Every finding on record at Nowata Nursing Center

Based on record review and interview, the facility failed to report an allegation of a crime toward a resident to OSDH and local law enforcement within 2 hours for 1 (#4) of 3 sampled residents reviewed for abuse.The DON identified 32 residents resided in the facility.Findings:A facility policy titled Policy and Procedure Regarding Responsibility of Reporting Allegations of Resident Abuse, Criminal Acts, Injury of Unknown Source, Neglect, Misappropriation of Property, and Exploitation, dated 10/11/22, read in part, It is the policy of this facility to act on all allegations of abuse, neglect, misappropriation of resident property, exploitation, injuries of unknown source and suspected criminal acts which included reporting the allegation withing the required time frame to the appropriate authorities.A quarterly assessment for Res #4, dated 04/18/25, showed the resident had a brief interview for mental status score of 12, indicating moderate cognitive impairment.A Transfer to Hospital Summary, dated 06/24/25 at 1:45 p.m., was found in the progress note section of Res #4's EMR. The summary, read in part, Note Text: Order received from [doctor name withheld] to transfer resident to hospital due to increased confusion, hallucinations, shortness of breath and abdominal breathing of 30 breaths per minute. The summary showed the facility nurse on duty had called the local acute care hospital and informed their staff the resident had received one half of a Xanax (antianxiety medication/controlled substance) tablet from a family member of the resident. A review of Res #4's EMR including active and discontinued medications, and the June 2025 medication and treatment administration records showed the resident was not ordered Xanax.On 01/29/26 at 10:13 a.m., LPN #1 was asked if they had any information regarding Res #4 having received a Xanax tablet from a family member. LPN #1 stated during a lunch break on 06/24/25 a family member of Res #4 had informed them they had given Res #4 one of their own Xanax tablets because the resident was yelling out for their dead husband. LPN #1 was asked what they had done with that information. They stated just after receiving the information about the Xanax, LPN #2 called them and told them Res #4 was going to be sent to the hospital. LPN #1 stated they informed LPN #2 during that call about the Xanax tablet having been given to the resident. They stated the ambulance staff was notified about the Xanax.On 01/29/26 at 10:30 a.m., LPN #2 was asked if they had any information about a Res #4 having been administered a Xanax tablet by a family member. They stated they did recall that had occurred but could not remember who had informed them of the incident. They stated they recalled being told of the specific family member who allegedly gave the medication to the resident. They stated they then called that family member who told LPN #2 that they had given the tablet to Res #4 and why they had done so. They stated they could not recall.On 01/29/26 at 10:54 a.m., the administrator stated they did recall the incident as it happened shortly after they began working at the facility. They stated the DON at the time, LPN #2, had informed them of the incident and that they had contacted the family member and confirmed the incident had occurred. They stated they recalled having a discussion with LPN #2 and the corporate nurse about reporting the incident, but they did not believe it was a reportable incident because there was no place on the incident reporting form (ODH 283) for the incident. The administrator stated if someone administered a resident their personal medication (controlled substance), they should have reported it as a criminal activity to OSDH.On 01/30/26 at 12:04 p.m., the administrator stated they had not fully followed their abuse policy.

Based on record review and interview, the facility failed to provide staffing data to CMS for the third quarter of 2024. The ADON stated 34 residents resided at the facility. Findings: A PBJ Staffing Data Report for the third quarter of 2024 (04/01/24 through 06/30/24) documented the facility had failed to submit the mandated staffing data for that quarter. On 11/20/24 at 1:50 p.m., the administrator stated they were the person who put in the data for the third quarter. They stated they had not followed up to ensure the data have been uploaded to CMS. They stated the person who usually uploaded the data had been out ill and they had put in the data remotely. They stated the business office manager would put in the data in the future.

