The Administrator stated the facility provided education for the staff early on regarding donning and doffing (to take off) PPE. The ICP KK stated the expectation for staff on the COVID-19 unit was to wear a N95 face mask, and a surgical mask that covered it. In addition, when staff were providing care to a resident, staff were to wear a face shield or goggles as protection from respiratory droplets. The Administrator stated CNA II should have asked for a new face mask and they could have easily provided it to her.

Based on observation, record review, resident and staff interview, the facility failed to implement the skin integrity care plan related to the nurse assessing skin integrity as needed for one resident (R)(R#66), and failed to implement the care plan related to staff provision of oral hygiene for one out of two residents reviewed for oral care (R#140). Both residents resided in Facility A. The sample size was 29 residents. Findings include: 1. During interview with R#66 on 5/6/19 at 1:05 p.m., he stated that he had been awake all night itching, and that the facility did not have anything effective to treat it. On 5/7/19 at 8:57 a.m., R#66 was in bed, and was observed to have linear scratch marks to his left lower leg, with redness to the surrounding skin. Review of R#66's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Score (BIMS) of 6 (a BIMS score between 0 and 7 indicates severe cognitive impairment). Review of R#66's skin integrity care plan revealed that he was at risk for skin tears and bruises due to having thin, fragile skin. Review of an intervention for this care plan dated 9/18/18 revealed that the nurse will assess skin integrity as needed. Nothing was seen in his care plans related to ongoing concerns with a rash and itching. This was confirmed during interview with MDS nurse FF on 5/8/19 at 5:52 p.m. Review of a history of topical medications ordered for R#66 revealed that there were nine orders for topical applications for dry skin, [MEDICAL CONDITION], itching and rash between 12/25/18 and 5/9/19. Review of a Nurse's Note dated 3/28/19 at 5:52 a.m. revealed: Very dry, flaky and itchy skin caused res (resident) to keep scratching his body which caused small bleeds all over, especially buttocks, stomach, back, arms and legs. Res was very upset and frustrated as he stated that he c/o (complained of) itching for a very long time and couldn't get any relief. Moisturizing cream was applied to his body several times during the night shift. During interview with R#66 on 5/9/19 at 9:48 a.m., he stated that he did not sleep at all last night due to the burning from the lotion that had been applied to his skin yesterday. Observation of R#66's skin at this time by Licensed Practical Nurse (LPN) Wound Care Nurse GG revealed that he had a scattered rash and/or small scabbed areas on his legs, especially the left posterior upper leg, his abdomen, and chest. When LPN GG removed R#66's incontinent brief, his buttocks were observed to be extremely red and excoriated in appearance, with bright red blood noted from weeping areas of skin on the brief and bed linen. During interview with CNA HH on 5/9/19 at 10:28 a.m., she stated that R#66 was always scratching his skin, and that when she came on duty in the morning there was always blood on his clothes and the sheets from him scratching his bottom, and she had to change him. She stated during further interview that she had told the treatment nurse about this. During interview with LPN II on 5/9/19 at 12:30 p.m., she stated that R#66 scratches himself, and has had rashes for a long time. She stated during further interview that she was not aware of the appearance of the excoriated skin on his bottom. Cross-refer to F 684. 2. Review of the medical record for R#140 revealed she was admitted with a [DIAGNOSES REDACTED]. Review of R#140's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS), of a 5, which indicated that resident was severely cognitive impaired. Review of Section G: Functional status on the Annual MDS dated [DATE] revealed that R#140 was an extensive assist for personal hygiene (mouth care) with one-person physical assist. R#140 had severe cognitive impairment and required staff assistance with her ADL's including personal hygiene. Reviewed on R#140 of the Care Plan dated 3/22/19 revealed the R#140 presents carious appearing upper teeth. R#140 is missing some teeth from top but has partial and her natural teeth are on the bottom. She needs staff assistance with her Oral hygiene and denture care. CNA will encourage resident to wear dentures for meals. CNA will provide care and remove any food after each meal. Interview on 5/7/19 at 7:35 a.m. with CNA DD, revealed that she documented ADLs in the electronic computerized system that was located at the nurse's station. Continued interview revealed that CNA DD, stated that mouth care was not documented separately in the computerized system. During interview with Certified Nursing Assistant (CNA) CC on 5/7/19 at 9:05 a.m., she stated that ADL care documentation is entered in the computer system. Continued interview revealed that mouth care was to be completed after each meal and as needed (PRN). Further interview with CNA CC, revealed that she had not completed mouth care on R#140 after breakfast this morning. She indicated that she is going to complete it after lunch. During interview with Licensed Practical Nurse (LPN) Unit Manager AA on 5/7/19 at 4:30 p.m., she verified that R#140 had food particles on her teeth. Review of R#140's ADL flowsheet updated on 4/22/19 revealed R#140's teeth were brown in color and teeth care was not done per ADL sheet and Flow sheet, Unit Manager and DON verified that the staff did not perform this care per their flowsheet. Refer to F677

Based on observation, record review, and staff interview, the facility failed to ensure that oral care was provided for one of four resident (R) R#140 who needed extensive assistance with personal hygiene. R#140 resided in Building A. Findings include: Review of the medical record for R#140 revealed she was admitted with a [DIAGNOSES REDACTED]. Review of the facility NHL-ADL Sheet revealed R#140 had severe cognitive impairment and required staff assistance with her ADL's including personal hygiene. Review of R#140's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated that the resident was severely cognitively impaired. Further review of this MDS revealed that R#140 needed extensive assistance for personal hygiene, which includes brushing teeth, with one-person physical assist. Observation on 5/6/19 at 11:00 a.m. revealed that R#140 was missing some of her top teeth, her bottom teeth were brown in color, and she had white debris on the two front teeth. Interview with R#140 at this time revealed that she did not remember if the staff had brushed her teeth today. Further observations on 5/6/19 at 2:34 p.m., and on 5/7/19 at 7:40 a.m., 12:34 p.m., 4:03 p.m., and 4:30 p.m. revealed that resident #140's bottom teeth were brown in color, and she had white debris on the two front teeth. Review of R#140's Activities of Daily Living (ADL) flowsheet updated on 4/22/19 revealed R#140's teeth were brown in color and teeth care was not done per ADL sheet and Flow sheet, Unit Manager and Director of Nursing verified that the staff did not perform this care per their flowsheet. During interview with Licensed Practical Nurse (LPN) Unit Manager AA, on 5/7/19 at 4:30 p.m., she verified that R#140 had food particles on her teeth. During interview with Certified Nursing Assistant (CNA) CC, on 5/7/19 at 9:05 a.m., she stated that ADL care documentation is entered in the computer system. Continued interview revealed that mouth care was to be completed after each meal and as needed (PRN). Further interview with CNA CC, revealed that she had not completed mouth care on R#140 after breakfast this morning. She indicated that she is going to complete it after lunch. Interview on 5/7/19 at 7:35 a.m. with CNA DD, revealed that she documented ADLs in the electronic computerized system that was located at the nurse's station. Continued interview revealed that CNA DD, stated that mouth care was not documented separately in the computerized system.

Based on observation, record review, resident and staff interview, the facility failed to identify and/or report an area of excoriation with bleeding to the buttocks in a timely manner, and continued itching from rashes, for one resident (R)(R#66), who resided in Facility A. The sample size was 29 residents. Findings include: During interview with R#66 on 5/6/19 at 1:05 p.m., he stated that he had been awake all night itching, and that the facility did not have anything effective to treat it. On 5/7/19 at 8:57 a.m., R#66 was in bed, and was observed to have linear scratch marks to his left lower leg, with redness to the surrounding skin. Review of R#66's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Score (BIMS) of 6 (a BIMS score between 0 and 7 indicates severe cognitive impairment). Review of R#66's skin integrity care plan revealed that he was at risk for skin tears and bruises due to having thin, fragile skin. Nothing was seen in his care plans related to ongoing concerns with a rash and itching. This was confirmed during interview with MDS nurse FF on 5/8/19 at 5:52 p.m. Review of R#66's physician progress notes [REDACTED]. 1/9/19: Hospital Problems: rash (present on admission). Noted with red rash to bilateral buttocks. Ordered [MEDICATION NAME] and [MEDICATION NAME] creams qs (every shift). 2/6/19: Chief complaint rash with itching to bilateral lower extremities. Multiple scratches noted to bilateral lower extremities. Rash noted with light red in color. New order for Lac-hydrin cream bid (twice a day) to bilateral lower extremities. 4/10/19: Itching: asteatotic [MEDICAL CONDITION]-lachydrin (sic) doing better. Rash: present on admission. Patient seems to have rash due to very dry skin. Anhidrotic [MEDICAL CONDITION]. We will start Lac-Hydrin on his legs twice daily. Review of R#66's Active Order Sets (Physician Orders) through 5/9/19 revealed current orders for: 12/25/18: [MEDICATION NAME] Moisturizing Cream topically two times daily as needed for dry skin. 1/29/19: [MEDICATION NAME] 0.5% cream topically two times daily as needed for rash and itching. 5/8/19 at 6:12 p.m.: Ammonium [MEDICATION NAME] (Lac-Hydrin) 12% lotion to abd (abdomen), legs and bilateral upper extremities topical bid (twice a day). 5/9/19 at 9:02 a.m.: Apply [MEDICATION NAME] to bil (bilateral) buttocks qshift. 5/9/19 at 10:51 a.m.: Apply [MEDICATION NAME] ointment to arms, legs, back and abd qshift (every shift) x 7 days. Review of a history of topical medications ordered for R#66 revealed: 12/25/18: [MEDICATION NAME] Moisturizing Cream topically twice a day PRN (as needed) for dry skin. 1/10/19: [MEDICATION NAME] 2.5% cream topically twice a day for 14 doses for rash (through 1/17/19). 1/10/19: [MEDICATION NAME] 2% cream topically twice a day for 14 doses for rash (through 1/17/19). 1/29/19: [MEDICATION NAME] 0.5% cream topically twice a day PRN for rash, itching. 2/6/19: Ammonium [MEDICATION NAME] (Lac-Hydrin) 12% lotion topically twice a day for 60 doses for rash (through 3/8/19). 3/13/19: Ammonium [MEDICATION NAME] (Lac-Hydrin) 12% lotion topically twice a day to bilateral lower extremities for seborrheic [MEDICAL CONDITION] (discontinued on 3/14/19). 3/13/19: [MEDICATION NAME] (Desowen) 0.05% cream topically twice a day for seborrheic [MEDICAL CONDITION] to right hip for ten doses (through 3/18/19). 5/8/19: Ammonium [MEDICATION NAME] (Lac-Hydrin) 12% lotion topically twice a day for seborrheic [MEDICAL CONDITION] to arms, leg and abdomen for 60 doses. 5/9/19: [MEDICATION NAME] ([MEDICATION NAME]) 0.1% ointment topically to arms, legs, back and abdomen every shift for 7 days. Review of R#66's wound records revealed: 12/30/18: Scratches to right hip, bleeding from resident scratching. 1/9/19: Bilateral rash buttocks, treatment with [MEDICATION NAME] and [MEDICATION NAME]. 2/6/19: Bilateral lower leg. Skin dry. Several small scabs from scratching. Treatment with Lac-Hydrin. 3/13/19: Dry skin bilateral legs and right hip. Treatment with Desowen and Lac-Hydrin. 5/9/19: Other wound (unspecified). Date first assessed 5/9/19 at 9:19 a.m. Location: Body. Review of Nursing Notes revealed the following: 12/25/18 1:17 p.m.: Res with scabbing and itching continuing to body. New order for [MEDICATION NAME] lotion. 1/6/19 11:20 p.m.: Resident's roommate reported that his roommates arm is bleeding. Noted a medium sized S/T (skin tear) on residents rt. (right) arm. Resident said he was scratching his arm and scratched it too hard. Causing the S/T on his arm. 1/16/19 3:18 p.m.: Resident scratched his right leg causing some red bloody skin. Various scratches covering the entire right lower extremity. 1/29/19 12:00 p.m.: Family reported to nurse that resident was bleeding. Upon entering room noted resident had 1 ST to left wrist and 2 areas on LFA (left forearm) which appeared to be scratches. Resident stated he had been scratching his arm. (Doctor) informed and new orders received for [MEDICATION NAME] cream and one time order for [MEDICATION NAME]. 1/30/19 3:08 p.m.: Resident with scabs all over body from itching. 3/28/19 5:52 a.m.: Very dry, flaky and itchy skin caused res to keep scratching his body which caused small bleeds all over, especially buttocks, stomach, back, arms and legs. Affected areas cleansed with wound cleanser, then normal saline applied, followed by prescribed lotion/cream. Res was very upset and frustrated as he stated that he c/o (complained of) itching for a very long time and couldn't get any relief. Moisturizing cream was applied to his body several times during the night shift. CNA (Certified Nursing Assistant) advised to always change res (resident) TShirt before bedtime. 4/12/19 11:37 a.m.: [MEDICATION NAME] cream 0.05% applied to the entire back and buttocks d/t (due to) itching. His skin is dry and red d/t scratches. 4/26/19 6:31 p.m.: He does scratch d/t itching causes minimum bleeding. 5/8/19 6:13 p.m.: Resident complaining of itching to bilateral arms, legs and abd (abdomen). Resident noted scratching areas. New order received to apply lac-hydrin lotion bid (twice a day). 5/9/19 10:41 a.m.: Upon assessment this a.m. patient refused to let Lac-Hydrin be applied. Lac-Hydrin started yesterday evening for asteatotic [MEDICAL CONDITION] exacerbation per doctor. Stated to this nurse that it stings after it is applied. Order received to dc (discontinue) Lac-Hydrin and start [MEDICATION NAME] ointment q (every) shift x 7 days. Patient has appointment scheduled with dermatologist for Monday 5/13/19. During interview with Licensed Practical Nurse (LPN) Treatment Nurse GG on 5/9/19 at 9:48 a.m., she stated that R#66 had a dermatology appointment scheduled in the past, but the family was unable to accompany him so it had to be canceled. She further stated that weekly skin assessments were done by the shower team CNAs, and were recorded on a paper form and kept in the Unit Manager's office. During interview with R#66 at this time, he stated that he did not sleep at all last night due to the burning from the lotion that had been applied to his skin yesterday. Interview with LPN Treatment Nurse GG at this time, she stated she would call the physician today to see if she wanted to change the order. Observation of R#66's skin at this time by LPN GG revealed that he had a scattered rash and/or small scabbed areas on his legs, especially the left posterior upper leg, his abdomen, and chest. When LPN GG removed R#66's incontinent brief, his buttocks were observed to be extremely red and excoriated in appearance, with bright red blood noted from weeping areas of skin on the brief and bed linen. Interview with LPN GG at this time, she stated that she was aware of the area, that it was blanchable, and that she had put some barrier cream on it that morning. Review of R#66's Skin Assessments from 3/22/19 to present revealed the following shower team CNA documentation: 3/22/19: No issues noted. 3/25/19: No issues noted. 3/29/19: Scars, bruises, and red rashes were noted by the CNA. After reviewing the assessment, LPN GG documented no rash, only dry skin. 4/1/19: Resident has been scratching bottom, drawing blood. Cream applied. (there was nothing seen in response to this from the treatment nurse). 4/5/19: Scratches documented on bilateral shoulders, a scab left anterior lower leg, and scratches on upper back and buttocks. 4/8/19: No skin issues noted. 4/10/19: Sores/scabs noted by CNA on right posterior back. The treatment nurse documented no sores, scabs, pt (patient) scratches. 4/14/19: Multiple scars/bruises documented anterior and posterior body. 4/17/19: Bruises on arms, legs, hands, and back. 4/22/19: Bruises and cuts all over body documented by CNA. The treatment nurse documented no cuts, pt scratches. 4/29/19: Multiple bruises anterior and posterior body, bleeding to left lower anterior leg. 5/1/19: Treatment area left lower anterior leg. The CNA documented redness to bottom, the treatment nurse made a notation that it blanches. 5/3/19: Bruises/scars anterior and posterior body. 5/8/19: Scratch right anterior shoulder area, scratches left anterior thigh, scratches back, right and left buttocks. (there was no indication on this skin assessment of excoriation to the buttocks). During interview with LPN Treatment Nurse GG on 5/9/19 at 9:55 a.m., she stated that it was possible that the skin on R#66's buttocks could have become that excoriated-looking between the time the skin assessment was done on 5/8/19, and this morning's observation. During interview with the LPN Unit Manager AA at this time, she stated that the facility policy was for skin assessments to be done weekly by the shower team, but the shower team CNAs may do it more often. During interview with CNA HH on 5/9/19 at 10:28 a.m., she stated that R#66 was always scratching his skin, and that when she came on duty in the morning there was always blood on his clothes and the sheets from him scratching his bottom, and she had to change him. She stated during further interview that she had told the treatment nurse about this. During interview with LPN II on 5/9/19 at 12:30 p.m., she stated that R#66 scratches himself, and has had rashes for a long time. She stated during further interview that she was not aware of the appearance of the excoriated skin on his bottom, because it would have been reported to the treatment nurse, as she had more expertise with skin conditions. Review of the facility policy Skin Assessment review/revision 9/01 revealed: Residents will be examined weekly by the CNA or nurse during their shower/bath for skin breakdown. Identified problems will be reported to the DON (Director of Nursing) or designee for review and assessment. Appropriate measures will be implemented.