Based on record review and interview, the facility failed to provide accurate CMS-10055 forms to residents who discharged from part A services for two (#31 and #32) of three sampled residents reviewed for accurate skilled services beneficiary notices. The ADON reported four residents had discharged from skilled services in the previous six months. Findings: An undated facility document titled, Form Instructions Skill Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), read in part, The SNF ABN provides information to the patient so that [they] can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. A CMS-10055 form, dated 02/16/24, documented it was for Resident #31 and had been approved via telephone by the resident's representative. The document did not document the estimated costs to the resident if they wished to continue the identified skilled services. The form did not document the resident representative's choice whether they wished to continue the services and bill Medicare for an official decision, continue services and bill the resident, or end the services. A CMS-10055 form, dated 08/31/24, documented it was for Resident #32 and included the resident's signature. The form did not include what type of skilled services that were to be billed to Medicare. On 11/19/24 at 11:41 a.m., ADON stated they must have forgotten to include the information on the forms for Residents #31 and #32. They stated the reason for this document was to inform the residents about the type of services to be provided and the residents financial responsibility if any. They stated not filling out the forms completely was an error on their part.

Based on record review and interview, the facility failed to ensure: a. an antianxiety medication was not prescribed on an as needed basis without a 14-day limit or a physician's explanation why it should be used beyond 14 days for one (#24); and b. gradual dose reductions were recommended or attempted for antidepressants for two (#17 and #30) of five sampled residents reviewed for unnecessary medications. The ADON reported 27 residents at the facility were prescribed psychotropic medications. Findings: A facility policy titled Policy for the Management of Resident Medication, dated 10/2017, read in part, For resident who require the us of these medications, gradual dose reductions will be attempted unless contraindicated, and behavioral interventions implemented in an effort to discontinue the medication. 1. Resident #17 had diagnoses of recurrent depressive disorder. A medication administration record, dated 11/01/24 through 11/30/24, documented Resident #17 had been ordered citalopram hydrobromide (SSRI) 40mg one time daily for recurrent depressive disorder on 12/01/23. The record documented the resident had received the medication routinely. 2. Resident #24 had diagnoses of anxiety disorder. A medication administration record, dated 11/01/24 through 11/30/24, documented Resident #24 had been ordered lorazepam (benzodiazepine) 0.5mg one tablet to be given as needed only once daily for restlessness and agitation. The order was dated 10/07/24. The record documented the resident had received a dose of that medication on 11/17/24. 3. Resident #30 had diagnoses of major depressive disorder. A review of Resident #30's medication order history found a medication order for trazodone ([NAME]) 50mg once daily with a start date of 12/13/24 and a discontinue date of 06/07/24. A second order for trazadone 50mg once daily had a start date of 06/07/24 and was active at the date of the review which was 11/20/24. A medication administration record, dated 06/01/24 through 06/30/24, documented two orders for trazodone 50mg to have been given once daily. One order's last documented dose was given on 06/06/24 and the other's first documented dose was given on 06/07/24. The record documented the resident received trazadone 50mg once daily each day of that month. On 11/19/24 at 2:13 p.m., the ADON stated they recalled PRN antipsychotics need a reason for the order to go beyond 14 days, but they did not catch this one. On 11/20/24 at 9:52 a.m., the ADON stated they had reviewed pharmacy records and found no gradual dose reduction had been recommended by the pharmacy or attempted by the physician for Resident #30's trazadone order. On 11/20/24 at 10:54 a.m., the ADON stated they reviewed Resident #17's medical record and pharmacy records, but did not find any documentation of a gradual dose reduction having been recommended or attempted for the resident's citalopram. They stated they were unable to locate a policy that specifically speaks to PRN psychotropics.

Based on observation and interview, the facility failed to ensure kitchen staff with beards wore beard guards while preparing food for the resident. The ADON stated 34 residents at the facility routinely ate meals provided by the facility kitchen staff. Findings: On 11/18/24 at 8:10 a.m., the facility's dietary manager and dietary aide #1 were observed working in the kitchen where food items were being prepared. Each had a beard and were not wearing beard guards. On 11/18/24 at 11:03 a.m., the facility's dietary manager and dietary aide #1 were observed in the food preparation area. They were not wearing beard guards. The dietary manager stated they did not have any beard guards in the facility. On 11/19/24 at 9:35 a.m., the administrator stated they were unaware there were not beard guards in the facility and would immediately obtains some. They stated the beard guards were required in the facility when preparing food.

Based on observation and interview, the facility failed to implement a policy related to enhanced barrier precautions to prevent the spread of MDROs in the facility. The ADON reported 34 residents resided in the facility. Findings: A facility Enhanced Barrier Precautions policy, revised 07/21/22, read in part, The expanded use of PPE .during high-contact care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms [MDRO] to or from staff hands or clothing or indirectly transferred from resident/client to resident/client during high-contact activities Use Enhanced Barrier Precautions when providing care to any resident/client with an indwelling medical device or colonized infection with an MDRO. On 11/18/24 at 8:30 a.m., a tour of the facility was conducted. No signage was noted on resident doors indicating EBP was implemented for at risk residents. On 11/21/24 at 12:35 p.m., CMA #1 stated to their knowledge enhanced barrier precautions were not in place in the facility. On 11/21/24 at 12:49 p.m., CNA #1 stated they were unaware what EBP was or how they were supposed to be used. On 11/21/24 at 1:15 p.m., the ADON stated they were still in the process of implementing EBP and they were not consistently using EBP in the facility.

Based on record review and interview, the facility failed to provide a written notice of transfer to a resident prior to a transfer to an acute care hospital for one (#32) of two sampled residents reviewed for hospitalization s and discharges. The ADON reported that seven residents had transferred to a hospital in the previous six months. Findings: A facility Transfer or Discharge Notice policy, dated December 2016, read in part, Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. A progress note, dated 08/27/24 at 7:50 a.m., documented Resident #32 had been sent to an acute care hospital for confusion and a low blood oxygen saturation rate. The note documented a family member of the family was notified of the situation. A progress note, dated 08/31/24 at 2:45 p.m., documented Resident #32 was returned to the facility from the hospital by a family member. On 11/21/24 at 9:35 a.m., Resident #32 stated they had been sent to the hospital earlier that year because of breathing problems. ON 11/21/24 at 9:50 a.m., RN #1 and LPN #1 stated they did not give a written notice of transfer to Resident #32 when they went to the hospital. They stated they had not heard of a written notice of transfer before. On 11/21/24 at 10:02 a.m., the ADON stated Resident #32 were not given a written notice of transfer when they had been sent to the hospital on 08/27/24. They stated they were unaware of the requirement for the written notice.

Based on record review and interview, the facility failed to provide a written notice of the bed hold policy when a resident was sent to a hospital for one (#32) of two sampled residents reviewed for hospitalization s and discharges. The ADON reported that seven residents had transferred to a hospital in the previous six months. Findings: A facility Bed-Hold and Returns policy, dated March 2017, read in part, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. A progress note, dated 08/27/24 at 7:50 a.m., documented Resident #32 had been sent to an acute care hospital for confusion and a low blood oxygen saturation rate. On 11/21/24 at 9:35 a.m., Resident #32 stated they had been sent to the hospital earlier that year because of breathing problems. On 11/21/24 at 9:50 a.m., RN #1 and LPN #1 stated they did not give a written notice of the bed hold policy when Resident #32 was sent to the hospital on 08/27/24. On 11/21/24 at 10:02 a.m., the ADON stated after review of Resident #32's records, they found no documentation of a bed hold policy having been given to the resident. They stated Resident #32 had not been given a written notice of the bed hold policy when they were sent to the hospital on 08/27/24.