Based on observation, record review, staff and resident interviews, the facility failed to ensure that one of one resident (R) (R#193) reviewed for vision receive proper treatment and assistive devices to maintain vision. The sample size was 24 residents. Findings include: Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's medication included but not limited to; [MEDICATION NAME] 0.2% ( eye drops for [MEDICAL CONDITION]) 1 drop 2x daily , [MEDICATION NAME] tab ( blood pressure) 25mg 3x day, [MEDICATION NAME] (pain medication) 5-325 mg tab x1 x6 hrs prn, [MEDICATION NAME] (insulin) 100 units /ml 7 units 3x daily, [MEDICATION NAME] (insulin) 7 units nightly, [MEDICATION NAME] tab(for blood pressure) 37.5 mg x2, [MEDICATION NAME] (for [MEDICAL CONDITION]) 0.5% 2x daily, Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section B: 1000. Vision - Impaired -B. 1200 Corrective Lens- NO /Section C: Brief Interview for Mental Status (BIMS) score 15 out of 15 which indicates no cognitive impairment. Review of R#193's care plan dated 4/29/19 revealed (Impaired Vision), Revealed R #193 reports impaired vision. He is not able to read small print. Review of record: dated 4/15/19 revealed R#193 not involved in Care Plan meeting. Request an order for [REDACTED]. During an interview on 5/9/19 at 9:10 a.m. with R#193 he stated that the Ophthalmologist could not accommodate him during his recent visit because he was on a stretcher and needed to be seated upright in order to perform the vision exam. R#193 stated he has blurry vision with headaches when reading or watching television and prefers not to use his outdated prescription glasses. He stated the room often appears very dark and it becomes difficult to see things. During an observation on 5/7/19 at 11:30 a.m. of R#193 revealed his room to have adequate lighting. His prescription glasses on the bedside table were observed to be dirty with fingerprints on the lens. During an interview on 5/7/19 at 4:42 p.m. with Licensed Practical Nurse (LPN) NN she stated she wasn't aware of the issues surrounding R#193's recent vision exam and stated she would reschedule his appointment immediately. She stated R#193 currently receives eye drops for complaints of headaches related to [MEDICAL TREATMENT] and pressure changes in his eye. During the interview LPN NN revealed R#193 returned from [MEDICAL TREATMENT] a month ago he appeared incoherent, complaining of an acute headache and eye pain. States when she called the attending physician, she was instructed to contact 911. On 5/7/19 at 6:00 p.m. an interview R#193 revealed R#193 entered the facility with his outdated prescription glasses, but never uses them and leaves the old glasses on his bedside table. States he reported his concerns about blurry vision and room darkness to several staff members on numerous occasions without changes. States he had surgery in the past on both eyes for [MEDICAL CONDITION] and the medical doctor (MD) at the most recent emergency room visit told him he has [MEDICAL CONDITION]. Reports MD prescribed him eye drops to relief pressure, stop pain and redness. The follow up appointment was canceled due to his stroke. Also, states he's not 100% sure if the facility was aware of the canceled Ophthalmologist appointment because of they weren't able to accommodate him. On 5/9/19 at 8:20 a.m. Registered Nurse QQ reported that R#193 was admitted into emergency room last night upon his request with complaints of headaches and eye pain. RN QQ states they have an eye doctor on staff at the facility and isn't sure why R#193 wasn't examined. RN QQ stated that all referrals, transportation and specialist appointments are made by unit secretary and kept on file. The exam follow-up communication is passed on to himself or LPN NN for review then returned to medical records to be scanned into the medical record. RN QQ states he was unaware of the issues surrounding R#193 appointment on 4/22/19. The follow-up documentation wasn't found in electronic medical record. On 5/9/19 Nurse RN QQ requested the documentation from medical record which revealed, Patient had an appt. for 4/22/19 at 3pm. He was on a stretcher and was unable to be removed from it and it seemed like he was in a lot of pain. Patient left and said he would call back to reschedule. On 5/9/19 at 10:49 a.m. an interview with Director of Nursing (DON) revealed that no follow up was done with R #193 4/22/19 vision appointment. States when she contacted the office today for the follow- up documentation they informed her R#193 refused to be seen on 4/22/19. States she's aware the follow-up communication doesn't reflect those claims. The DON acknowledged that her staff drop the ball in this situation. In a normal process the Unit Manager or LPN NN would contact the doctor's office for new orders and send the information to medical records to be scanned into electronic record.

Based on observation, record review, and staff interview, the facility failed to ensure that two opened multi-dose vials of PPD (Purified Protein Derivative) were labeled with an open date to be able to determine when to discard the vial in one of two medication room refrigerators observed at Facility A, and failed to ensure that two medications were not used past their expiration date (one bottle of floorstock aspirin currently used for two residents (R)(R#22 and R#216), and one bottle of Aloe Vera capsules used for one resident (R#24)) on one of two medication carts observed at Facility A. There was a total of five medication storage rooms and nine medication carts in Facility A and Facility B combined. The sample size was 29 residents. Findings include: 1. Observation in the medication refrigerator located in the medication room on Unit 3 in Facility A on 5/7/19 at 12:27 p.m. revealed that there were two opened multi-dose vials of PPD ([MEDICATION NAME], Purified Protein Derivative, Diluted [MEDICATION NAME]), which contained ten 0.1-mL (milliliter) PPD tests when full. Further observation revealed that both bottles had manufacturer's expiration dates of 9/20 (September 2020), but neither the bottles or box they came in were labeled with the date they were opened. Continued observation revealed that one vial was approximately half-full, and the other vial approximately two-thirds full. This observation was verified by Licensed Practical Nurse (LPN) JJ at this time, who stated during interview that whenever a multi-dose vial was opened, it should be labeled with the open date. LPN JJ stated during continued interview that she did not know how long PPD vials were good for once they were opened. 2. On 5/8/19 at 10:25 a.m., the Unit 1 North medication cart in Facility A was checked with LPN KK. One floorstock bottle of aspirin 325 mg (milligram) tablets was observed to have an expiration date of 04/19 (April 2019). Continued observation revealed a 90-capsule bottle of Aloe Vera 500 mg capsules, with an expiration date of 7-2018 (July (YEAR)). This was verified during interview with LPN KK at this time, who stated the Aloe Vera capsules were most likely brought in by family for R#24, as the bottle was labeled with her name handwritten in black ink. During continued interview, LPN KK stated that it was the night shift nurse's responsibility to check the medication cart for expired meds, and that both of these medications were currently in use for residents. During observation in the Unit 1 medication room at this time, all of the floorstock bottles of aspirin were noted to have dates on the bottles later than 04/19, and LPN KK stated that she would replace the aspirin bottle on the medication cart labeled 04/19 with a bottle that was not expired. Review of R#24's Active Order Sets revealed an order for [REDACTED].#216's Active Order Sets revealed an order for [REDACTED].#22's Active Order Sets revealed an order for [REDACTED].>Review of R#24's electronic Medication Administration Record [REDACTED]#216's e-MAR revealed that he received two doses of the aspirin daily from 5/1/19 through 5/7/19, and had received the first scheduled dose on 5/8/19. Review of R#22's e-MAR revealed that he received the aspirin once daily from 5/1/19 through 5/8/19. During interview with the Director of Nursing (DON) on 5/8/19 at 12:40 p.m., she stated that the nurses and Unit Managers were responsible for checking for expired medications on the medication carts. She stated during continued interview that whenever a multi-dose vial was opened, it should be labeled with the open date. The DON further stated that a vial of PPD was good for 30 days after it was opened. Review of the manufacturer's insert for [MEDICATION NAME] (PPD) revealed: Vials in use for more than 30 days should be discarded. Review of the facility policy Multi-Dose Vials-Patient Care (undated) revealed: All multi-dose vials are labeled with an expiration date of 28 days from the date the vial is first opened. Labeling with only the date opened is not acceptable. All multi-dose vials with the exception of insulin and reconstituted injectable medications should be discarded when empty, when suspected or visible contamination occurs, or when the manufacturer's stated expiration date is reached.

Based on observation, record review and staff interview, the facility failed to administer a subcutaneous (SQ) injection in a sanitary manner for one resident (R)(#163) by one of two nurses observed administering SQ injections to two residents in Facility A. In addition, the facility failed to dispose of a lancet after a fingerstick blood sugar (FSBS) for one resident (R#163) per facility policy and manufacturer's guidelines to prevent the potential for bloodborne illness. Three residents total were observed getting a FSBS (two residents in Facility A, and one resident in Facility B) performed by three different nurses. The sample size was 29 residents. Findings include: 1. On 5/8/19 at 9:52 a.m., Licensed Practical Nurse (LPN) EE was observed preparing a scheduled dose of [MEDICATION NAME] (a long-acting insulin) for R#163. LPN EE took the prepared syringe with a cap covering the needle to R#163's room, cleaned the resident's right upper arm with an alcohol swab, and removed the cap covering the needle. Further observation revealed that LPN EE dropped the uncapped syringe on the resident's bed sheets, and before the surveyor could intervene the nurse quickly picked up the syringe and gave the injection in the resident's arm. After leaving R#163's room on 5/8/19 at 10:01 a.m., LPN EE was unable to describe how she gave the injection and stated she did not remember dropping the syringe. She stated during further interview that if she had dropped a syringe, she should have disposed of it and prepared another dose with a new syringe. During interview with the Director of Nursing (DON) on 5/8/19 at 12:40 p.m., she stated that if a nurse dropped a syringe with an uncapped needle, that the nurse should discard the needle and syringe and prepare another dose. Review of inservice material Information Zone Training (YEAR) and 2019 provided by the Infection Control nurse on 5/9/19 at 4:51 p.m. revealed: Infection Prevention & Control - Bloodborne Pathogens Bloodborne pathogens are disease producing organisms that may be transmitted through blood or other body fluids. Bloodborne pathogens are spread in the workplace in the following ways: Sharps, cuts, splashes. Bloodborne pathogens are spread through injuries from contaminated sharps. You should handle sharps carefully. You should never bend, break or recap needles and dispose of used sharps promptly in a sharps container only. Waste Disposal: Place sharps in sharps container. Review of a listing of staff completing the facility's required annual training, that included the infection control education above, revealed that LPN EE completed the training on 10/15/18. 2. On 5/8/19 at 4:00 p.m. The Charge Nurse (EE) was observed performing a glucometer check for one resident R#163. The nurse was observed cleaning the glucometer with Sani-wipes times three - thoroughly wet the machine then placed it on a paper towel on top of the med cart to air dry - stated that she would leave it for three minutes. After the three minutes passed - the Charge Nurse sanitized her hands, gathered her supplies, knocked on resident's door and asked permission to enter - she then explained to the resident what she was going to do. The nurse provided privacy by pulling the privacy curtain - placed glucometer on paper towel and cup with lancet, alcohol wipes and cotton ball on the over-the-bed table - washed her hands, donned gloves and cleaned the resident's tip of the thumb on the left hand with alcohol - wiped with a cotton ball, got another drop of blood and placed on strip - results 289. The nurse then told the resident the results. Then observed the nurse as she picked up the glucometer in one hand and with the other she picked up the lancet and trash - pulled off her gloves and wrapped the lancet it one of the gloves, folded the other glove over the first glove and disposed both gloves in the resident's bathroom trash receptacle. When asked, the nurse verified that she threw the used lancet in the trash can - further stated that she didn't like to take the used lancet out of the room to the needle box on the cart which was in the hallway. On 5/8/19 at 4:35 p.m an interview was conducted with the DON who stated that she would expect the nurse to dispose of the used lancet either in the trash can or in the needle box since they are self-sheathing. Review of the facility form entitled 'Glucose Meter Visual Observation Form' revealed the 'operator' was Charge Nurse (EE) and that she was checked off 9/27/18 on scanning the patient identification (ID) into the glucometer; appropriate cleaning of site, used 2nd drop of blood; opened strip correctly; proper handling & cleaning of meter, results need to be traceable (docked) and further review of the form revealed that it was signed by a 'superuser.' Review of the facility's policy entitled 'Laboratory Services - Glucose Testing Point of Care' with approval date 10/16/17 revealed under Section VII. 'Patient Test Procedure - Arterial, Venous, Capillary or Neonate Blood' pages four and five - with steps A through V outlining the step by step procedure for obtaining the resident's blood for glucose testing with step S. 'Discard lancet in a biohazard sharps container.' Review of the insert which is included in the boxes of lancets (used by the nursing staff) entitled 'BD Microtainer - Contact-Activated Lancet' revealed under Universal Precautions: Handle all biologic samples and blood collection 'sharps' (lancets, needles, leur adapters, and blood collection sets) in accordance with the policies and procedures of your facility. Obtain appropriate medical attention in the event of any exposure to biologic samples (e.g. through a puncture injury) since samples may transmit [MEDICAL CONDITIONS](AIDS), or other infectious diseases. Utilize any built-in used needle protector if the blood collection device provides one. Discard all blood collection 'sharps' in biohazard containers approved for their disposal.

Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the dry storage area were securely wrapped, labeled and dated and failed to discard food items by expiration date in one building (A) of two facility buildings. In addition, the facility failed to maintain sanitary conditions of the Resident diet Kitchens on three of three units in one building (A) of two facility buildings. The sample size was 39. Findings include: 1. During initial tour observation on [DATE] from 11:17 a.m. to 11:30 a.m., revealed the following items located in the dry storage area without an open date or use by date on the products: one 80 ounce box of opened and unsealed grits; one 80 ounce box of opened and unsealed pancake batter; one 50 pound bag of sugar, one 50 pound bag of flour and one 50 pound bag of batter stored in plastic containers; one 28 ounce box of opened and unsealed cream of wheat; one 48 ounce bag of elbow pasta noodles; one five gallon bucket of pinto beans and one five gallon bucket of split peas. In addition, a 16 fluid ounce bottle of opened cooking wine/cherry with expiration date of ,[DATE] was in the dry storage area. Upon further investigation of the walk-in cooler revealed a clear square canister with cherries with red juice without a open date or use by date and a 16 fluid ounce opened bottle of lemon juice with expiration date of ,[DATE]. On [DATE] at 11:30 a.m., Dietary Manager (DM) verified the box of grits, box of pancake batter, box of cream of wheat and bag of elbow pasta noodles were all opened and unsealed without an open date or use by date on the packaging. She further verified a bucket of pinto beans, bucket of split peas, bagged sugar, bagged flour and bagged batter were all stored in plastic containers, but were without evidence of open date or use by date on either of the containers. Review of the policy titled Food Storage and Handling with a revised date [DATE], revealed it is the policy of the dining services department to cover, label, date and store all foods in a safe, appropriate manner. 2. On [DATE] at 9:20 a.m., during observation of Unit One resident pantry, revealed one 48 ounce bottle of Glucerna 1.2 cal Enteral feeding bottle in pantry cupboard with ,[DATE] expiration date. Also in the resident refrigerator was a plastic bag on second rack with moldy grapes inside bag and a opened 48 ounce bottle of cranberry juice without open or use by date. Interview on [DATE] at 9:20 a.m., with Unit Manager (UM) AA, verified the Enteral feeding was expired, and the bag of moldy grapes, and opened cranberry juice were all discarded. She stated that no one person is responsible for the refrigerator and food items, but that all the unit one staff are supposed to work together to keep it clean. 3. On [DATE] at 12:39 p.m., during observation of Unit two resident pantry, revealed the microwave oven had brown liquid matter on glass tray and on the bottom of the microwave. Also, dried brown particles were noted on the roof inside the microwave. Interview with Unit Manager (UM) CC on [DATE] at 12:39 p.m., verified the microwave was dirty. She stated that there is not a specific cleaning schedule, but all the staff work together to make sure the pantry is kept clean. 4. On [DATE] at 12:50 p.m. during observation of Unit three resident pantry, revealed no temperature recording for the day on either of the two mini refrigerators used for resident items. Mini refrigerator sitting on top of counter had three white plastic bags with food items in them without names or dates on them, one plastic bag with food items in it had a resident name, but no date on it. In the mini refrigerator under the counter, revealed the bottom shelf was dirty with light brown dried material on it, one 48 ounce bottle of opened cranberry juice without open or use by date. On the counter to the left of the sink, were three dirty breakfast bowls with food debris dried on inside of bowls, loose brown gritty substance resembling coffee grounds on shelf of cupboard over sink. Interview on [DATE] at 12:50 p.m., with UM BB verified the items in both mini refrigerators were not labeled and the refrigerators were not clean. She also verified the dirty dishes on the counter and the brown gritty material in the cupboard. She further stated it is everyone's responsibility to keep the pantry clean, and that staff know items need to be dated, by whoever puts the items in the refrigerators. She stated as the Unit Manager, she is ultimately responsible to make sure that the unit is kept clean and organized. Review of the facility policy titled Personal Food Storage with effective date of (MONTH) (YEAR), indicated that food prepared for immediate consumption must be labeled and dated for up to 48 hours. Food that is for immediate consumption, but not consumed immediately will be discarded after 48 hours.