Based on record review and interview, the facility failed to ensure a dose reduction recommendation was provided for one (#9) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 07/27/23, documented 15 residents who received psychoactive medications. Findings: Resident #9 admitted on [DATE], with diagnoses which included schizophrenia and depression. Review of Patient Discharge Instructions from the discharging hospital, dated 03/03/21, revealed Resident #9 admitted to the facility with psychoactive medications which included, Risperidone 3mg one tablet one time a day, and chlorpromazine Hcl 50 mg two tablets one time a day. An Expanded DRR [Drug Regimen Review] Report, dated 06/10/21, read in part, .Chlorpromazine 100mg daily ordered on adminssion[sp] with risperidone 3mg daily also ordered on admission dx schizophrenia . No recommendation was made for a reduction to these medications. The report was signed by the attending physician, the Director of Nursing, and the pharmacist. The care plan, dated 10/04/21, documented Resident #9 received psychotropic medications, it did not document any behaviors associated with psychotropic medications. A pharmacy Medical Director Report, dated 01/21/22, read in parts, .Spoke with [the medical director] and it was decided to not decrease or increase any of [Resident #9's] medications .He was admitted on this regimen and has been stable. He is alert oriented to time place and situation. No changes in medications . This has been the rationale since Resident #9 was admitted to the facility. Review of monthly medication regimen reviews, dated from January 2022 through July 2023, revealed no recommendations in a reduction of psychoactive medications. The Treatment Administration Record, dated May 2023, revealed Resident #9 had refused the medication risperidone one time out of 31 opportunities. The record documented Resident #9 had not received the medication risperidone due to sleeping six times out of 31 opportunities. A psychological Progress Note, dated 05/05/23, revealed Resident #9 stated they were doing well on their current medications. The note documented Resident #9 denied auditory/visual hallucinations, delusions, and self harming behavior. A quarterly assessment, dated 06/17/23, documented no evidence of delirium. The assessment documented Resident #9 had no hallucinations or delusions, and had not displayed any behavioral symptoms. The Treatment Administration Record, dated June 2023, revealed Resident #9 had refused the medication chlorpromazine HCL one time out of 30 opportunities. Resident #9 did not receive the medication due to sleeping one time out of 30 opportunities. The treatment record revealed Resident #9 had refused the medication risperidone three times out of 30 opportunities and had not received the medication due to sleeping one time out of 30 opportunities. A psychological Progress Note, dated 06/02/23, documented Resident #9 stated they were doing well on their current medications. Resident #9 had a bright affect and smiled. The note documented Resident #9 denied depression, anxiety, sleep issues or night terrors, was able to focus to watch television, and denied auditory/visual hallucinations, delusions, and self harming behaviors. The Treatment Administration Record, dated July 2023, documented Resident #9 had not received the medication chlorpromazine HCL one time out of 31 opportunities due to sleeping. The record documented Resident #9 had not received the medication risperidone nine times out of 31 opportunities, once for a refusal, and eight times for sleeping. A psychological Progress Note, dated 07/07/23, documented Resident #9 stated they were doing well on their current medications, and denied issues related to depression, anxiety, sleep, moods, or hallucinations. Review of current physician orders revealed, Resident #9 had continued to receive the medications of Risperidone and chlorpromazine HCL. Review of facility nursing progress notes, revealed no concerns for behaviors. On 08/01/23 at 11:17 a.m., the pharmacy consultant was asked how often gradual dose reductions were required. They stated every six months and yearly after that. The consultant stated Resident #9 came to the facility on the psychoactive medications from a hospital, and they asked the facility not to change the medications for Resident #9. The consultant was asked where the request was documented. They stated it may be in the admitting paperwork or the discharge paperwork from the hospital. The consultant stated they believed Resident #9 was the only resident the had not done a reduction on.