Based on observation, record review, resident and staff interview, the facility failed to implement the care plans related to monitoring the ([MEDICAL TREATMENT]) shunt site daily for signs of infection for one resident (R) (R #196), and to provide oxygen as ordered for one resident (R #161). Both residents resided in Building A. The sample size was 39 residents. Findings include: 1. Review of R #196's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he received [MEDICAL TREATMENT]. Review of R #196's care plan for [MEDICAL CONDITION] with [MEDICAL TREATMENT] revealed that he returned from the hospital on [DATE] with a [MEDICAL TREATMENT] catheter to the right upper chest, that he was scheduled for [MEDICAL TREATMENT] related to [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]), and that he had a permanent [MEDICAL TREATMENT] catheter (AV (arteriovenous) fistula) placed on 2/8/18. Review of the interventions for this care plan revealed to monitor the shunt site for signs and symptoms of infection. Observation on 3/27/18 at 1:28 p.m. revealed that R #196 had a gauze dressing over his left upper arm, as well as a dressing partially covering a vas cath (a central venous catheter used for [MEDICAL TREATMENT]) on his right chest. During interview with R #196 at this time, he stated that the [MEDICAL TREATMENT] center used the site in his left upper arm for his [MEDICAL TREATMENT] three times a week. During interview with Licensed Practical Nurse (LPN) EE on 3/28/18 at 2:13 p.m., she stated that she did not know where R #196's [MEDICAL TREATMENT] was. During interview with LPN FF on 3/29/18 at 1:59 p.m., she stated that she was not aware that R #196 had an AV fistula in his left arm. During interview with LPN Unit Manager AA at this time, she stated that she could not find any documentation that staff was checking the [MEDICAL TREATMENT] when he returned from [MEDICAL TREATMENT]. During interview with LPN DD on 3/29/18 at 2:15 p.m., she stated that she was aware that R #196 had an AV fistula in his arm, but could not find any documentation that the nurses were checking the site. Cross-refer to F 698. 2. Review of the clinical record for R#161 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Review of the care plan initiated on 10/23/17 and revised on 3/12/18, revealed that resident has [DIAGNOSES REDACTED]. DO not increase flow without order. Observation on 3/26/18 at 3:44 p.m., 3/27/18 at 8:57 a.m. and 4:58 p.m., 3/28/18 at 8:48 a.m., 11:37 a.m. and 3:39 p.m.,and 3/29/18 at 8:39 a.m. revealed Oxygen concentrator set on five liters being delivered via Nasal Cannula (N/C). No date noted on the tubing for any of the observed dates. Interview on 3/29/18 at 4:55 p.m. with Licensed Practical Nurse (LPN) DD stated the resident's oxygen order is for 3 liters. She stated she checks the flow rate every day, but had not had a chance to check it today before Unit Manager (UM) told her it was not set on the correct flow rate. She stated weekend night shift nurses change the tubing every week, and she is not sure if they label the tubing with the date change. Interview on 3/29/18 at 5:30 p.m., with Director of Nursing (DON) stated that her expectations are for care plans to be followed. If changes in are needed on the care plans, then the nurses are supposed to write the changes immediately, so it is not forgotten. Cross Refer 695

Based on observation, clinical record review, facility Entity Reported Incident review, facility Follow-Up/Final Report review, resident interview, and staff interview, the facility failed to timely implement monitoring to ensure adequate supervision in response to a resident-to-resident altercation involving one (1) male resident (#1), who was alleged by female Resident "A" to have touched her, from a total survey sample of eleven (11) residents. After an allegation made by female Resident "A" that male Resident #1 had fondled her breast, touched her crotch, and ripped her blouse on 07/24/2014, the facility instructed staff to prevent Resident #1 from being alone privately with Resident "A", but failed to ensure monitoring of the whereabouts of Resident #1. Resident #1 was then observed by staff on 07/26/2014 touching the breast of female Resident #2 while in a darkened dining room. Facility staff was then instructed to ensure Resident #1 was not left alone with any female resident, and routine monitoring of the whereabouts of Resident #1 was initiated on 07/28/2014. This resulted in harm for female Resident #2, in that during the facility's investigation of the 07/26/2014 incident involving her and male Resident #1, Resident #2 stated to facility staff that during the incident, she had been "afraid" to ask Resident #1 to stop touching her. Findings include: Review of facility Entity Reported Incident Intake Number GA 966 revealed a Facility Report Fax Form (FRFF) dated 07/25/2014 which documented that on 07/24/2014, staff responded to the room of female Resident "A" after hearing cries for help. This FRFF documented Resident "A" alleged that Resident #1 (a male resident) was trying to touch her breast and was trying to "rape" her. This FRFF also documented that buttons were observed off the blouse of Resident "A", with no other clothing removed or disturbed. Record review for Resident "A", the female resident referenced in the above 07/25/2014 FRFF, revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of June 2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident "A" had a Brief Interview for Mental Status (BIMS) Summary Score of 12, indicating moderate cognitive impairment. Section G - Functional Status of this MDS documented that Resident "A" had been independent for ambulation, but had utilized a cane/crutch and a wheelchair as mobility devices during the look-back period. Resident "A"'s Care Plan documented additional [DIAGNOSES REDACTED]. Record review for Resident #1, the male resident referenced in the above 07/25/2014 FRFF, revealed an Annual MDS assessment having an Assessment Reference Date of 07/15/2014 which documented in Section C - Cognitive Patterns that the resident had a short-term memory problem and was moderately impaired in cognitive skills for daily decision making; this Section also documented the BIMS interview had not been conducted for Resident #1 due to the resident rarely/never understanding. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #1 utilized a wheelchair as a mobility device. During an observation of Resident #1 conducted on 09/11/2014 at 11:45 a.m., Resident #1 was ambulating himself via wheelchair down the Unit 1 hallway, thus revealing the resident to be self-ambulatory. Record review for Resident "A" revealed a Nurse's Notes (NN) entry dated 07/24/2014 timed at 6:35 p.m. which documented that while certified nursing assistants (CNAs) were picking up dinner trays, they heard Resident "A" yelling for help. This NN documented that upon opening the door to Resident "A"'s room, CNA staff observed Resident "A" sitting face-to-face with a male resident (Resident #1), and at that time, Resident "A" began yelling "Help, get him out, he's raping me". This NN documented that a CNA notified the nurse, and the male resident was escorted from Resident "A"'s room back to his room on another Unit. The NN documented that Resident "A" stated to the nurse that the male resident had ripped her shirt, and upon assessment, buttons were noted missing from her shirt. Resident "A" stated that the male resident had come to see her and was trying to touch her breast when the buttons were ripped off the shirt. Resident "A" stated that she told the male resident to stop, but he would not stop, and that was when she called for help. This NN further documented Resident "A" stated that she did not want the male resident in her room any more, and was told to press the call light and to notify staff if the male resident came back to her room. A subsequent NN entry of 07/24/2014 timed at 7:00 p.m. for Resident "A" documented that the resident was again questioned about her allegation involving Resident #1 referenced in the 07/24/2014, 6:35 p.m. NN as above. This subsequent NN documented that during this interview, Resident "A" again told the nurse that the male resident had grabbed her breast and had torn her shirt, also stating that the male resident had grabbed her crotch. During an interview with Resident "A" conducted on 08/12/2014 at 1:45 p.m. as part of this abbreviated survey, Resident "A" stated that she and Resident #1, whom she identified by name, had been good friends, but further stated that during the 07/24/2014 incident referenced above, Resident #1 had grabbed her blouse and torn off the buttons, causing her to yell. A facility Follow Up/Final Report (FU/FR) of 08/01/2014, submitted by the facility's Administrator as a follow-up report to the FRFF of 07/25/2014 referenced above, documented the facility's investigation and response to the 07/24/2014 alleged incident involving Resident "A" and Resident #1 during which Resident #1 was alleged to have touched Resident "A"s breast, torn the buttons off her shirt, and touched her crotch. This FU/FR documented that facility investigation had confirmed, via documentation from nursing staff and CNA staff, the details of the 07/24/2014 incident. This FU/FR documented that facility staff were not aware of prior incidents involving Resident #1 having touched female residents inappropriately or having acted out inappropriately. The Resolution portion of this FU/FR documented that it had been discussed with staff to monitor the location of Resident #1, paying special attention to him being in any area privately with Resident "A". In addition, Resident "A" was asked to use the call light or call out if Resident #1 returned to her room. However, review of Resident #1's clinical record revealed no evidence to indicate that facility staff conducted any additional monitoring of Resident #1, or of the location of Resident #1, on 07/24/2014 or 07/25/2014. This was despite the 08/01/2014 FU/FR referenced above indicating that staff had been instructed to monitor the location of Resident #1 in response to the resident-to-resident altercation referenced in Resident "A"'s 07/24/2014, 6:35 p.m. NN, as above, which documented Resident "A"'s allegations that Resident #1 had attempted to touch her breasts and had ripped her shirt. This was also despite Resident "A" to have alleged, as per the NN entry of 07/24/2014 at 7:00 p.m. referenced above, that during this incident, Resident #1 had also grabbed her crotch. During an interview with the DON conducted on 08/13/2014 at 10:45 a.m., the DON stated that prior to the 07/24/2014 incident involving Resident #1 and Resident "A", no staff had reported observing any observations of inappropriate touching by Resident #1. The DON acknowledged that after the 07/24/2014 incident involving Resident "A" and Resident #1, the facility did not put monitoring of Resident #1's behavior in place, stating that the facility concluded the incident involved an issue just between Resident "A" and Resident #1 that would not have an effect on other residents. The DON stated that after the incident of 07/24/2014, staff had been instructed to monitor Resident #1's location in regard to Resident "A", but not with any other female residents. The DON acknowledged there had been no documentation of staff monitoring related to Resident #1 after the 07/24/2014 incident involving Resident "A". Review of facility Entity Reported Incident Intake Number GA 004 revealed that the facility reported a second incident involving Resident #1, that being a resident-to-resident altercation of 07/26/2014 involving Resident #1 and female Resident #2. This facility Reported Incident Intake documented that Resident #1 was observed with his hand inside Resident #2's blouse. Record review for Resident #2, the female resident referenced in the Entity Reported Incident Intake above, revealed a Quarterly MDS assessment having an Assessment Reference Date of 05/15/2014 which documented in Section C - Cognitive Patterns that the female resident had both short-term and long-term memory problems and was severely impaired in cognitive skills for daily decision-making. Section C - Cognitive Patterns also documented that the BIMS interview was not conducted due to Resident #2 rarely or never having the capacity to understand. Section I - Active [DIAGNOSES REDACTED].#2 had [DIAGNOSES REDACTED]. A Nurse's Notes (NN) entry 07/26/2014, timed at 7:50 p.m., for Resident #2 documented that at approximately 9:15 a.m. on that date, a CNA brought Resident #2 out of the dining room after seeing a male resident (Resident #1) with his hands down her shirt. Continued review of this NN revealed that the two residents were separated by the CNA, who contacted her supervisor immediately. The NN documented the supervisor then contacted the facility's security service, along with the family member of Resident #2, who contacted the police. Record review for Resident #1 revealed a NN of 07/26/2014, timed at 7:30 p.m. which documented the resident-to-resident altercation referenced in Resident #2's 07/26/2014, 7:50 p.m. NN above. Resident #1's NN documented that a CNA, noting that the dining room light went out, stopped and looked through a window into the dining room to observe Resident #1's hand down Resident #2's shirt, fondling her. This NN documented the supervisor was notified, and also documented that the Nurse Practitioner, when contacted, ordered Zantac 150 milligrams, twice daily. The NN further documented that Resident #1 was told he was to eat in his room and could go outside only if no female residents were present outside or in the dining room. A FU/FR dated 08/04/2014, related to the 07/26/2014 incident involving Resident #1 and Resident #2 and submitted to the State Agency related to Entity Reported Incident Intake Number GA 004 referenced above, documented that on 07/26/2014 at around 9:30 a.m., a CNA was passing the Unit III Dining Room when she noticed the light in the Dining Room turned off. The CNA entered the room to find Resident #2 and Resident #1 face-to-face in their wheelchairs, with the hand of male resident Resident #1 inside the blouse of female Resident #2. This FU/FR documented the CNA immediately separated the two residents and contacted the Licensed Practical Nurse (LPN) supervisor, who spoke with Resident #2. This FU/FR further documented that during the LPN's interview with Resident #2, Resident #2 confirmed that Resident #1 had touched her. The FU/FR documented that when the LPN asked Resident #2 where Resident #1 had touched her, Resident #2 stated that Resident #1 had touched her breasts, and also pointed to the area between the legs. The LPN then specifically asked Resident #2 if Resident #1 had touched her between the legs, and Resident #2 responded "Yes". The LPN contacted the facility's Administrator, who instructed the LPN to contact the facility's Security Department. A facility Security Guard responded and counseled Resident #1 regarding the resident's behavior. A written statement of 07/31/2014, obtained as part of the facility's investigation into the resident-to-resident altercation involving Resident #1 and Resident #2 referenced in the 08/04/2014 FU/FR as above, documented an interview with Resident #2 and the facility's Social Worker. This written statement by the Social Worker documented that she had spoken with Resident #2 about the incident involving the male resident (Resident #1) which had occurred the past weekend (on 07/26/2014). The Social Worker documented that when Resident #2 was asked if, during the incident, she had asked the male resident to stop, Resident #2 replied, "I didn't...I didn't...I was afraid to." The Social Worker further documented that when Resident #2 was asked if she was afraid of the man involved in the incident, Resident #2 replied "yeah." The Investigation section of the 08/04/2014 FU/FR for the 07/26/2014 incident between Resident #1 and Resident #2 documented this was the second incident involving Resident #1 being inappropriate with a female resident, specifically referencing the first incident of 07/24/2014 involving Resident #1 and Resident "A". The Resolution section of this FU/FR documented the following actions had been taken to help prevent reoccurrence: the Administrator explained to Resident #1 that a similar occurrence could result in legal repercussions; staff received in-service training to instruct them that Resident #1 could not be left alone with any female residents; Resident #1 was moved to a room on a different hall so that he was farther away from Resident #2; and staff were documenting Resident #1's behavior on a daily basis. Further record review for Resident #1 revealed that the 07/26/2014, 7:30 p.m. NN referenced above, which documented Resident #1 having been instructed to go outside or to the dining room only if no female residents were present, revealed the nurse documented that Resident #1 had done well in complying on the date of 07/26/2014. Further record review for Resident #1 revealed no evidence of any additional staff monitoring of the whereabouts of Resident #1 for the remainder of 07/26/2014 (after the 07/26/2014, 7:30 p.m. NN referenced above) or 07/27/2014, related to staffs' instruction to ensure Resident #1 was not left alone with female residents. Review of Resident #1's July 2014 Routine Medications (RM) sheet revealed an entry specifying that staff monitor Resident #1 for inappropriate behaviors each shift, and documented that on the 7:00 a.m. - 7:00 p.m. shift of 07/28/2014, facility nursing staff initiated the per-shift monitoring of Resident #1's behavior. This represented a two-day delay in the initiation of routine monitoring of Resident #1's behavior after the 07/26/2014 incident involving Resident #1 being observed fondling Resident #2 in the dining room, resulting in staff being instructed to ensure Resident #1 was not left alone with female residents. During an interview with the DON conducted on 08/12/2014 at 2:30 p.m., the DON acknowledged that staff per-shift monitoring of Resident #1 was not initiated until 07/28/2014. During a post-survey Quality Assurance telephone interview with the Administrator and DON conducted on 10/03/2014 at 2:20 p.m., the Administrator stated that after the incident of 07/26/2014 involving Resident #1 and Resident #2, the CNA who observed the incident notified the Charge Nurse, who then notified the RN manager and the Administrator. The DON stated the Charge Nurse conducted an in-service for all staff present, including CNA and licensed nursing staff, environmental services staff, and dietary staff, instructing them that Resident #1 could not be alone with female residents. The DON stated that the incident was documented in the 24 Hour Report so that nursing staff of later shifts would be aware of the need to prevent Resident #1 from being alone with female residents. When asked how staff were instructed to monitor Resident #1 to ensure that he was not left alone with female residents, the DON said that all staff were instructed to monitor Resident #1 on a constant basis, but acknowledged there was no specific frequency for monitoring to occur. The Administrator acknowledged there was no specific document or process by which staff members were to show evidence of the specified monitoring of Resident #1. Based on the above, female Resident "A" alleged that on 07/24/2014, male Resident #1 grabbed her breast, tore her shirt, and grabbed her crotch. Facility staff were instructed on 07/24/2014 to monitor the location of Resident #1 to prevent his being in any private area with Resident "A". However, there was no evidence to indicate that staff monitored the whereabouts of Resident #1 on 07/24/2014 and 07/25/2014 to ensure that Resident #1 was not alone in a private area with Resident "A". Then, on 07/26/2014, staff observed Resident #1 with his hand inside the blouse of female Resident #2 fondling her while in a dining room with the light turned off. Resident #2 told staff that Resident #1 had touched her breasts and alleged he had also touched her between the legs. Resident #2 also told staff during interview that she had been afraid to ask Resident #1 to stop during the incident. This resulted in harm for Resident #2. After the resident-to-resident altercation of 07/26/2014, staff were instructed to ensure Resident #1 was not left alone with any female residents, but no frequency of monitoring was specified. There was no evidence to indicate that staff monitored the whereabouts of Resident #1 on 07/27/2014. Per-shift monitoring of Resident #1 was not initiated until 07/28/2014.