Based on interview and record review, it was determined the facility failed to ensure the physician had provided a clinical rationale when he/she disagreed with a recommendation made by the consulting pharmacist during a medication regimen review for three (#1, 15, and #22) of five sampled residents whose records were reviewed for unnecessary medications. This had the potential to affect all 30 residents who resided in the facility. Findings: 1. Resident #1 was admitted to the facility with diagnoses which included major depressive disorder, mood affective disorder, anxiety disorder, and sexual aversion disorder. The assessment documented the resident had been administered an antidepressant and had not received an antipsychotic medication seven days of the seven day look back period. A monthly medication regimen review, dated 12/09/20, documented, Could we DC sliding Scale insulin increasing [MEDICATION(S)]? The physician's response was, Disagree. He had not documented a clinical rationale as to why he had disagreed. An annual assessment, dated 03/10/21, documented the resident was moderately impaired in cognition, required extensive assistance with bed mobility, transfer and most ADLs. The physician order summary report, dated 05/26/21, documented, .[MEDICATION(S)] Solution Pen-Injector 18MG/3ML .Inject 0.6 mg subcutaneously one time a day . On 05/26/21 at 3:14 p.m., the pharmacist/owner was asked why a rationale had not been provided when the physician disagreed with the recommendation to discontinue the sliding scale insulin and increase the [MEDICATION(S)]. He stated he would work with the physician in finding a solution. 2. Resident #15 was admitted to the facility with diagnoses which included, unspecified dementia with behavioral disturbance, vascular dementia with behavioral disturbance, and psychotic disorder with delusions due to known physiological condition. A significant change assessment, dated 07/22/2020, documented the resident's cognition was severely impaired. The resident required maximum assistance for ADLs, and was incontinent of bowel and bladder. The assessment documented an antidepressant had been administered seven days of the seven day look back period. Physician orders, dated May 2021, documented [MEDICATION(S)] tablet 100 mg, administer one tablet by mouth one time a day related to other [CONDITION(S)]. A medication regimen review, dated 05/06/21, documented, Current orders include [MEDICATION(S)] 100 mg ordered 06/20. May we try decreasing [MEDICATION(S)] to 75 mg daily at bedtime. The physician disagreed but had not provided a clinical rationale as to why he disagreed. On 05/24/21 at 1:00 p.m., the pharmacist was asked why a clinical rationale had not been provided by the physician when he disagreed with the pharmacist's recommendation to decrease the resident's [MEDICATION(S)]. He stated he would call the physician to get a rationale and make him aware of what was needed. 3. Resident #22 was admitted to the facility with diagnoses which included depression, [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], and anxiety. An annual assessment, dated 04/10/21, documented the resident was cognitively intact, required supervision with walking and locomotion, limited assistance with bed mobility, transfers, and personal hygiene. The resident utilized a walker and cane for mobility, and received an antidepressant and hypnotic medication seven days of the seven day look back period. A medication regimen review, dated 08/17/20, documented, .Current orders include [MEDICATION(S)] 50mg daily. May we decrease to 25mg daily . The physician's response was, Disagree. He had not documented a clinical rationale as to why he had disagreed. The physician order summary report, dated 05/26/21, documented, .[MEDICATION(S)] Tablet 50 MG .Give 1 tablet by mouth one time a day . On 05/26/21 at 3:10 p.m., the pharmacist/owner was asked what the procedure was for medication review and gradual dose reduction for [CONDITION(S)] medication. He stated the medications were reviewed monthly and they were to attempt a gradual dose reduction of [CONDITION(S)] medication twice in the first year and annually thereafter. He was asked how the physician received the pharmacist's recommendations. He stated the physician received the recommendations during his weekly visit. He was asked why the physician had not included a clinical rationale when he disagreed with the 08/17/20 recommendation to decrease resident #22's [MEDICATION(S)]. He stated pharmacy recommendations and rationales were discussed during the weekly physician visits. He was asked where that was documented. He stated it had not been documented.

Based on observation, interview, and record review, it was determined the facility failed to ensure infection control had been maintained by serving meals in a manner to prevent cross contamination for three (noon meals) of three meal services observed for infection control. The facility identified 30 residents who received nourishment from the kitchen and 18 resident who routinely ate in the dining room. Findings: A facility policy titled, Handwashing/Hand Hygiene, dated August 2015, documented, .The facility considers hand hygiene the primary means to prevent the spread of infections .Hand hygiene products and supplies ( .alcohol-based hand rub .) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .Use an alcohol-based hand rub .for the following situations .Before and after direct contact with residents .After contact with objects (e.g., [for example] medical equipment) in the vicinity of the resident .Before and after assisting a resident with meals . On 05/18/21 at 11:50 a.m., the noon meal service was observed in the dining room. During meal service, staff was observed to touch residents clothing protector, wheelchair, and assist multiple residents, without sanitizing their hands. At 12:17 p.m., a staff member was observed to follow another staff member to a supply closet, retrieve several bottles of hand sanitizer, and carry them to the dining room. On 05/19/21 at 12:58 p.m., staff was observed to deliver a meal tray to a resident room, reposition the resident's bedside table, deliver a meal tray to a second resident room, place the meal tray on the bedside table, and remove the plastic cover from the drinking glass without sanitizing their hands. On 05/20/21 at 12:55 p.m., the noon meal was observed in the dining room. During meal service, staff was observed to reposition their face mask, wipe their hands on their pants, and deliver resident meal trays without sanitizing their hands. CNA (certified nursing assistant) #1 was observed to pick up a resident's bread with her fingers and assist multiple residents without sanitizing her hands. On 05/20/21 at 2:05 p.m., CNA #1 was asked how she ensured infection control was maintained during meal service. She stated by sanitizing your hands, ensuring tables and eating utensils were clean, and cleaning the resident's hands and face when they were finished eating. She was asked how she ensured infection control was maintained when assisting multiple residents during meal service. She stated by sanitizing hands between residents but I know that I don't every time. While in the dining room, she was asked where the hand sanitizer was located. She stated, Not in here. She stated she usually had it in her pocket. She was asked if she had hand sanitizer in her pocket at this time. She stated no. CNA #1 was informed of the observation during meal service regarding touching a resident's bread with bare hands. On 05/20/21 at 2:50 p.m., dietary aide #1 was asked how he ensured infection control was maintained during meal service. He stated by ensuring resident's received their own meals. He was asked how he ensured infection control was maintained during meal delivery. He stated he would deliver a resident meal tray then pick up another meal tray to deliver. He was asked how he ensured infection control while delivering meals to multiple residents. He stated I don't know. He was asked where the hand sanitizer was located in the dining room. He stated there was a bottle on the shelf by the kitchen serving window. He was asked why he did not sanitize his hands between residents while delivering meals. He stated he was in a hurry. On 05/26/21 at 11:10 a.m., LPN (licensed practical nurse) #1 was asked how she ensured staff maintained infection control during meal service. She stated staff knew to sanitize their hands between residents and carry hand sanitizer in their pockets. She was asked where hand sanitizer was located in the dining room. She stated there was none in the dining room but staff carried hand sanitizer in their pocket and it was available on the medication cart outside the dining room. She was asked if staff would sanitize their hands if hand sanitizer was not accessible. She stated maybe not.

Based on observation, interview, and record review, it was determined the facility failed to ensure the dishwasher temperatures were maintained at the manufacturer's recommended temperature during use. The facility identified 30 residents who received meals from the kitchen. Findings: A facility policy titled, Dishwashing Machine Use, dated March 2010, documented, .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately .If hot water temperatures .do not meet requirements, cease use of dishwashing machine immediately until temperatures .are adjusted . On 05/18/21 at 10:45 a.m., the dish machine was observed to reach a wash temperature of 100 degrees F (Fahrenheit) and a rinse temperature of 100 degrees F. The manufacturer's label documented minimum temperature for wash and rinse was 120 degrees F. A Dish Machine Temperatures/Sanitizer log, dated May 2021, documented dish machine temperatures, dated May 17, 2021, of 120 degrees F wash and 138 degrees F rinse for breakfast, 121 degrees F wash and 139 degrees F rinse for lunch, and 120 degrees F wash and 141 degrees F rinse for dinner. At 11:00 a.m., the dietary manager was asked what temperature the dish machine should reach during the wash and rinse cycle. She stated at least 120 degrees but may have to run the machine more than once to reach that temperature. At 11:10 a.m., the dish machine, following several runs, was observed to reach a wash temperature of 115 degrees F and a rinse temperature of 115 degrees F. The dietary manager was asked what the procedure was when the dish machine temperature did not meet minimum requirements. She stated the dishes would not be used and maintenance would be notified.

Based on interview and record review, it was determined the facility failed to utilize a Registered Nurse at least eight consecutive hours a day, seven days a week. The facility identified 25 residents who resided in the facility. Findings: On 05/18/21, during entrance conference the administrator was asked if the facility had any nursing waivers. She stated no. Staffing was reviewed for the period of May 9th through May 15, 2021. The review revealed the facility had been without an RN for eight consecutive hours, seven days a week on the following days: ~Thursday, 05/06/21, had an RN for 1.25 hours in a 24 hour period; ~Monday, 05/10/21; ~Tuesday, 05/11/21; and ~Wednesday, 05/12/21. On 05/26/21 at 2:41 p.m., the executive director was asked why they had been without an RN on the day mentioned above. She stated it had been difficult trying to find an RN to work. She stated the DON had gotten married and was gone on those dates. Staffing was reviewed for the period of 12/01/2020 through January 31, 2021. The review revealed the facility had been without an RN (registered nurse) for eight consecutive hours, seven days a week on the following days: ~Tuesday, 12/22/20; ~Monday, 12/28/20; ~Wednesday, 12/30/20; ~Thursday, 12/31/20; ~Friday, 01/01/21; ~Wednesday, 01/06/21; ~Thursday, 01/07/21; ~Friday, 01/08/21; ~Monday, 01/11/21; ~Tuesday, 01/12/21; ~Thursday, 01/14/21; ~Friday, 01/15/21; ~Monday, 01/18/21; ~Tuesday, 01/19/21; ~Wednesday, 01/20/21; ~Thursday, 01/21/21; ~Friday, 01/22/21; ~Monday, 01/25/21; ~Tuesday, 01/26/21; ~Wednesday, 01/27/21; ~Thursday, 01/28/21; and ~Friday, 01/29/21. On 05/26/21 at 2:45 p.m., the executive director was asked why there was no RN for 22 days in December 2020 and January 2021. She stated they had no DON (director of nursing) or RN.