Based on staff interview, clinical record review, Resident Information Sheet review, Routine Medications Sheet review, and review of the facility's Allegation of Correction, the facility failed to ensure that resident care was provided in accordance with the Care Plan regarding staff supervision of five (5) residents (who resided in Building "B") who had been assessed and care planned as being at risk for wandering/elopement (#24, #65, #134, #204, and "D"), and for one (1) resident (#180) in Building "A", related to the administration of blood pressure medication in accordance with the Care Plan, on the total survey sample of forty-nine (49) residents. This failure of staff to provide supervision in accordance with the Care Plans of Residents #24, #65, #134, and #204, who all wandered and were at risk of elopement, placed these residents at an increased risk of elopement from the facility. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on August 28, 2013 at 5:15 p.m. The situation with the unsafe and unsecured service hallway exit causing the Immediate Jeopardy was identified to have existed as of March 02, 2013, and was removed on August 30, 2013. The Administrator acknowledged the need for securing this hazardous area, acknowledged having prior knowledge of this area, and acknowledged that there was no evidence of effective corrective action to address the situation. The facility had thus failed develop and implement timely corrective actions to ensure the required supervision and safety of residents at risk for elopement, thus placing Residents #24, #65, #134, #204 and "D" at risk for elopement. An Allegation of Correction to Ensure Safety of Wandering Residents was received on August 29, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 30, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility continued to in-service staff on monitoring wandering residents, verified the accuracy of resident care plans of those residents, and ensured that appropriate actions were in place to monitor residents with wandering behaviors. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents with exit-seeking behaviors. In addition, the facility put measures in place to ensure that interior and exterior exit doors at the service hallway exit were modified to prevent wandering residents from exiting the facility. Observations were conducted to assess both the placement and the function of these modifications. Findings include: 1. Record review for Resident "D", a resident of Building "B", revealed an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 09/09/2012 which documented the resident's 08/28/2012 admission to the facility. A Wandering Screen of 10/15/2012 documented that the resident was ambulatory, used a wheelchair, and had indications of dementia. A 03/02/2013, 06:26 p.m. Nurse's Notes entry documented that Resident "D" was found sitting outside in a wheelchair at the loading dock. During an interview with Licensed Practical Nurse (LPN) "GG" and Registered Nurse (RN) "EE" conducted on 08/28/2013 at 2:02 p.m., these staff members acknowledged the 03/02/2013 incident involving Resident "D" during which the resident had exited through an unsecured exit service hallway onto the loading dock. These staff members also acknowledged that Resident "D" had worn a WanderGuard bracelet. Review of the Resident Care Plan for Resident "D" revealed an entry dated 03/07/2013 which documented that Resident "D" had made attempts to exit the facility, and referenced a goal that the resident would not wander out of the building unattended. An Intervention on the Resident Care Plan specified for staff to check placement of the resident's WanderGuard every shift. During an interview conducted on 08/30/2013 at 4:00 p.m., MDS Coordinator RN "EE" stated that WanderGuard shift-checks specified by resident Care Plans were to be documented on the Resident Information Sheet (RIS). She stated that Certified Nursing Assistants (CNAs) reviewed the RIS determine the care to provide to their assigned residents, and CNAs were to initial this RIS to indicate that resident WanderGuard checks had been completed. However, review of Resident "D"'s RIS for the month of May 2013 revealed no staff initials or any evidence indicating that WanderGuard checks had been completed, as specified by the Care Plan, on seven (7) occasions (May 2, 3, 13, 17, 25, 27 and 31, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on seven (7) occasions (May 5, 9, 11, 20, 25, 26 and 29, 2013 ) for the 3:00 p.m. to 11:00 p.m. shifts; and on eight (8) occasions (May 3, 5, 6, 11, 12, 21, 24 and 26, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of June 2013, there were no staff initials on the RIS or any evidence indicating that WanderGuard checks had been completed for Resident "D", as specified by the Care Plan, on two (2) occasions (June 9 and 23, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on six (6) occasions (June 9, 15, 16, 17, 21 and 28, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on five (5) occasions (June 3, 5, 17, 18 and 28, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of July 2013, there were no staff initials on the RIS or any evidence indicating that WanderGuard checks had been completed for Resident "D", as specified by the Care Plan, on four (4) occasions (July 5, 7, 16 and 22, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on five (5) occasions (July 2, 8, 17, 22 and 24, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on six (6) occasions (July 4, 5, 8, 17, 24 and 29, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. During an interview conducted on 08/30/2013 at 3:30 p.m., the Director of Nursing (DON) acknowledged that there was no evidence to indicate that WanderGuard checks had been conducted every shift, as specified by the Care Plan. Based on the above, the facility failed to ensure that staff monitored Resident "D", in accordance with the Care Plan Intervention specifying every-shift monitoring, to ensure adequate supervision to address the resident's risk for elopement, even though the resident had a history of [REDACTED]. Cross refer to F323, example 1, for more information regarding Resident "D". 2. Record review for Resident #24, a resident of Building "B", revealed an Annual MDS assessment with an Assessment Reference Date of 06/13/2013 which documented in Section E - Behavior that the resident had exhibited wandering behavior. Further clinical record review revealed a 06/20/2013 Care Plan entry which documented that Resident #24 was at risk for elopement, and referenced the resident's use of a WanderGuard bracelet for this risk of elopement. As an Intervention, the Care Plan specified for staff to check placement of the resident's Wanderguard device every shift. However, review of Resident #24's RIS for the month of May 2013 revealed no staff initials or any evidence indicating that WanderGuard checks had been completed, as specified by the Care Plan, on seven (7) occasions (May 2, 3, 13, 17, 25, 27 and 31, 2013) for the 7:00 a.m. to 3:00 p.m. shifts.; on seven (7) occasions (May 5, 9, 11, 20, 25, 26 and 29, 2013) for the 3:00 p.m. to 11:00 p.m. shifts: and, on seven (7) occasions (May 5, 6, 11, 12, 21, 24 and 26, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of June 2013, there was no evidence on the RIS to indicate that WanderGuard checks had been completed, as specified by the Care Plan, for Resident #24 on two (2) occasions (June 9 and 23, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on four (4) occasions (June 9, 17, 21 and 28, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on five (5) occasions (June 3, 5, 17, 18 and 28, 2013) for the 11:00 p.m. to 7:00 a.m. shifts For the month of July 2013, there was no evidence on the RIS to indicate that WanderGuard checks had been completed, as specified by the Care Plan, for Resident #24 on three (3) occasions (July 6, 7 and 26, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on three (3) occasions (July 2, 8, and 24, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on four (4) occasions (July 4, 5, 8 and 24, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. . For the month of August 2013, there was no evidence on the RIS to indicate that WanderGuard checks had been completed, as specified by the Care Plan, for Resident #24 on four (4) occasions (August 1, 19, 21 and 23, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on three (3) occasions (August 16, 21 and 22, 2013) on the 3:00 p.m. to 11:00 p.m. shifts, and on two (2) occasions (August 21 and 29, 2013) on the 11:00 p.m. to 7:00 a.m. shifts. During an interview conducted on 08/30/2013 at 3:30 p.m., the Director of Nursing (DON) acknowledged that there was no evidence to indicate that WanderGuard checks had been conducted every shift, as specified by the resident's Care Plan. Based on the above, the facility failed to adequately supervise Resident #24 by failing to conduct per-shift checks of the resident's WanderGuard device, as specified by the resident's Care Plan. Cross refer to F323, example 4, for more information regarding Resident #24. 3. Record review for Resident #204, a resident of Building "B", revealed an Annual MDS assessment with an Assessment Reference Date of 06/10/2013 which documented in Section E - Behavior that the resident wandered daily. Further record review revealed a Care Plan entry dated 06/18/2013 for Resident #204 which documented attempts to exit the facility, with an Intervention documenting that the resident utilized a WanderGuard device. This Care Plan Intervention also specified that staff check placement of the WanderGuard every shift. As indicated in the 8/30/2013, 4:00 p.m. interview with RN Coordinator "EE" referenced above, these per-shift WanderGuard checks were to be documented by staff on the resident's RIS However, review of the May 2013 RIS for Resident #204 revealed no evidence to indicate that the WanderGuard checks had been completed, as specified by the Care Plan, on six (6) occasions (May 17, 25, 26, 29, 30 and 31, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on five (5) occasions (May 2, 10, 14, 20 and 24, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on four (4) occasions (May 2, 10, 14 and 16, 2013) on the 11:00 p.m. to 7:00 a.m. shifts. For the month of June 2013, the RIS for Resident #204 revealed no evidence to indicate that the WanderGuard checks had been completed, as specified by the resident's Care Plan, on four (4) occasions (June 1, 2, 6 and 18, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on two (2) occasions (June 6 and 13, 2013) on the 3:00 p.m. to 11:00 p.m. shifts; and on two (2) occasions (June 6 and 21, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of July 2013, the RIS for Resident #204 revealed no evidence to indicate that WanderGuard checks had been completed, as specified by the resident's Care Plan, on six (6) occasions (July 1, 2, 5, 7, 29 and 30, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on two (2) occasions (July 19 and 31, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on two (2) occasions (July 5 and 18, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of August 2013, the RIS for Resident #204 revealed no evidence to indicate that WanderGuard checks had been completed, as specified by the resident's Care Plan, on three (3) occasions (August 12, 13, and 19, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on five (5) occasions (August 2, 4, 12, 14 and 25, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. During an interview conducted on 08/30/2013 at 3:30 p.m., the DON acknowledged the lack of evidence to indicate that the WanderGuard checks were conducted every shift as specified by the resident's Care Plan. Based on the above, the facility failed to ensure adequate supervision for Resident #204, who was at risk for elopement, by failing to conduct the per-shift checks of the resident's WanderGuard device, as specified by the Care Plan. Cross refer to F323, example 5, for more information regarding Resident #204. 4. Record review for Resident #65, a resident of Building "B", revealed a Quarterly MDS assessment with an Assessment Reference Date of 06/21/2013 which documented in Section E - Behavior that the resident exhibited wandering behavior on a daily basis. Further record review revealed that Resident #65's current Care Plan documented, with an entry originally dated 04/12/2013, that the resident had attempted to exit the building, and documented that the resident utilized a WanderGuard device as an Intervention to address the risk for elopement. An additional Intervention on the Care Plan specified that staff check placement of the WanderGuard every shift. As indicated in the 8/30/2013, 4:00 p.m. interview with RN Coordinator "EE" referenced above, these per-shift WanderGuard checks were to be documented by staff on the resident's RIS However, review of the July 2013 RIS for Resident #65 revealed no evidence to indicate that WanderGuard checks had been completed, as specified by the Care Plan, on ten (10) occasions (July 2, 5, 7, 12, 13, 14, 15, 16, 23 and 28, 2013) for the 7:00 a.m. to 3 :00 p.m. shifts; on three (3) occasions (July 1, 10 and 24, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on ten (10) occasions (July 4, 5, 6, 11, 17, 18, 19, 20, 21 and 24, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. For the month of August 2013, there was no evidence on the RIS of Resident #65 that the WanderGuard checks had been completed, as specified by the Care Plan, on four (4) occasions (August 2, 10, 18 and 26, 2013) for the 7:00 a.m. to 3:00 p.m. shifts; on three (3) occasions (August 14, 25 and 28, 2013) for the 3:00 p.m. to 11:00 p.m. shifts; and on seven (7) occasions (August 3, 4, 12, 14, 20, 22 and 27, 2013) for the 11:00 p.m. to 7:00 a.m. shifts. Based on the above, the facility failed to adequately supervise Resident #65, who was at risk for elopement, by failing to conduct per-shift checks of the resident's WanderGuard device, as specified by the resident's Care Plan. Cross refer to F323, example 6, for more information regarding Resident #65. 5. Record review for Resident #134, a resident of Building "B", revealed a Quarterly MDS assessment with an Assessment Reference Date of 07/26/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section E - Behavior of this MDS documented that the resident had exhibited wandering behavior daily. Further record review revealed that a Care Plan to address the resident's known behavior of wanting to leave the building was developed originally on 11/18/2011, and had been reviewed by the facility as recently as 08/18/2013. An Intervention on the Care Plan to address the resident's wandering/elopement risk identified the resident's use of a WanderGuard device, and specified that staff were to make sure the resident had the Wanderguard applied each day. However, review of Resident #134's RIS, used to document WanderGuard checks, revealed that the resident's WanderGuard usage was not included on this RIS, and further revealed no evidence to indicate that the daily WanderGuard checks had been done by staff, as specified by the resident's Care Plan. During an interview conducted on 8/30/13 at 3:30 p.m., RN MDS Coordinator "EE" acknowledged that there was no evidence to indicate that the resident's Wanderguard device had been checked as specified by the Care Plan. Based on the above, the facility failed to adequately supervise Resident #134, who was at risk for elopement, by failing to conduct the specified daily checks of the WanderGuard, as specified by the resident's Care Plan. Cross refer to F323, example 10, for more information regarding Resident #134. 6. Record review for Resident #180, a resident of Building "A", revealed a Care Plan entry which identified that the resident had a potential for unstable blood pressure (BP) related to hypertension, [MEDICAL CONDITIONS], and a history of a [MEDICAL CONDITION] infarction with a coronary artery bypass graft. Interventions to address this resident's risk for unstable blood pressure included to give medications as ordered and to monitor the effect of the medications on the resident's blood pressure. Review of the current physician's orders [REDACTED]. The resident was also ordered to received the medication Carvedilol 3.125 mg twice a day, and to hold the medication for a SBP less than 110 or a pulse of less than 60. However, review of Resident #180's July 2013 Routine Medications sheet revealed, and interview with Unit Manager "BB" on 08/29/2013 at 12:29 p.m. acknowledged, that the resident's [MEDICATION NAME] was not held as ordered on [DATE] when the SBP was 106, and that the Carvedilol was not held as ordered on [DATE] at 9:00 a.m. when the SBP was 108/73. Additionally, review of Resident #180's August 2013 Routine Medications sheet revealed, and interview with Unit Manager "BB" on 08/29/2013 at 12:40 p.m. acknowledged, that staff did not hold the Carvedilol on 08/06/2013 at 5:00 p.m. when the resident's pulse was 55; did not hold the Carvedilol on 08/12/2013 at 5:00 p.m. when the pulse was 59; did not hold the Carvedilol on 08/21/2013 at 9:00 a.m. when the SBP was 108; and did not hold the Carvedilol on 08/22/2013 at 9:00 a.m. when the SBP was 97. On the occasions referenced above, Resident #180 was administered doses of [MEDICATION NAME] and Carvedilol in error and in conflict with parameters established by the physician's orders [REDACTED]. This was despite the Care Plan Intervention, as referenced above, which specified that Resident #180 was to receive medications as ordered by the physician. Cross refer to F309, example 2, for more information regarding Resident #180. Based on the above, related to resident elopement-prevention, the facility failed to provide the required WanderGuard monitoring, as specified by the Care Plans of Resident #s 24, 65, 134, 204 and "D". All of these residents had been assessed as having wandering behaviors, were documented as exhibiting wandering/elopement behaviors, were at risk of elopement, and had Care Plan Interventions specifying that the WanderGuard devices utilized to assist in elopement-prevention be monitored. Facility staff failed to monitor these WanderGuard devices as specified. This failure had caused, or had the likelihood to cause, serious harm, injury or death to these residents. The Immediate Jeopardy was determined to be removed on 08/30/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/28/2013, improvements were made to the glass sliding doors. The glass sliding doors on the service hall were repaired by Plant Operations so that they would no longer automatically open. In addition, the electric eye was disabled on the sliding glass doors by Plant Operations. The sliding glass doors now require a staff proximity badge to enter or exit the facility. B. On 08/29/2013, improvements were made to the metal double doors leading to the service entrance. A service technician from the door service company adjusted the length of time the doors remain open, once activated. Additionally, a sensor was added to the doors that sounded loudly if anyone with a wander alert bracelet entered these double doors. C. On 08/29/2013, the procedure by which staff monitored residents at risk for elopement was modified and implemented to allow for the monitoring of the facility's WanderGuard system. This procedure included the monitoring of both WanderGuard-protected doors and WanderGuard devices, via a door monitoring book and a WanderGuard device monitoring form. Monitoring is accomplished as follows: - An assigned CNA on each unit checked each resident who utilizes a WanderGuard device on each shift to ensure the presence and correct function of the device. This check was accomplished utilizing an electronic checking device. The CNA then initialed the WanderGuard Device monitoring form to document each resident checked. This WanderGuard device checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance (QA) Committee to determine the frequency of ongoing monitoring. - Once weekly, the Unit Secretary of each unit checks each door having a WanderGuard alarm to ensure that the alarm is functioning properly. This check is accomplished utilizing an electronic checking device. The Unit Secretary then initials the door monitoring book to document the check. This WanderGuard door alarm checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance Committee to determine the frequency of ongoing monitoring. - The Director of Nursing (or in her absence, the Unit Manager for each unit on the 7:00 a.m.-3:00 p.m. shift, and the Unit Supervisor for the 3:00 p.m.-11:00 p.m. and the 11:00 p.m.-7:00 a.m. shifts) will monitor the process referenced above of documenting WanderGuard device checks and WanderGuard door alarm checks. D. On 08/29/2013, staff in-service education was conducted related to the facility's complete procedure for monitoring wandering residents, which included the following: - Staff was instructed on the procedure by which WanderGuard devices and WanderGuard-protected doors are checked for proper function. - Staff was instructed on the computer system utilized to track and monitor WanderGuard bracelets. Staff was informed that the computer on Unit 1 had a blueprint of the facility which indicated the locations all monitored doors, with each door being numbered and the legend also being on the fire panel door. - Staff was instructed on the exact method by which the computer monitors resident WanderGuard devices, and was also trained on how to reset the system when necessary. - Staff was informed that the list of residents utilizing WanderGuard devices is included on the Safety Device List, and is also included in the Activities of Daily Living books and in the Assignment Book. - Staff received a review of the facility's elopement procedures, related to both residents utilizing WanderGuard devices and those residents who do not utilize WanderGuard devices. - Staff was instructed on the method to monitor WanderGuard devices to ensure proper function, and on how to acquire a new WanderGuard device during non-business hours. Related to the staff in-service referenced above, as of 08/29/2013, eighty-five (85) of the total of 135 staff members assigned to Building A, and eighty-four (84) of the total of 129 staff members assigned to Building B, had been trained (representing all staff who worked on 08/28/2013 and 08/29/2013). The remaining staff members would receive inservice training upon their return to work, or remotely via telephone, and will be inserviced before allowing direct resident care. E. On 08/29/2013, the facility implemented a procedure for the ongoing evaluation of residents at risk for elopement which included the Patients At Risk (PAR) Committee. This Committee is to meet weekly, and their review is to include each resident who is at risk for elopement. This review is to assess the care provided to each resident who is at risk. This Committee and its function is monitored by the Director of Nursing, who is a PAR Committee member, and will report monitoring results to the QA Committee. F. On 08/29/2013, the facility had reviewed the Care Plans of all residents determined to be at risk for elopement. The Care Plans were reviewed and revised to reflect the necessary approaches needed to ensure proper care and supervision of these residents. The facility's Clinical Coordinator and Director of Nursing will audit each resident's Care Plan at the time of each Quarterly MDS review to ensure accuracy and to identify potential problems with the care planning process. G. On 08/29/2013, the facility implemented a procedure to ensure the ongoing involvement of the facility's QA Committee in the assessment and oversight of the facility's procedures related to the WanderGuard system and elopement-prevention. The procedure includes the following: - The Director of Nursing will present a Committee report which details the results of staffs' WanderGuard door alarm monitoring, via the door monitoring form, and resident WanderGuard Device monitoring, via the WanderGuard device monitoring form, to allow the QA committee to evaluate the effectiveness of monitoring. The frequency of staff monitoring will also be reviewed and will be revised as needed. - The Director of Nursing will present a Committee report which details the results of the facility's PAR Committee reviews, which includes a review of the care provided to residents at risk for elopement. - The Director of Nursing will report the results of the quarterly Care Plan process audits at each quarterly Quality Assurance (QA) Committee meeting. - The QA Committee will meet quarterly to accomplish these reviews, as outlined above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on August 30, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had conducted staff in-service training related to the facility's WanderGuard and elopement prevention system, with eighty-five (85) of 135 Building "A" staff and eighty-four (84) of 129 Building "B" staff having been trained as of 08/29/2013. However, fifty (50) Building "A" staff and forty-five (45) Building "B" staff were not working and not available for the in-service due to their work schedule or some type of leave, so these remaining staff members would need to be inserviced upon their return to work. Also, the Director of Nursing will be providing ongoing monitoring of staffs' WanderGuard door alarm monitoring via the door monitoring form, and WanderGuard Device monitoring via the WanderGuard device monitoring form, to ensure staff compliance with this monitoring process. However, this process had been implemented on 08/29/2013, one day prior to the 08/30/2013 exit date of the standard survey. Additionally, the Director of Nursing will also present the findings of staff WanderGuard device monitoring, door alarm monitoring, PAR Committee reviews, and Care Plan audits to the QA Committee quarterly to allow the QA Committee to evaluate, on an ongoing basis, the effectiveness and frequency of monitoring. However, as of the 08/30/2013 exit date of this standard survey, the QA Committee had not yet met to initiate the evaluation of the effectiveness of these new interventions and monitoring to ensure resident health and safety, related to elopement prevention. The QA Committee's next scheduled meeting is the first week of October 2013. Therefore, the non-compliance continues, but the scope and severity level was reduced to an "E" level.

Based on observation, staff interview, clinical record review, facility investigative Detailed Report review, facility Wandering list review, facility electronic mail correspondence document review, and review of the facility's Allegation of Correction, the facility failed to make timely corrective actions to secure an unsecured service hallway facility exit, thus resulting in an elopement risk for fourteen (14) sampled residents of Building "B" who had been identified as having wandering behavior (Resident #s 5, 21, 24, 65, 87, 88, 134, 193, 204, 209, 214, 220, 319, and "D"), on the total survey sample of forty-nine (49) residents. Resident #88, Resident #193, and Resident "D" had subsequently gained access to this unsecured hallway, and Resident "D" had actually eloped through the hallway onto the facility's loading dock in subfreezing weather. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on [DATE] at 5:15 p.m. The situation with the unsafe and unsecured service hallway area causing the Immediate Jeopardy was identified to have existed as of [DATE] (when Resident "D" eloped through this hallway) and was removed on [DATE]. The Administrator acknowledged the need for securing this hazardous area, acknowledged being aware of the need for corrective actions since the beginning of February 2013, but further acknowledged that there was no evidence of effective corrective actions to address the known problem as of this survey date. The facility's failure to develop and implement timely correction actions allowed Resident "D" to elope through this service hallway and gain access to the facility's loading dock area while the external environmental temperature was approximately 30 degrees Fahrenheit. Resident #88 and Resident #193, who both had wandering behaviors, had also gained access to this unsecured hallway and had approached the facility exit doors. An Allegation of Correction to Ensure Safety of Wandering Residents was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "E" while the facility continued to in-service staff on monitoring wandering residents, verified the accuracy of resident care plans of those residents, and ensured that appropriate actions were in place to monitor residents with wandering behaviors. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents with exit-seeking behaviors. In addition, the facility put measures in place to ensure interior and exterior exit doors at the service hallway were modified to prevent wandering residents from exiting the facility. Observations were conducted to assess both the placement and the function of these modifications. Findings include: 1. Record review for Resident "D", a resident of Building "B", revealed an Admission Minimum Data Set assessment with an Assessment Reference Date of [DATE] which documented the resident's [DATE] admission to the facility. This MDS documented in Section C-Cognitive Patterns a score of "00" for the resident's Brief Interview for Mental Status (BIMS) score, indicating severe cognitive impairment. This MDS also documented in Section E-Behavior that the resident experienced delusions, and documented a [DIAGNOSES REDACTED]. Section G-Functional Status of this MDS documented that the resident utilized a wheelchair for mobility. A Quarterly MDS with an Assessment Reference Date of [DATE] documented a BIMS score of "03" at that time, and documented in Section G-Functional Status that the resident continued to utilize a wheelchair for mobility. Wandering Screens of [DATE] and [DATE] for Resident "D" documented that the resident was ambulatory, used a wheelchair, and had indications of dementia. During an observation conducted on [DATE] at 12:35 p.m., Resident "D" was observed in the dining room waiting for lunch, and was observed to have a WanderGuard device in place on the left leg. Record review for Resident "D" revealed a Nurse's Notes entry of [DATE] at 06:26 p.m. which documented that the resident had been noted sitting outside in a wheelchair at the loading dock. A facility investigative Detailed Report which referenced Resident "D" documented an incident which occurred on [DATE] at 06:20 p.m. during which the resident had gone down a facility service hallway, had approached the glass doors at the end of the hallway, and had gone outside unattended. This Report documented that the loading dock doors did not have an alarm or scanning badge opener, and noted that the doors would open automatically when approached. This Report further documented that on the day when the resident went outside without staffs' knowledge, the environmental temperature was approximately 30 degrees Fahrenheit. Staff became aware of the resident's exit from the facility when the resident was knocking on the glass doors. A plant operations staff member heard the resident and let him/her back into the building. Review of Resident "D"'s review revealed a Nurse's Note dated [DATE] which also documented that Resident "D" had gotten outside of the building to the loading dock, and that the resident's family had been notified of this incident of elopement. Further record review for Resident "D" revealed a Nurse's Notes entry of [DATE] which documented that Resident "D" was noted to have increased agitation, and was again trying to get out of the building. This Nurse's Notes entry documented that the physician was notified and an order was obtained to increase the resident's dose of risperidone. During an interview with Licence Practical Nurse (LPN) "GG" and Registered Nurse (RN) "EE" conducted on [DATE] at 2:02 p.m., these staff members acknowledged the incident of elopement involving Resident "D" referenced above, which had occurred on the 3:00 p.m. - 11:00 p.m. shift around dinner time. These staff members stated that after dinner, Resident "D" had exited the building out to the loading dock. Kitchen staff had found the resident and let him/her back into the facility. These staff members stated that Resident "D" had worn a WanderGuard bracelet since admission, and stated that the resident had in the past tried to get to the loading dock a lot. These staff members further stated that the facility had moved to the current location, from a previous location, in October of 2012, and that since that time, attempts had been made to address a problem with the exit doors on the service hallway leading to the loading dock. During an interview with the Administrator conducted on [DATE] at 4:17 p.m., the Administrator referenced the facility's move to the current location from a previous location in October of 2012, and acknowledged an ongoing problem related to the exit doors to the service hallway exit not being secured. She stated that a badge reader had been installed two 2 weeks prior on the double glass sliding exit doors located at the exit end of the service hallway exit. She stated that the facility did utilize a WanderGuard alarm system on most exit doors throughout the facility, but further acknowledged that there was no WanderGuard sensor on the service hallway exit doors (either on the automatic double metal doors which allowed entrance to the service hallway, or on the double glass sliding exit doors which exited from the hallway directly onto the loading dock) to prevent wandering residents from exiting through the hallway. During an observation conducted on [DATE] at 12:05 p.m., the service hallway exit through which Resident "D" had exited the facility on [DATE] was observed. This service hallway, which exited the building, opened off of another internal facility corridor through two automatic double metal doors. This hallway was located adjacent to the dining room/kitchen area and the activities area, and lead to the exterior of the building through two automatic glass sliding exit doors. This service hallway was out of the direct line-of-sight view of a nurse's station or any area where staff provided direct resident care. The staff time clocks were located in this area. Closed metal double doors at one end of this service hallway allowed entry into the service hallway by opening only via electronic badge. When opened via electronic badge, these automatic metal access doors remained open, with a delay of approximately ten (10) to fifteen (15) seconds before closing, and no alarm was noted on these metal doors. At the opposite end of the service hallway, approximately ninety-five feet away from the metal doors, were unalarmed automatic double glass sliding doors which, upon approach, opened automatically to the exterior of the building onto the facility's loading dock. These double glass sliding exit doors were observed to be equipped with a badge reader, however, the doors were observed to open when approached without the use of an electronic badge. The loading dock, upon which the glass doors exited, extended out approximately eighteen (18) feet from the glass double doors to the edge of the dock, where there was a four-foot drop to the cement pavement below. There were no safety rails located on the loading dock between the double glass exit doors and the edge of the loading dock. During an observation conducted later in the afternoon of [DATE] at 3:30 p.m., a sign, which was posted on the wall inside of the service hallway and adjacent to the automatic double metal doors (which allowed entry into the hallway), instructed staff not to place carts past that certain point. During an interview conducted at the time of this observation, the Administrator stated that this sign had been posted in response to the fact that if an object such as a cart was placed in close proximity to these automatic double metal doors, the electronic sensor on the doors would be inactivated and these doors, once opened, would remain open. During an interview conducted [DATE] at 5:15 p.m., the facility's Long Term Care (LTC) Director acknowledged a problem with this service hallway exit. The LTC Director further stated, as had the Administrator in the [DATE], 4:17 p.m. interview above, that an electronic badge reader had been added to the automatic double glass sliding doors which exited to the facility's loading dock approximately two weeks prior to this survey. However, the LTC Director further clarified that this badge reader had not actually been activated, and thus the glass sliding exit doors would still open automatically when approached, even without a badge. In addition to the information above which was provided during administrative staff interviews, the facility provided copies of the following electronic mail correspondence documents which were related to the noted problem with these service hallway exit doors. Review of these electronic mail correspondence documents revealed that they had been generated by facility administrative staff since Resident "D"'s [DATE] elopement and were addressed to other facility administrative/corporate staff, and revealed the following: - Electronic mail correspondence dated [DATE] (two days after Resident "D"'s elopement from the facility, as referenced above) documented an issue of the risk of resident elopement and injury from the service hallway, also noting that the door closure took too long. - Electronic mail correspondence dated [DATE] had a notation in the Subject area indicating that the correspondence was related to "Back door safety issues". The correspondence further documented a continuing problem with the doors to the facility's loading dock, and that residents were getting through the doors into the hallway and out the back door onto the loading dock. - Electronic mail correspondence dated [DATE] had a notation in the Subject area indicating that the correspondence was related to the facility "loading dock door". This correspondence further documented that the electric eye that caused the door to open automatically was a danger to some persistent residents who were able to get into the hallway. An electronic response, also dated [DATE], to this correspondence noted a recommendation that a badge reader be placed on the sliding glass door leading to the loading dock area, and noted that a badge reader was currently installed to gain access to the service hallway (via the double metal doors) but further noted that residents were able to get into this area due to the time delay with body guard. - Electronic mail correspondence dated [DATE] documented a continuing issue with the service hall not being locked. This correspondence further noted that residents continued to get through the doors, and that someone could go off the loading dock if this problem was not resolved. - Electronic mail correspondence dated [DATE] documented that the facility was continuing to have problems with the door system, in that the doors often did not lock and did not alarm, allowing residents to get through the doors. - Electronic mail correspondence dated [DATE] referenced the service hall exit, and indicated that residents continued to attempt to get out of the facility. However, despite Resident "D"'s elopement from the facility through the service hallway exit doors on [DATE], despite facility staffs' acknowledgement of awareness that an ongoing problem had existed with the exit doors in this service hall, and despite electronic correspondence between administrative staff noting the problem of the exit doors being unsecured and representing a risk to residents during March, April, May, June and July of 2013, there was no evidence of corrective action having been taken to address the problem until two weeks prior to this standard survey of [DATE]-30, 2013. That action involved the placing of an electronic badge reader on the double sliding glass doors located at the exit end of the service hallway which lead to the loading dock. However, this electronic badge reader had not been activated as of initiation of this standard survey, and thus the automatic glass doors would open automatically without an electronic badge when approached. In addition, the automatic double metal doors which allowed entrance into this service hallway via electronic badge, once opened, still had a delay of ten (10) to fifteen (15) seconds before closing, and would remain open if an object were located in close proximity to the doors. Additionally, neither set of exit doors were alarmed. This situation represented the potential for residents with wandering/elopement behaviors to gain access to the unsecured service hallway exit corridor, through the unsecured double metal doors, and then to exit through the unsecured glass doors onto the facility's loading dock, as Resident "D" had done on [DATE]. In addition, subsequent to the [DATE] elopement of Resident "D" referenced above, the facility revised the Resident Care Plan of Resident "D", identifying the resident's attempts to exit the facility, and specifying as an Intervention for staff to check the placement of the resident's Wanderguard every shift. During an interview conducted on [DATE] at 4:00 p.m., Minimum Data Set (MDS) Coordinator RN "EE" stated that when a resident's Care Plan indicated the Wanderguard be checked every shift, the WanderGuard was listed on the Resident Information Sheet (RIS). This was the information the Certified Nursing Assistants (CNAs) used to provide care to their assigned residents. The CNAs were to initial this RIS to indicate all resident care had been completed, including WanderGuard checks. However, review of Resident "D"'s RIS for the months of May, June, and July of 2013 revealed no staff initials or any evidence indicating that care, including WanderGuard checks, had been completed for this resident on the following months, dates and shifts: For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 13, 17, 25, 27 and 31, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 11, 20, 25, 26 and 29, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 6, 11, 12, 21, 24 and 26, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE] and 23, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 16, 17, 21 and 28, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 17, 18 and 28, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 16 and 22, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 17, 22 and 24, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 8, 17, 24 and 29, 2013. During an interview conducted on [DATE] at 3:30 p.m., the Director of Nursing (DON) stated she could could not confirm that WanderGuard checks had been conducted every shift if no documentation was included in the areas on RIS sheet. During an observation of Resident "D" conducted on [DATE] at 4:35 p.m. Resident "D" was observed seated in the hallway next a door, asking "How are you going to get out?" In addition to Resident "D" referenced above, the following residents who resided in Building "B" had also been identified by the facility to have wandering behavior, as indicated on a Wander's list provided by the facility, and were at risk of elopement (One of these residents, #319, was deceased and thus was not listed on the current Wander's list): 2. Record review for Resident #193 revealed Quarterly MDS assessments with assessment reference dates of [DATE] and [DATE] which documented BIMS scores of 06 and 03, respectively, in Section C - Cognitive Patterns, indicating severe cognitive impairment. Both of these MDS assessments documented in Section E - Behavior that the resident had experienced wandering behavior daily, and documented in Section G - Functional Status that the resident required no physical help/setup help only, from staff for locomotion, utilizing a walker as a mobility device. The [DATE] MDS assessment documented in Section I - Active [DIAGNOSES REDACTED]. During the [DATE], 4:17 p.m. interview with the Administrator referenced above, the Administrator revealed an incident during which Resident #193 had gotten through the internal doors and into the service hallway exit which lead to the loading dock exit doors. The Administrator stated that the resident had approached the double glass doors but had not exited the building during this incident. Additional record review for Resident #193 revealed a physician's progress notes entry of [DATE] which documented that the resident continued to push on the facility's outside doors, trying to find a way out. However, based on the above, the facility failed to ensure a safe environment for Resident #193, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. 3. Record review for Resident #88 revealed MDS Quarterly Assessments with Assessment Reference Dates of [DATE] and [DATE] which both documented in Section G-Functional Status that the resident needed no physical help from staff for locomotion, and that the resident utilized a wheelchair as a mobility device. Both MDS Quarterly assessments documented in Section I-Active [DIAGNOSES REDACTED]. Additionally, the [DATE] Quarterly MDS documented in Section C - Cognitive Patterns that the resident's BIMS score was 05, and the [DATE] MDS documented a BIMS score of 03, indicating severe cognitive impairment. Wandering Screens for Resident #88 completed on [DATE] and [DATE] each documented the resident utilized a wander alert device to the right leg/ankle. During the [DATE], 4:17 p.m. interview with the Administrator referenced above, she revealed that there had been an incident during which Resident #88 had also gotten through the internal doors and into the service hallway exit which lead to the loading dock exit doors. The resident had approached the double glass doors, but had not actually exited the building. However, based on the above, the facility failed to ensure a safe environment for Resident #88, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. 4. Record review for Resident #24 revealed an Annual MDS assessment with an Assessment Reference Date of [DATE] which documented in Section C - Cognitive Patterns a BIMS score of 06, indicating severe cognitive impairment. Section E - Behavior of this MDS assessment documented that the resident had exhibited wandering behavior, and documented in Section G - Functional Status that the resident utilized a wheelchair as a mobility device. Additionally, Wandering Screens had been completed on [DATE] and [DATE] which also documented the resident's history of wandering, and documented indications of dementia. During an interview with RN "EE" conducted on [DATE] at 4:00 p.m., this nurse stated that Resident #24 used of a WanderGuard bracelet for wandering behavior. Further clinical record review for Resident #24 revealed a [DATE] Care Plan entry which documented that the resident was at risk for exiting the building, having made attempts to exit the facility, and also referenced the use of a WanderGuard bracelet. An Intervention to address this elopement risk specified for staff to check placement of the Wanderguard every shift. However, review of Resident #24's RIS for the months of May, June, July, and August of 2013 revealed no staff initials or any evidence indicating that care, including WanderGuard checks, had been completed for this resident on the following months, dates and shifts: For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 13, 17, 25 and 27 and 31, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 11, 20, 25, 26 and 29, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 11, 12, 21, 24 and 26, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE] and 23, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 21 and 28, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 17, 18 and 28, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE] and 26, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], and 24, 2013. - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 8 and 24, 2013. For [DATE] - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 21 and 23, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE] and 22, 2013; -11:00 p.m. to 7:00 a.m. shifts on [DATE] and 29, 2013. During an interview conducted on [DATE] at 3:30 p.m., the Director of Nursing (DON) stated she could could not confirm that WanderGuard checks had been conducted every shift if no documentation was included in the areas on RIS sheet. Based on the above, the facility failed to ensure a safe environment for Resident #24, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. The facility also failed to adequately supervise Resident #24 by failing to conduct the specified per-shift checks of the resident's WanderGuard device. 5. Record review for Resident #204 revealed an Annual MDS assessment with an Assessment Reference Date of [DATE] which documented in Section C - Cognitive Patterns that the resident could not participate in the BIMS test, but that the resident had both short-term and long-term memory problems. Section E - Behavior of this MDS documented that the resident wandered daily, and Section G - Functional Status documented that the resident utilized a wheelchair as a mobility device. Observation of Resident #204 on [DATE] at 5:30 p.m. revealed the resident up in a Broda Chair with a WanderGuard applied to the right leg. During an interview with RN "EE" conducted on [DATE] at 4:00 p.m., this nurse acknowledged that Resident #204 utilized a WanderGuard bracelet. Further record review revealed a current Care Plan entry for Resident #204 which documented that the resident had made attempts to exit the facility, and specified as an Intervention for staff to check placement of the resident's WanderGuard device every shift. As indicated in the [DATE], 4:00 p.m. interview with RN Coordinator "EE" referenced above, these per-shift WanderGuard checks were to be documented by staff on the resident's RIS However, review of the May, June, July, and [DATE] RIS for Resident #204 revealed no initials or other evidence to indicate that the WanderGuard checks had been completed for the following months, dates and shifts: For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 26, 29, 30 and 31, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE], 14, 20 and 24, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 14 and 16, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 6 and 18, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE] and 13, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE] and 21, 2013. For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts on [DATE], 5, 7, 29 and 30, 2013; - 3:00 p.m. to 11:00 p.m. shifts on [DATE] and 31, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE] and 18, 2013. For [DATE]: - 3:00 p.m. to 11:00 p.m. shifts on [DATE], and 19, 2013; - 11:00 p.m. to 7:00 a.m. shifts on [DATE], 12, 14 and 25, 2013. During an interview conducted on [DATE] at 3:30 p.m., the DON stated she could not confirm the WanderGuard checks were conducted every shift as specified if the areas on the RIS sheet were blank. Based on the above, the facility failed to ensure a safe environment for Resident #204, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. The facility also failed to adequately supervise Resident #204 by failing to conduct the specified per-shift checks of the resident's WanderGuard device. 6. Record review for Resident #65 revealed a Quarterly MDS assessment with an Assessment Reference Date of [DATE] which documented in Section C - Cognitive Patterns that the resident had a BIMS score of 99, indicating that the resident had not participated in the BIMS interview, but further documented that the resident had both short-term and long-term memory problems. Section E - Behavior of this MDS assessment documented that the resident exhibited wandering behavior on a daily basis, and Section G - Functional Status documented that the resident utilized a wheelchair as a mobility device. During an observation of Resident #65 conducted on [DATE] at 3:00 p.m., the resident was observed to have a WanderGuard device applied to the right leg. Further record review revealed that Resident #65's current Care Plan documented that the resident had attempted to exit the building in the past, and an Intervention to address the resident's risk of elopement specified that staff check the placement of the resident's WanderGuard device every shift. As indicated in the [DATE], 4:00 p.m. interview with RN Coordinator "EE" referenced above, these per-shift WanderGuard checks were to be documented by staff on the resident's RIS However, review of the July and [DATE] RIS for Resident #65 revealed no initials or other evidence to indicate that the WanderGuard checks had been completed for the following months, dates and shifts: For [DATE]: - 7:00 a.m. to 3 :00 p.m. shifts of [DATE], 7, 12, 13, 14, 15, 16, 23 and 28, 2013; - 3:00 p.m. to 11:00 p.m. shifts of [DATE] and 24, 2013; - 11:00 p.m. to 7:00 a.m. shifts of [DATE], 6, 11, 17, 18, 19, 20, 21 and 24, 2013; For [DATE]: - 7:00 a.m. to 3:00 p.m. shifts of [DATE], 18 and 26, 2013; - 3:00 p.m. to 11:00 p.m. shifts of [DATE] and 28, 2013; - 11:00 p.m. to 7:00 a.m. shifts of [DATE], 12, 14, 20, 22 and 27, 2013. Based on the above, the facility failed to ensure a safe environment for Resident #65, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. The facility also failed to adequately supervise Resident #65 by failing to conduct the specified per-shift checks of the resident's WanderGuard device. 7. Record review for Resident #214 revealed a Quarterly MDS assessment with an Assessment Reference Date of [DATE] which documented in Section C - Cognitive Patterns that the resident had a BIMS score of 01, indicating severe cognitive impairment. Section E - Behavior of this MDS assessment documented that the resident wandered daily, and Section G - Functional Status documented that the resident was independent for locomotion. A WanderGuard Screen had documented that the resident wore a WanderGuard bracelet on the left leg. Further record review for Resident #214 revealed a Care Plan entry, most recently reviewed on [DATE], which documented that the resident had made attempts to exit the building in the past. However, based on the above, the facility failed to ensure a safe environment for Resident #214, who exhibited wandering/elopement behavior and was at risk for elopement, by failing to make timely, effective corrective actions to address the known risk of the unsecured service hallway exit. 8. Record review for Resident #319, who had resided in Building "B", revealed an Admission MDS assessment with an Assessment Reference Date of [DATE] which documented an admission date of [DATE]. Section C - Cognitive Patterns of this MDS documented that the resident had a BIMS score of 04, which indicated severe cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an Assessment Reference Date of [DATE] documented in Section E - Behaviors that the resident had wandered daily, with a subsequent MDS of [DATE] documenting that the resident had deceased . Review of a Psychiatric Medication Evaluation dated [DATE] revealed that the resident's memory was significantly impaired, with no safety awareness, and that the resident was very confused and forgetful. Review of Interdisciplinary Care Plan notes dated [DATE] noted that facility staff met with family of Resident #319 to discuss a plan to help keep the resident safe, and noted that he/she wandered constantly and wore a WanderGuard device. Additionally, review of Resident #319's Fall Risk Care Plan revealed that the resident had a history of [REDACTED]. Review of Skilled Nurse's Notes for Resident #319 revealed an entry of [DATE], for 3:00 p.m.-11:00 p.m., which documented that the resident propelled self without difficulty, and frequent attempted to go out of doors. During an interview with the Director of Nurses conducted on [DATE] at 3:01 p.m., she acknowledged Resident #319 had attempted exit from the facility via an exit door. During an interview with MDS Nurse "GG" conducted on [DATE] at 3:22 p.m., she stated that she recalled that another resident's family member had let Resident #319 out of