Based on interview and record review, it was determined the facility failed to: ~Provide sufficient qualified nursing staff to provide nursing and related services; and ~Ensure staffing met the state minimum requirement. This had the potential to affect all 30 residents who resided in the facility. Findings: 1. On 05/18/21, during entrance conference the executive director was asked if the facility had any nursing waivers. She stated no. Staffing was reviewed for the period of May 9th through May 15, 2021. The review revealed the facility had been without an RN for eight consecutive hours, seven days a week on the following days: ~Thursday, 05/06/21, had an RN for 1.25 hours in a 24 hour period; ~Monday, 05/10/21; ~Tuesday, 05/11/21; and ~Wednesday, 05/12/21. On 05/26/21 at 2:41 p.m., the executive director was asked why they had been without an RN on the day mentioned above. She stated it had been difficult trying to find an RN to work. She stated the DON had gotten married and was gone on those dates. 2. Staffing was reviewed for the period of 12/01/2020 through 01/31/21. The review revealed the facility lacked sufficient staff according to state minimum staffing ratios on the following dates and shifts: ~During the first shift, 7:00 a.m. to 3:00 p.m., for three of 62 days; and ~During the second shift, 3:00 p.m. to 11:00 p.m., for three of 62 days, where direct care staffing was reviewed. ~12/14/20 - Census 32 - minimum required man hours for second shift 32 - the facility had provided 27.56; ~12/15/20 - Census 32 - minimum required man hours for second shift 32 - the facility had provided 25.43; ~12/16/20 - Census 32 - minimum required man hours for second shift 32 - the facility had provided 24.94; ~12/26/20 - Census 29 - minimum required man hours for first shift 39 - the facility had provided 33.35; ~12/27/20 - Census 29 - minimum required man hours for first shift 39 - the facility had provided 32; and ~01/03/21 - Census 26 - minimum required man hours for first shift 35 - the facility had provided 30.67. On 05/26/21 at 2:45 p.m., the executive director was asked why there was not sufficient staffing on several days and shifts December 2020 and January 2021. She stated we had staff that quit and staff that tested positive for covid-19 and could not work. She stated we did everything we could. She was asked how they ensured residents received care on days and shifts without sufficient staffing. She stated everyone helped provide resident care.