Based on observation, staff interview, clinical record review, Wandering Screen review, and review of the facility's Allegation of Correction, the facility failed to develop comprehensive Care Plans which addressed the wandering behavior/elopement-potential of six (6) sampled residents who had been identified as having wandering behavior/elopement-potential (Resident #s 21, 24, 87, 88, 204, and 319), on the total survey sample of forty-nine (49) residents. For these residents, the facility had thus failed to ensure that the Care Plan addressed the need for staff supervision which was necessary to prevent resident elopement and to ensure resident safety. Resident "D" had subsequently eloped by gaining access to an unsecured service hallway exit and had exited onto the facility's loading dock. Resident #319 had also exited the facility through an exit door. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on August 28, 2013 at 5:15 p.m. The situation involving this unsafe and unsecured service hallway area causing the Immediate Jeopardy was identified to have existed as of March 02, 2013 (when Resident "D" eloped through this hallway) and was removed on August 30, 2013. The Administrator acknowledged the need for securing this hazardous area, acknowledged being aware of the need for corrective actions since the beginning of February 2013, but further acknowledged that there was no evidence of effective corrective actions to address the known problem as of this standard survey date. The facility's failure to develop and implement timely correction actions allowed Resident "D" to elope through this service hallway and gain access to the facility's loading dock area while the external environmental temperature was approximately 30 degrees Fahrenheit. Resident #319 had also eloped. An Allegation of Correction to Ensure Safety of Wandering Residents was received on August 29, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 30, 2013. The facility remained out of compliance at a lower scope and severity of "E" while the facility continued to in-service staff on monitoring wandering residents, verified the accuracy of resident care plans of those residents, and ensured that appropriate actions were in place to monitor residents with wandering behaviors. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents with exit-seeking behaviors. In addition, the facility put measures in place to ensure the interior and exterior exit doors at the service hallway exit were modified to prevent wandering residents from exiting the facility. Observations were conducted to assess both the placement and the function of these modifications. Findings include: 1. Record review for Resident #88 revealed an Admission MDS assessment with an Assessment Reference Date of 11/11/2012 which documented the resident's 10/30/2012 admitted . Section I - Active [DIAGNOSES REDACTED]. A Wandering Screen for Resident #88 completed on 10/30/2012 documented that the resident utilized a wander alert device which was applied to the right ankle. Review Resident 88's initial comprehensive Care Plan, dated 11/11/2012, revealed a noted problem related to a diversional activity deficit that included an Intervention to check the resident's WanderGuard every shift. However, there was no evidence of any reference on this Care Plan to address the resident's exit-seeking behaviors or interventions to address these behaviors. During an 08/28/2013, 4:17 p.m. interview with the Administrator, she revealed an incident during which Resident #88 had gained access to the unsecured service hallway which exited to the facility's loading dock and had approached the double glass exit doors which opened onto the loading dock. Additionally, record review revealed a physician's progress notes entry of 04/01/2013 which documented that Resident #88 continued to push on the facility's outside doors. However, further record review revealed that, despite Resident #88's continued attempts to elope from the facility, there was no evidence to indicate that any reference to Resident #88's exit-seeing behaviors was added to the resident's comprehensive Care Plan until 08/28/2013 (during this standard survey). On 08/28/2013, a Care Plan Focus area was added indicating that the resident wandered without a purpose daily throughout the facility. A Goal indicated that the resident would not wander out of the building unattended, and multiple Interventions to address the elopement risk were identified. During an interview with Licensed Practical Nurse (LPN) "GG" conducted on 08/29/2013 at 11:10 a.m., this nurse acknowledged that a comprehensive Care Plan which addressed the wandering/elopement potential of Resident #88 had not been developed timely. Based on the above, the facility failed to develop a comprehensive Care Plan which referenced Resident #88's exit-seeing behaviors. Rather, a Care Plan which referenced the resident's elopement risk was developed approximately ten (10) months after the resident's admission to the facility. Cross refer to F323, example 3, for more information regarding Resident #88. 2. Record review for Resident #319, who had resided in Building "B", revealed an Admission MDS assessment with an Assessment Reference Date of 03/12/2013 which documented an admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an Assessment Reference Date of 06/07/2013 documented in Section E - Behaviors that the resident had wandered daily. Interdisciplinary Care Plan notes dated 05/07/13 documented that Resident #319 wandered and wore a WanderGuard device, and Resident #319's Fall Risk Care Plan documented a history of falls and also the use of a WanderGuard. Review of the comprehensive Care Plan for Resident #319 revealed Care Plan entries for the resident's fall-potential and cognitive loss, but there was no Care Plan entry which identified the history of wandering behavior or the resident's risk for elopement. During an interview with MDS Nurse "GG" conducted on 08/30/2013 at 3:22 p.m., this nurse stated that she did not develop a separate Care Plan entry for wandering or exit-seeking behaviors. She further stated that because there was an Intervention in the Care Plan related to Resident #319's fall-potential, and since this entry referenced the use of a WanderGuard, this would alert staff to the wandering behaviors. She further stated that she remembered another resident's family member had let Resident #319 out of an exit door on one occasion in the past, but acknowledged that she did not include the resident's elopement in the resident's Care Plan. Based on the above, the facility failed to develop a comprehensive Care Plan for Resident #319 which addressed the resident's known wandering behavior and history of elopement, thus failing to develop individualized Interventions to ensure the adequate monitoring and supervision of this resident. Cross refer to F323, example 8, for more information regarding Resident #319. 3. Record review for Resident #21 revealed an Admission MDS assessment with an Assessment Reference Date of 03/19/2013 which documented that the resident was admitted to the facility on [DATE]. Section I - Active [DIAGNOSES REDACTED]. Continued review of the MDS referenced above revealed that Section E - Behavior documented that the resident had not exhibited wandering behaviors. Additionally, a Wandering Screen completed on Resident #21's 03/07/2013 admission to the facility on [DATE] also indicated that the resident was assessed as not being at risk for wandering, and indicated that the resident did not need a wander device at that time. Review of Resident #21's comprehensive Care Plan developed 03/20/2013 revealed that this Care Plan made no reference to the resident having wandering behaviors. A second Wandering Screen completed for Resident #21 on 04/22/2013 (one month after the development of the Care Plan) did document that a wander device was needed and placed at that time However, further review of the initial comprehensive Care Plan for Resident #21 (which had been developed on 03/20/2013 in response to the resident's initial admission of 03/07/2013) revealed no evidence to indicate that any reference was added to the comprehensive Care Plan related to wandering behavior, even though a Wandering Screen completed only one month later, on 04/22/2013, identified that a wander device was necessary and had been placed. During an interview with MDS LPN "GG" conducted on 08/30/2013 at 3:40 p.m., this nurse stated that initially on admission on 03/07/2013, a wandering assessment had been completed for Resident #21 and that at that time, the resident did not need a WanderGuard device. However, Nurse "GG" further stated that she had subsequently been informed in April that a WanderGuard had been placed on the resident, but further acknowledged that the resident's comprehensive Care Plan had not been edited to reflect wandering behaviors. Further record review for Resident #21 revealed that on 08/29/2013 (during this standard survey), a Focus area was added to the resident's Comprehensive Care Plan which indicated that the resident wandered without a purpose daily throughout the facility, and identified multiple Interventions to address this wandering behavior. Based on the above, the facility failed to develop a Comprehensive Care Plan for Resident #21 which addressed the resident's wandering behavior and use of a WanderGuard device, even though the need for this device due to wandering had been identified soon after the resident's facility admission. Cross refer to F323, example 11, for more information regarding Resident #21. 4. Record review for Resident #87 revealed an Admission MDS assessment with an Assessment Reference Date of 10/20/2012 which documented an admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED]. Additionally, Quarterly MDS assessments with Assessment Reference Dates of 01/17/2013 and 04/15/2013 documented, in Section E - Behavior, that the resident continued to wander daily. During an observations of Resident #87 conducted on 08/29/2013 at 10:45 a.m. and at 4:00 p.m., the resident was observed with a WanderGuard device present on the right leg. Additionally, review of the Code Purple Book utilized for WanderGuard device monitoring revealed documentation that the resident had been wearing a WanderGuard and that the device had been checked regularly to ensure the device was functioning properly. However, a review conducted on 08/29/2013 (during this standard survey) of Resident #87's comprehensive Care Plan revealed no evidence that the Care Plan referenced a problem related to the resident's wandering and elopement-potential, or to reflect any Interventions to address this risk. During an interview RN "EE", MDS Coordinator, on 08/29/2013 at 11:30 a.m., this nurse acknowledged that she could not locate a Care Plan for wandering for Resident #87. Further record review revealed that on 08/29/2013, after inquiry about the resident's Care Plan, a comprehensive Care Plan intervention was developed which reflected Resident #87's wandering and elopement-potential, with multiple Interventions identified and listed. However, further review of this Care Plan revealed that one of the Interventions for wandering instructed staff to monitor the resident's location with visual checks frequently throughout the day and night if necessary. This Care Plan Intervention failed to identify any measurable metric describing the exact frequency by which staff were to monitor the resident, or when this monitoring would, or would not, be necessary. Based on the above, the facility failed to develop a Comprehensive Care Plan, complete with measurable specific Interventions, for Resident #87 which addressed the resident's wandering behavior and use of a WanderGuard device. Cross refer to F323, example 14, for more information regarding Resident #87. 5. Record review for Resident #24, a resident in Building "B", revealed an Annual MDS assessment with an Assessment Reference Date of 06/13/2013 which documented in Section E - Behavior that the resident had exhibited wandering behavior. Additionally, a Wandering Screen completed on 04/03/2013 had also documented the resident's history of wandering, and documented indications of dementia. The 06/20/2013 comprehensive Care Plan entry documented that Resident #24 was at risk for exiting the building, and that attempts had been made to exit the facility. An Intervention to address this risk was to place a WanderGuard bracelet on the resident, and an additional Intervention specified that staff monitor the resident's location with visual checks frequently throughout the day and night. However, there was no measurable metric on the Care Plan, related to this Intervention specifying staff monitoring, as to how often the resident would be monitored. During an interview conducted on 08/30/2013 at 4:00 p.m., RN MDS Coordinator "EE" acknowledged that this Intervention related to resident monitoring was not individualized for the resident. Based on the above, even though the comprehensive Care Plan of Resident #24 identified the resident's risk for exiting the building and eloping, and noted the need for monitoring, the facility failed to develop a measurable Intervention to be utilized by staff to accomplish the necessary monitoring to address the resident's wandering/elopement potential. Cross refer to F323, example 4, for more information regarding Resident #24. 6. Record review for Resident #204, a resident in Building "B", revealed an Annual MDS assessment with an Assessment Reference Date of 06/10/2013 which documented in Section C - Cognitive Patterns that the resident had both short-term and long-term memory problems. Section E - Behavior of this MDS documented that the resident wandered daily. A Wandering Screen performed 03/27/2013 indicated Resident #204 had dementia and a history of wandering in the past 6 months, and documented that a WanderGuard device was used on the resident's Broda Chair. Review of the comprehensive Care Plan dated 06/18/2013 for Resident #204 revealed a Focus area indicating that the resident was at risk for exiting the building, and that attempts had been made to exit the facility. Interventions were developed to address this elopement-risk, with one Intervention being to monitor the resident's location with visual checks frequently throughout the day and night if necessary. There was no indication on this comprehensive Care Plan of the specific, exact frequency that staff were to monitor the resident, or when monitoring would, and would not, be necessary. During an interview conducted on 08/30/2013 at 4:00 p.m., RN MDS Coordinator " EE " acknowledged that the interventions referenced above were not individualized for the resident. Based on the above, even though the comprehensive Care Plan identified the need for monitoring as necessary related to Resident #204's risk of elopement, the facility failed to develop measurable Care Plan Interventions which identified the exact frequency by which staff were to monitor, or when monitoring would be required, related to the resident's wandering/elopement potential. Cross refer to F323, example 5, for more information regarding Resident #204. Based on the above examples, the facility failed to ensure that comprehensive Care Plans were developed for Resident #s 21, 24, 87, 88, 204, and 319, who all exhibited wandering/elopement behaviors, to ensure the adequate staff monitoring and supervision of these residents. The Immediate Jeopardy was determined to be removed on 08/30/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/28/2013, improvements were made to the glass sliding doors. The glass sliding doors on the service hall were repaired by Plant Operations so that they would no longer automatically open. In addition, the electric eye was disabled on the sliding glass doors by Plant Operations. The sliding glass doors now require a staff proximity badge to enter or exit the facility. B. On 08/29/2013, improvements were made to the metal double doors leading to the service entrance. A service technician from the door service company adjusted the length of time the doors remain open, once activated. Additionally, a sensor was added to the doors that sounds loudly if anyone with a wander alert bracelet enters these double doors. C. On 08/29/2013, the procedure by which staff monitored residents at risk for elopement was modified and implemented to allow for the monitoring of the facility's WanderGuard system. This procedure included the monitoring of both WanderGuard-protected doors and WanderGuard devices, via a door monitoring book and a WanderGuard device monitoring form. Monitoring is accomplished as follows: - An assigned CNA on each unit checks each resident who utilizes a WanderGuard device on each shift to ensure the presence and correct function of the device. This check is accomplished utilizing an electronic checking device. The CNA then initials the WanderGuard Device monitoring form to document each resident checked. This WanderGuard device checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance (QA) Committee to determine the frequency of ongoing monitoring. - Once weekly, the Unit Secretary of each unit checks each door having a WanderGuard alarm to ensure that the alarm is functioning properly. This check is accomplished utilizing an electronic checking device. The Unit Secretary then initials the door monitoring book to document the check. This WanderGuard door alarm checking process will continue for four (4) weeks, and then will be evaluated by the facility's QA Committee to determine the frequency of ongoing monitoring. - The Director of Nursing (or in her absence, the Unit Manager for each unit on the 7:00 a.m.-3:00 p.m. shift, and the Unit Supervisor for the 3:00 p.m.-11:00 p.m. and the 11:00 p.m.-7:00 a.m. shifts) will monitor the process referenced above of documenting WanderGuard device checks and WanderGuard door alarm checks. D. On 08/29/2013, staff in-service education was conducted related to the facility's complete procedure for monitoring wandering residents, which included the following: - Staff was instructed on the procedure by which WanderGuard devices and WanderGuard-protected doors are checked for proper function. - Staff was instructed on the computer system utilized to track and monitor WanderGuard bracelets. Staff was informed that the computer on Unit 1 had a blueprint of the facility which indicated the locations of all monitored doors, with each door being numbered and the legend also being on the fire panel door. - Staff was instructed on the exact method by which the computer monitored resident WanderGuard devices, and was also trained on how to reset the system when necessary. - Staff was informed that the list of residents utilizing WanderGuard devices was included on the Safety Device List, and was also included in the Activities of Daily Living books and in the Assignment Book. - Staff received a review of the facility's elopement procedures, related to both residents utilizing WanderGuard devices and those residents who do not utilize WanderGuard devices. - Staff was instructed on the method to monitor WanderGuard devices to ensure proper function, and on how to acquire a new WanderGuard device during non-business hours. Related to the staff in-service referenced above, as of 08/29/2013, eighty-five (85) of the total of 135 staff members assigned to Building A, and eighty-four (84) of the total of 129 staff members assigned to Building B, had been trained (representing all staff who worked on 08/28/2013 and 08/29/2013). The remaining staff members would receive inservice training upon their return to work, or remotely via telephone, and will be inserviced before being allowed to provide direct resident care. E. On 08/29/2013, the facility implemented a procedure for the ongoing evaluation of residents at risk for elopement which included the Patients At Risk Committee. This Committee is to meet weekly, and their review is to include each resident who is at risk for elopement. This review is to assess the care provided to each resident who is at risk. This Committee and its function is monitored by the Director of Nursing, a member of the Committee. F. On 08/29/2013, the facility had reviewed the Care Plans of all residents determined to be at risk for elopement. The Care Plans were reviewed and revised to reflect the necessary approaches needed to ensure proper care and supervision of these residents. The facility's Clinical Coordinator and Director of Nursing will audit each resident's Care Plan at the time of each Quarterly MDS review to ensure accuracy and to identify potential problems with the care planning process. The Director of Nursing will then report to the facility's G. On 08/29/2013, the facility implemented a procedure to ensure the ongoing involvement of the facility's QA Committee in the assessment and oversight of the facility's procedures related to the WanderGuard system and elopement-prevention. The procedure includes the following: - The Director of Nursing will present a Committee report which details the results of staffs' WanderGuard door alarm monitoring, via the door monitoring form, and resident WanderGuard Device monitoring, via the WanderGuard device monitoring form, to allow the QA committee to evaluate the effectiveness of monitoring. The frequency of staff monitoring will also be reviewed and will be revised as needed. - The Director of Nursing will present a Committee report which details the results of the facility's Patients At Risk Committee reviews, which includes a review of the care provided to residents at risk for elopement. - The Director of Nursing will report the results of the quarterly Care Plan process audits at each quarterly QA Committee meeting. - The QA Committee will meet quarterly to accomplish these reviews, as outlined above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on August 30, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had conducted staff in-service training related to the facility's WanderGuard and elopement prevention system, with eighty-five (85) of 135 Building "A" staff and eighty-four (84) of 129 Building "B" staff having been trained as of 08/29/2013. However, fifty (50) Building "A" staff and forty-five (45) Building "B" staff were not working and not available for the in-service due to their work schedule or some type of leave, so these remaining staff members would need to be inserviced upon their return to work. Also, the Director of Nursing will be providing ongoing monitoring of staffs' WanderGuard door alarm monitoring via the door monitoring form, and WanderGuard Device monitoring via the WanderGuard device monitoring form, to ensure staff compliance with this monitoring process. The facility's Clinical Coordinator and Director of Nursing will be performing an audit of each resident's Care Plan at the time of each Quarterly MDS review to identify potential problems, and the Director of Nursing will provide ongoing updates to the QA Committee regarding the facility's care planning process. However, this process had been implemented on 08/29/2013, one day prior to the 08/30/2013 exit date of the standard survey. Additionally, the Director of Nursing will also be presenting the findings of staff WanderGuard device monitoring, door alarm monitoring, PAR Committee reviews, and Care Plan audits to the QA Committee quarterly to allow the QA Committee to evaluate, on an ongoing basis, the effectiveness and frequency of monitoring. However, as of the 08/30/2013 exit date of this standard survey, the QA Committee had not yet met to initiate the evaluation of the effectiveness of these new interventions and monitoring to ensure resident health and safety, related to elopement prevention. The QA Committee's next scheduled meeting is the first week of October 2013. Therefore, the non-compliance continues, but the scope and severity level was reduced to an "E" level.

Based on staff interview, facility electronic correspondence review, facility Wander's list review, and review of the facility's Allegation of Correction, the facility's governing body failed to ensure effective corrective action to address a problem, of which facility's administrative staff had made the governing body aware, involving unsecured service hallway exit doors in Building "B" which placed residents who had wandering behaviors at risk for elopement. In addition, the facility failed to ensure measures were in place to monitor residents with wandering behaviors. This failure affected Resident "D", who resided in Building "B" and who had eloped through the unsecured exit doors, and thirteen (13) additional residents who also resided in Building "B" and who also had wandering behaviors (# 5, # 21, # 24, # 65, # 87, # 88, # 134, # 193, # 204, # 209, # 214, # 220 and # 319), on the total survey sample of forty-nine (49) residents. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on August 28, 2013 at 5:15 p.m. The situation with the unsafe and unsecured service hallway area causing the Immediate Jeopardy was identified to have existed as of March 02, 2013, and was removed on August 30, 2013. The Administrator acknowledged the need for securing this hazardous area, and acknowledged being aware of the need for corrective actions to the unsecured exit doors of this service hallway exit since the elopement of Resident "D" on 03/02/2013, but further acknowledged that the unsecured hallway exit doors had not been modified to prevent resident exit and elopement. The facility's failure to develop and implement timely and effective correction actions to the situation involving the unsecured facility exit which had allowed Resident "D" to elope also allowed Resident #88 and Resident #193 to gain access to and enter this unsecured hallway exit. An Allegation of Correction to Ensure Safety of Wandering Residents was received on August 29, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 30, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility continued to in-service staff on monitoring wandering residents, verified the accuracy of resident care plans of those residents, and ensured that appropriate actions were in place to monitor residents with wandering behaviors. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents with exit-seeking behaviors. In addition, the facility made modifications to ensure that both the interior and exterior exit doors of the service hallway exit were secure to prevent wandering residents from exiting the facility. Observations were conducted to assess both the placement and the function of these modifications. Findings include: Cross refer to F323. On 08/30/2013 at 1:30 p.m., an interview was conducted with the Administrator of Building "B" and the facility's Long Term Care Director. During the interview, the Administrator stated that she had been aware of a problem with the unsecured interior service hall doors and the unsecured automatic sliding glass exit doors at the opposite since the exit hallway since the elopement of Resident "D" on 03/02/2013. She stated a Safety Alert Report had been sent to the facility's corporate entity on 03/04/2013 to alert the safety department and to determine what needed to be done to correct the issue with the doors. A copy of the Safety Alert Report was provided by the Administrator, and review of the Report indicated that the length of time before the doors closed was too long. The report also requested the sliding glass doors at the end of the hallway which exited to the loading dock be accessed by employee badge or keypad only. She stated that signs had been placed at the doors to alert staff to watch for residents, however, at the time of the survey, neither set of doors had been modified in a way that would prevent residents from getting past the doors. During a subsequent interview with the Administrator conducted on 08/28/2013 at 4:17 p.m., the Administrator again acknowledged an ongoing problem related to the exit doors to the service hallway exit. She stated that two weeks prior, a badge reader had been installed on the automatic glass sliding doors at the end of the service hallway which exited to the facility's loading dock, but that neither these doors nor the automatic double metal doors located at the opposite end of the hallway had a WanderGuard sensor to prevent wandering residents from exiting the facility through this hallway onto the loading dock. During a subsequent interview conducted 08/28/2013 at 5:15 p.m., the facility's Long Term Care (LTC) Director stated that the electronic badge reader which was added to the automatic double glass sliding doors which exited to the facility's loading dock approximately two weeks prior had not actually been activated. Copies of facility electronic mail correspondence, some of which was dated 04/15/2013, 04/29/2013, 05/23/2013, 05/28/2013, and 07/23/2013 were provided and were noted to be addressed to facility corporate representatives. This electronic correspondence referenced ongoing problems with these exit doors not locking and being unsecured, and referenced the risk of residents getting out of the exit doors. The electronic mail dated 04/15/2013 from the facility's Administrator to the governing body's Engineering Operations Manager (EOM) indicated a continuing problem with the back sliding doors to the loading dock, with residents getting through the hallway doors and out the back door onto the loading dock. An electronic mail response from the EOM, also dated 04/15/2013, indicated that the Security Systems Coordinator (SSC) was looking at a solution. The 04/29/2013 electronic mail dated 04/29/2013 from the Administrator to the SSC questioned the status of door parts for the repair of the doors, and documented continued problems keeping residents from exiting. The 05/23/2013 electronic mail from the SSC referenced obtaining a quote for modification of a video intercom, and a 05/28/2013 electronic mail from the SSC referenced a quote allowing relocation of a badge reader down the corridor to the loading dock door. Additionally, the electronic mail dated 07/23/2013 from the facility's LTC Director to the SSC documented that the door controls had still not been changed. The Administrator also provided a copy of Building "B"'s Wander's list which identified that Resident #s 5, 21, 24, 65, 87, 88, 134, 193, 204, 209, 214, 220, and 319, as well as Resident "D", had all been identified by the facility as having wandering/elopement behaviors. Based on the above, the facility's governing body had failed to provide a secure environment for Resident #s 5, 21, 24, 65, 87, 88, 134, 193, 204, 209, 214, 220, #319, and "D". All of these residents had been assessed as having wandering behaviors and were at risk of elopement. However, the facility's governing body had failed to ensure timely correction actions, and an effective resolution, to the known problem of residents' ability to exit through the unalarmed and unsecured service hall exit doors. This failure had caused, or had the likelihood to cause, serious harm, injury or death to these residents. The Immediate Jeopardy was determined to be removed on 08/30/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/28/2013, improvements were made to the glass sliding doors. The glass sliding doors on the service hall were repaired by Plant Operations so that they would no longer automatically open. In addition, the electric eye was disabled on the sliding glass doors by Plant Operations. The sliding glass doors now require a staff proximity badge to enter or exit the facility. B. On 08/29/2013, improvements were made to the metal double doors leading to the service entrance. A service technician from the door service company adjusted the length of time the doors remained open, once activated. Additionally, a sensor was added to the doors that sounds loudly if anyone with a wander alert bracelet entered these double doors. C. On 08/29/2013, the procedure by which staff monitored residents at risk for elopement was modified and implemented to allow for the monitoring of the facility's WanderGuard system. This procedure included the monitoring of both WanderGuard-protected doors and WanderGuard devices, via a door monitoring book and a WanderGuard device monitoring form. Monitoring was accomplished as follows: - An assigned CNA on each unit checks each resident who utilized a WanderGuard device on each shift to ensure the presence and correct function of the device. This check was accomplished utilizing an electronic checking device. The CNA then initials the WanderGuard Device monitoring form to document each resident checked. This WanderGuard device checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance Committee to determine the frequency of ongoing monitoring. - Once weekly, the Unit Secretary of each unit checks each door having a WanderGuard alarm to ensure that the alarm is functioning properly. This check is accomplished utilizing an electronic checking device. The Unit Secretary then initials the door monitoring book to document the check. This WanderGuard door alarm checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance Committee to determine the frequency of ongoing monitoring. - The Director of Nursing (or in her absence, the Unit Manager for each unit on the 7:00 a.m.-3:00 p.m. shift, and the Unit Supervisor for the 3:00 p.m.-11:00 p.m. and the 11:00 p.m.-7:00 a.m. shifts) will monitor the process referenced above of documenting WanderGuard device checks and WanderGuard door alarm checks. D. On 08/29/2013, staff in-service education was conducted related to the facility's complete procedure for monitoring wandering residents, which included the following: - Staff was instructed on the procedure by which WanderGuard devices and WanderGuard-protected doors are checked for proper function. - Staff was instructed on the computer system utilized to track and monitor WanderGuard bracelets. Staff was informed that the computer on Unit 1 had a blueprint of the facility which indicated the locations all monitored doors, with each door being numbered and the legend also being on the fire panel door. - Staff was instructed on the exact method by which the computer monitors resident WanderGuard devices, and was also trained on how to reset the system when necessary. - Staff was informed that the list of residents utilizing WanderGuard devices is included on the Safety Device List, and is also included in the Activities of Daily Living books and in the Assignment Book. - Staff received a review of the facility's elopement procedures, related to both residents utilizing WanderGuard devices and those residents who do not utilize WanderGuard devices. - Staff was instructed on the method to monitor WanderGuard devices to ensure proper function, and on how to acquire a new WanderGuard device during non-business hours. Related to the staff in-service referenced above, as of 08/29/2013, eighty-five (85) of the total of 135 staff members assigned to Building A, and eighty-four (84) of the total of 129 staff members assigned to Building B, had been trained (representing all staff who worked on 08/28/2013 and 08/29/2013). The remaining staff members would receive inservice training upon their return to work, or remotely via telephone, and will be inserviced before allowing direct resident care. E. On 08/29/2013, the facility implemented a procedure for the ongoing evaluation of residents at risk for elopement which included the Patients At Risk Committee. This Committee is to meet weekly, and their review is to include each resident who is at risk for elopement. This review is to assess the care provided to each resident who is at risk. This Committee, and its function is monitored by the Director of Nursing. F. On 08/29/2013, the facility had reviewed the Care Plans of all residents determined to be at risk for elopement. The Care Plans were reviewed and revised to reflect the necessary approaches needed to ensure proper care and supervision of these residents. The facility's Clinical Coordinator and Director of Nursing will audit each resident's Care Plan at the time of each Quarterly MDS review to ensure accuracy and to identify potential problems with the care planning process. G. On 08/29/2013, the facility implemented a procedure to ensure the ongoing involvement of the facility's QA Committee in the assessment and oversight of the facility's procedures related to the WanderGuard system and elopement-prevention. The procedure includes the following: - The Director of Nursing will present a Committee report which details the results of staffs' WanderGuard door alarm monitoring, via the door monitoring form, and resident WanderGuard Device monitoring, via the WanderGuard device monitoring form, to allow the QA committee to evaluate the effectiveness of monitoring. The frequency of staff monitoring will also be reviewed and will be revised as needed. - The Director of Nursing will present a Committee report which details the results of the facility's Patients At Risk Committee reviews, which includes a review of the care provided to residents at risk for elopement. - The Director of Nursing will report the results of the quarterly Care Plan process audits at each quarterly Quality Assurance (QA) Committee meeting. - The QA Committee will meet quarterly to accomplish these reviews, as outlined above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on August 30, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had conducted staff in-service training related to the facility's WanderGuard and elopement prevention system, with eighty-five (85) of 135 Building "A" staff and eighty-four (84) of 129 Building "B" staff having been trained as of 08/29/2013. However, fifty (50) Building "A" staff and forty-five (45) Building "B" staff were not working and not available for the in-service due to their work schedule or some type of leave, so these remaining staff members would need to be inserviced upon their return to work. Also, the Director of Nursing will be providing ongoing monitoring of staffs' WanderGuard door alarm monitoring via the door monitoring form, and WanderGuard Device monitoring via the WanderGuard device monitoring form, to ensure staff compliance with this monitoring process. However, this process had been implemented on 08/29/2013, one day prior to the 08/30/2013 exit date of the standard survey. Additionally, the Director of Nursing will also present the findings of staff WanderGuard device monitoring, door alarm monitoring, PAR Committee reviews, and Care Plan audits to the QA Committee quarterly to allow the QA Committee to evaluate, on an ongoing basis, the effectiveness and frequency of monitoring. However, as of the 08/30/2013 exit date of this standard survey the Committee had not yet met to initiate the evaluation of the effectiveness of these new interventions and monitoring to ensure resident health and safety, related to elopement prevention. The QA Committee's next scheduled meeting is the first week of October 2013. Therefore, the non-compliance continues, but the scope and severity level was reduced to an "E" level.

Based on staff interview, facility electronic mail correspondence review, and Quality Assessment and Assurance Quarterly Meeting information, the facility failed to ensure that the Quality Assessment and Assurance Committee (QA&A Committee) developed and implemented a corrective plan to correct an identified problem of unsecured service hallway exit doors in Building "B", of which the QA&A Committee had knowledge, which placed residents who had wandering behaviors at risk for elopement. This failure affected Resident "D", who resided in Building "B" and who eloped through these unsecured exit doors, and thirteen (13) additional residents having wandering behaviors (# 5, # 21, # 24, # 65, # 87, # 88, # 134, # 193, # 204, # 209, # 214, # 220 and # 319), all of whom also resided in Building "B", on the total survey sample of forty-nine (49) residents. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of Immediate Jeopardy on August 28, 2013 at 5:15 p.m. The situation involving the unsafe and unsecured service hallway area causing the Immediate Jeopardy was identified to have existed as of March 02, 2013, when Resident "D" had eloped, and was removed on August 30, 2013. The Administrator acknowledged the need for securing this hazardous area, and provided a copy of a facility QA&A Committee report which indicated the Committee's prior knowledge of this problem, but acknowledged the unsecured hallway exit doors had not been modified to prevent resident exit. The failure of the facility's QA&A Committee to develop and implement timely correction actions to correct these unsecured hallway exit doors had placed all wandering residents in Building "B" at risk of elopement. An Allegation of Correction to Ensure Safety of Wandering Residents was received on August 29, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 30, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility continued to in-service staff on monitoring wandering residents, verified the accuracy of resident care plans of those residents, and ensured that appropriate actions were in place to monitor residents with wandering behaviors. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents with exit-seeking behaviors. In addition, the facility made modifications to ensure that both sets of exit doors (interior and exterior) of the service hallway exit were secure to prevent wandering residents from exiting the facility. Observations were conducted to assess both the placement and the function of these modifications. Findings include: Cross refer to F323. An interview was conducted on 08/30/2013 at 1:30 p.m. with the Administrator of Building "B" and the facility's Long Term Care Director. During the interview, the Administrator stated that she had been aware of a problem with the interior automatic metal service hall double doors and the automatic sliding glass exit doors of the service hallway exit since the elopement of Resident "D". An unrequested copy of the facility's QA&A Committee's Quarterly Meeting minutes was provided to the survey team. These minutes referenced January, February and March 2013 facility data. Review of these minutes revealed a notation indicating discussion by the Committee regarding the exit doors at service entrance areas. A notation indicated that the facility's administrator was working on the problem. The Administrator provided copies of electronic mail correspondence for the months of April, May, June, July, and August of 2013, addressed both to and from facility administrative staff and corporate representatives, which referenced a problem with these exit doors related to the doors being unsecured. However, during a subsequent interview with the Administrator conducted on 08/28/2013 at 4:17 p.m., the Administrator acknowledged that the problem related to the service hallway exit doors being unsecured remained ongoing. She further acknowledged that that there was no WanderGuard sensor or alarm on these service hallway exit doors to prevent wandering residents from exiting through the hallway. A copy of Building "B"'s Wander's list was provided and identified that Resident #s 5, 21, 24, 65, 87, 88, 134, 193, 204, 209, 214, 220, and 319, as well as Resident "D", had all been identified as having wandering/elopement behaviors. Based on the above, the facility's QA&A Committee failed to ensure that timely corrective actions were developed and implemented to correct the problem related to the unsecured service hallway exit doors, of which the Committee had been aware of since at least March of 2013. This failure placed Resident #s 5, 21, 24, 65, 87, 88, 134, 193, 204, 209, 214, 220, and "D", who had all been assessed as having wandering behaviors, at risk of elopement. The Immediate Jeopardy was determined to be removed on 08/30/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/28/2013, improvements were made to the glass sliding doors. The glass sliding doors on the service hall were repaired by Plant Operations so that they would no longer automatically open. In addition, the electric eye was disabled on the sliding glass doors by Plant Operations. The sliding glass doors now require a staff proximity badge to enter or exit the facility. B. On 08/29/2013, improvements were made to the metal double doors leading to the service entrance. A service technician from the door service company adjusted the length of time the doors remain open, once activated. Additionally, a sensor was added to the doors that sounds loudly if anyone with a wander alert bracelet enters these double doors. C. On 08/29/2013, the procedure by which staff monitored residents at risk for elopement was modified and implemented to allow for the monitoring of the facility's WanderGuard system. This procedure included the monitoring of both WanderGuard-protected doors and WanderGuard devices, via a door monitoring book and a WanderGuard device monitoring form. Monitoring is accomplished as follows: - An assigned CNA on each unit checks each resident who utilizes a WanderGuard device on each shift to ensure the presence and correct function of the device. This check is accomplished utilizing an electronic checking device. The CNA then initials the WanderGuard Device monitoring form to document each resident checked. This WanderGuard device checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance Committee to determine the frequency of ongoing monitoring. - Once weekly, the Unit Secretary of each unit checks each door having a WanderGuard alarm to ensure that the alarm is functioning properly. This check is accomplished utilizing an electronic checking device. The Unit Secretary then initials the door monitoring book to document the check. This WanderGuard door alarm checking process will continue for four (4) weeks, and then will be evaluated by the facility's Quality Assurance Committee to determine the frequency of ongoing monitoring. - The Director of Nursing (or in her absence, the Unit Manager for each unit on the 7:00 a.m.-3:00 p.m. shift, and the Unit Supervisor for the 3:00 p.m.-11:00 p.m. and the 11:00 p.m.-7:00 a.m. shifts) will monitor the process referenced above of documenting WanderGuard device checks and WanderGuard door alarm checks. D. On 08/29/2013, staff in-service education was conducted related to the facility's complete procedure for monitoring wandering residents, which included the following: - Staff was instructed on the procedure by which WanderGuard devices and WanderGuard-protected doors are checked for proper function. - Staff was instructed on the computer system utilized to track and monitor WanderGuard bracelets. Staff was informed that the computer on Unit 1 had a blueprint of the facility which indicated the locations all monitored doors, with each door being numbered and the legend also being on the fire panel door. - Staff was instructed on the exact method by which the computer monitors resident WanderGuard devices, and was also trained on how to reset the system when necessary. - Staff was informed that the list of residents utilizing WanderGuard devices is included on the Safety Device List, and is also included in the Activities of Daily Living books and in the Assignment Book. - Staff received a review of the facility's elopement procedures, related to both residents utilizing WanderGuard devices and those residents who do not utilize WanderGuard devices. - Staff was instructed on the method to monitor WanderGuard devices to ensure proper function, and on how to acquire a new WanderGuard device during non-business hours. Related to the staff in-service referenced above, as of 08/29/2013, eighty-five (85) of the total of 135 staff members assigned to Building A, and eighty-four (84) of the total of 129 staff members assigned to Building B, had been trained (representing all staff who worked on 08/28/2013 and 08/29/2013). The remaining staff members would receive inservice training upon their return to work, or remotely via telephone, and will be inserviced before allowing direct resident care. E. On 08/29/2013, the facility implemented a procedure for the ongoing evaluation of residents at risk for elopement which included the Patients At Risk Committee. This Committee is to meet weekly, and their review is to include each resident who is at risk for elopement. This review is to assess the care provided to each resident who is at risk. This Committee, and its function is monitored by the Director of Nursing, who will report findings to the QA&A Committee quarterly. F. On 08/29/2013, the facility had reviewed the Care Plans of all residents determined to be at risk for elopement. The Care Plans were reviewed and revised to reflect the necessary approaches needed to ensure proper care and supervision of these residents. The facility's Clinical Coordinator and Director of Nursing will audit each resident's Care Plan at the time of each Quarterly MDS review to ensure accuracy and to identify potential problems with the care planning process. G. On 08/29/2013, the facility implemented a procedure to ensure the ongoing involvement of the facility's QA Committee in the assessment and oversight of the facility's procedures related to the WanderGuard system and elopement-prevention. The procedure includes the following: - The Director of Nursing will present a Committee report which details the results of staffs' WanderGuard door alarm monitoring, via the door monitoring form, and resident WanderGuard Device monitoring, via the WanderGuard device monitoring form, to allow the QA committee to evaluate the effectiveness of monitoring. The frequency of staff monitoring will also be reviewed and will be revised as needed. - The Director of Nursing will present a Committee report which details the results of the facility's Patients At Risk Committee reviews, which includes a review of the care provided to residents at risk for elopement. - The Director of Nursing will report the results of the quarterly Care Plan process audits at each quarterly Quality Assurance (QA) Committee meeting. - The QA Committee will meet quarterly to accomplish these reviews, as outlined above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on August 30, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had conducted staff in-service training related to the facility's WanderGuard and elopement prevention system, with eighty-five (85) of 135 Building "A" staff and eighty-four (84) of 129 Building "B" staff having been trained as of 08/29/2013. However, fifty (50) Building "A" staff and forty-five (45) Building "B" staff were not working and not available for the in-service due to their work schedule or some type of leave, so these remaining staff members would need to be inserviced upon their return to work. Also, the Director of Nursing will be providing ongoing monitoring of staffs' WanderGuard door alarm monitoring via the door monitoring form, and WanderGuard Device monitoring via the WanderGuard device monitoring form, to ensure staff compliance with this monitoring process. However, this process had been implemented on 08/29/2013, one day prior to the 08/30/2013 exit date of the standard survey. Additionally, the Director of Nursing will also present the findings of staff WanderGuard device monitoring, door alarm monitoring, PAR Committee reviews, and Care Plan audits to the QA Committee quarterly to allow the QA Committee to evaluate, on an ongoing basis, the effectiveness and frequency of monitoring. However, as of the 08/30/2013 exit date of this standard survey the Committee had not yet met to initiate the evaluation of the effectiveness of these new interventions and monitoring to ensure resident health and safety, related to elopement prevention. The QA Committee's next scheduled meeting is the first week of October 2013. Therefore, the non-compliance continues, but the scope and severity level was reduced to an "E" level.

Based on observation, record review, resident interview, staff interview, facility Pain Management Policy review, and Wound Care Specialist Evaluation review, the facility failed to perform a pressure ulcer dressing change in a manner to address verbalized and expressed pain by one (1) resident (Resident "C", who resided in Building "B"). This failure to recognize and treat this pain for Resident "C" resulted in actual harm (observed and expressed pain, as evidenced by the resident's yelling out and exhibiting facial grimacing during treatment, and stating during interview that the procedure had been painful). In addition, the facility failed to administer cardiac medication per the parameters specified by the physician's orders [REDACTED]. [REDACTED]. The survey sample size was forty-nine (49) residents. Findings include: Review of the facility's Pain Management Policy revealed that the Policy noted that each resident had the right to experience effective management and relief of pain. The Policy specified that each resident was to be assessed on admission for pain location, duration, description, intervention, and response, and that pain would be analyzed utilizing a visual analog scale for pain assessment (scoring of 0 - 10). The Policy further specified that resident pain would be re-assessed at every shift and as necessary, and that intervention was required for any resident with a pain score of 5 or greater, or any pain that was unacceptable to a resident. 1. Record review for Resident "C" revealed a Wound Care Specialist Evaluation of 08/22/2013 which documented that the resident had a Stage 4 pressure wound with tunneling to the left buttock, and documented that the resident had contractures. A current physician's orders [REDACTED]. Another current physician's orders [REDACTED].), 1/2 tablet three (3) times daily. There was also a current physician's orders [REDACTED]. two (2) tablets every four (4) hours as needed. There was no evidence of additional orders for pain medication for Resident "C". A Minimum Data Set assessment, with an Assessment Reference Date of 03/04/2013, documented in Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 08/27/2013 at 8:46 a.m., the Wound Care Nurse (WCN) prepared and collected wound materials needed for treatment to Resident "C"'s Stage 4 coccyx wound to include: Silversorb Gel Pack with [MEDICATION NAME], normal saline, gauze and [MEDICATION NAME], and collagen strips. The WCN washed her hands, put on gloves, and began to reposition Resident "C". At that time, Resident "C" began exclaiming "My leg!" The WCN then repositioned a pillow between the resident's contracted knees, and removed a soiled dressing to reveal a wound which appeared to be around dime-size and shape. The WCN cleaned the wound using aseptic technique and began to pack the wound tunnel with collagen and [MEDICATION NAME]. At that time, Resident "C" started to scream "Oh! Oh!" while holding on to the right siderail and grimacing. The WCN stated to the resident "Take a deep breath", and did not show any indication that she identified the expressed and obvious pain the resident was having at the time. During an interview with Resident "C"on 08/27/2013 at 9:02 a.m., after the wound care treatment referenced above, the resident stated "That was painful." During an interview with Licensed Practical Nurse (LPN) "FF" conducted on 08/27/2013 at 9:10 a.m., she revealed that Resident "C" had been given two (2) [MEDICATION NAME] 325 mg. tablets, and a dose of [MEDICATION NAME] that morning at 8:00 a.m. This nurse further stated that at times, Resident "C" did scream out with movement of his/her legs. During interview with the WCN on 08/27/2013 at 9:15 a.m. who had provided the wound care treatment to Resident "C", this nurse acknowledged that she could have identified Resident "C"'s pain more by asking if the resident was in pain. This nurse further stated that some days, the resident did not scream. During an interview conducted on 08/27/2013 at 9:45 a.m., Registered Nurse (RN) "HH", when asked what would be the expectation for Resident "C" with a Stage 4 pressure sore with tunneling and showing evidence of pain. This nurse stated that when a resident was yelling out during wound treatment, she would have stopped the treatment and addressed the pain. During an interview with Registered Nurse (RN) "EE" conducted on 08/30/2013 at 12:15 p.m., this nurse stated that her expectation of someone with bilateral contractures to the knees and a Stage 4 wound to the buttocks would be that the resident would be in significant pain. She stated that Resident "C" had some pain, but not at a pain level greater than five (5). This nurse stated that when asked, sometimes Resident "C" would say he/she was in pain, and that when the resident expressed pain, the nurse would make the physician aware. Record review for Resident "C" revealed a Physician's Telephone Orders form of 08/27/2013, the date of the treatment observation referenced above, which documented a physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that the physician had been made aware of Resident "C" experiencing pain during treatment prior to staff obtaining this order for [MEDICATION NAME] on the date of the resident's 08/27/2013 pressure sore treatment referenced above. 2. Record review for Resident #180 revealed an Assessment MDS with an Assessment Reference Date of 05/24/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of Resident #180's physician's orders [REDACTED]. - [MEDICATION NAME] 2.5 milligrams (mgs) daily, and to hold the medication for a systolic blood pressure (SBP) less than 110 or a pulse less than 60 - Carvedilol 3.125 mgs. twice a day, and to hold the medication for a SBP less than 110, or a pulse less than 60 However, review of the resident's July and August 2013 Routine Medications sheets revealed that these medications were not held as ordered on the following days and at the following times: - The Carvedilol was not held on 07/19/2013 at 9:00 a.m. when the SBP was 108; - The [MEDICATION NAME] was not held on 07/22/2013 when the SBP was 106; - The Carvedilol was not held on 08/06/13 at 5:00 p.m. when the pulse was 55; - The Carvedilol was not held on 08/12/13 at 5:00 p.m. when the pulse was 59; - The Carvedilol was not held on 08/21/13 at 9:00 a.m. when the SBP was 108; - The Carvedilol was not held on 08/22/13 at 9:00 a.m. when the SBP was 97. The above findings were verified during interviews with Unit Manager "BB" conducted on 08/29/2013 at 12:29 p.m. and 12:40 p.m. 3. Record review for Resident #48 revealed a Minimum Data Set assessment with an Assessment Reference Date of 06/24/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. (a diuretic) to be given daily, and for a 2000 milliliter fluid restriction (for which the resident had signed a refusal). Another physician's orders [REDACTED]. Review of the June 2013 Routine Medications form, where resident weighs were documented, for Resident #48 revealed a weight gain from 188.0 pounds on 06/19/2013 to 194.8 pounds on 06/21/2013 (6.8 pounds in two days). A Nurse's Notes entry dated 06/24/2013 timed at 8:00 p.m. documented that Resident #48 had complained of wheezing at 6:45 p.m., and that a slight expiratory wheeze was noted in the upper and lower lobes on the right side. This Nurse's Notes entry documented that the physician was notified of the resident's symptoms, but there was no evidence to indicate that the physician was notified of the resident's weight gain of 6.8 pounds over the 2-day period. A subsequent Nurse's Notes entry of 06/24/2013 timed at 10:00 p.m. documented an order had been received for a chest X-ray. A chest X-ray taken that night showed an [MEDICAL CONDITION] chest with chronic appearing interstitial changes, but no infiltrate or effusion. Review of August 2013 Routine Medications form for Resident #48 revealed a weight of 186.0 pounds on 08/23/2013 and a weight of 193.2 on 08/26/2013 (a gain of 7.2 pounds in 3 days). However, further review of the clinical record revealed no documented evidence to indicate that the physician had been notified, per the physician's orders [REDACTED]. During interviews with Unit Manager "BB" conducted on 08/29/2013 at 9:45 a.m. and 10:30 a.m., she verified that there was no documentation that the physician was called as per the order to report the weight gains of Resident #48 noted above.