Based on observation and interview, it was determined the facility failed to: ~Ensure chemicals were secured for one of one utility closets observed for hazardous materials; and ~Ensure equipment was properly stored and the room locked for one of five resident room on the north hall, and one of 12 resident rooms on the dining room hall observed for storage. The facility identified 30 residents who resided in the facility. Findings: A facility policy titled, Storage Areas, Maintenance, dated December 2009, documented, .Maintenance storage areas shall be maintained in a clean and safe manner .Cleaning supplies .must be stored as instructed on the labels of such products . On 05/18/21 at 12:56 p.m., an unlocked and unoccupied resident room on the north hall was observed to contain the following: ~Four beds; and ~One wheelchair. At 1:00 p.m., the DON (director of nursing) was asked how many residents wandered in the facility. He stated two. At 1:05 p.m., the maintenance supervisor was asked how long the unoccupied resident room had been used for storage. He stated he did not know. He was asked why the resident room was being used for storage. He stated he did not know. He was asked what kept residents from entering the resident room being used for storage. He stated nothing. He was asked if a resident entering the room was a potential accident hazard. He stated yes. On 05/18/21 at 2:40 p.m., an unlocked and unoccupied resident room on the dining room hall was observed to contain the following: ~Four lifts; ~One wheelchair; ~One wedge; ~One shelf (on floor); and ~One cardboard box filled with miscellaneous items (sitting on top of chest of drawers). On 05/18/21 at 2:45 p.m., a utility closet, located on the dining room hall, was observed to be unlocked. The utility closet was observed to contain several cleaning products on the floor, cleaning products stacked on shelves, and an unlocked housekeeping cart. The following chemicals were observed unsecured on the housekeeping cart: ~A bottle of bowl cleaner; ~A bottle of disinfectant cleaner; and ~A bottle of disinfectant cleaner and deodorizer. A review of the chemicals safety instructions revealed the following: ~The bowl cleaner documented, .Wear safety glasses and gloves .Causes severe skin [CONDITION(S)] and eye damage .Store locked up .Keep out of reach of children . ~The disinfectant cleaner documented, .Keep out of reach of children .Danger .In case of emergency, call a poison control center or doctor for treatment advice . The disinfectant cleaner and deodorizer documented, .Keep out of reach of children . No wanderers were observed near or trying to enter these areas. At 2:55 p.m., the housekeeping supervisor was asked why the utility closet door was unlocked. She stated the door was usually locked. She was asked what would keep a resident from entering the utility closet. She stated it was usually locked. She was asked if a resident entering the unlocked utility closet was a potential accident hazard. She stated yes. At 3:10 p.m., maintenance was asked why the resident room, located on the dining room hall, was being used for storage. He stated he did not know. He was asked if a resident entering the room was a potential accident hazard. He stated yes.

Based on interview and record review, it was determined the facility failed to electronically transmit data to the CMS system within 14 days after completion of an annual assessment for one (#1) of 19 sampled residents whose MDS assessments were reviewed. This had the potential to affect all 30 residents who resided in the facility. Findings: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual assessment, dated 03/10/21, had a notation in red that read, Export Ready. A resident assessment had been triggered for further investigation related to the MDS record being over 120 days old. On 05/26/21 at 2:41 p.m., the executive director was asked who was responsible for transmitting MDS data to CMS. She stated they have been without a full time MDS person since November 2020. She stated their MDS person was only part time. She was asked what their process was for transmitting MDS data. She stated once the DON has signed the data information it was transmitted. She was asked why resident #1's assessment data, entered 03/10/21, had not been transmitted and still read, Export Ready. She stated when they were submitted it came up in a batch and the date has to be changed. She stated the date had not been changed so it did not come up to transmit.

Based on interview and record review, it was determined the facility failed to ensure a comprehensive assessment was accurate related to hospice services for one (#23) of 12 sampled residents whose assessments were reviewed. The facility identified 30 residents who resided in the facility. Findings: A facility policy titled, Electronic Transmission of the MDS (minimum data set), dated September 2010, documented, .All staff members responsible for completion of the MDS receive training on the assessment .Staff members are trained on updates/revisions to the MDS form and software upgrades as they are released . Resident #23 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 12/18/20, documented, .Admit to [Hospice name withheld] . A review of the hospice record revealed the resident had been admitted to hospice on 12/18/20. A quarterly assessment, dated 12/21/20, documented the resident was cognitively intact and required supervision with most ADLs (activities of daily living). The assessment had not revealed the resident had a condition or chronic disease that resulted in a life expectancy of less than six month. There was no documentation in the assessment that the resident had received hospice services. A physician order, dated 02/18/21, documented to discharge the resident from [Hospice name withheld]. An annual assessment, dated 03/26/21, documented the resident was cognitively intact, required supervision with most ADLs, had a condition or chronic disease that may result in a life expectancy of less than six months, and received hospice care. On 05/26/21 at 2:45 p.m., the executive director was asked who was responsible for the MDS assessment. She stated the facility had not had full time MDS staff member since November 2020. She stated all departments had been completing their pertinent section of the MDS. She was asked what timeframe was used as a reference when completing the MDS. She stated a seven day look back. She was asked why resident #23's MDS assessment, dated 12/21/20, had not reflected the resident received hospice care. She stated she was not sure. She stated that assessment was not accurate. She was asked why the resident's MDS assessment, dated 03/26/21, had not reflected he had a condition or chronic disease that could result in a life expectancy of less than six months and/or received hospice care. She stated she was not sure but that assessment was not accurate.

Based on interviews, it was determined the facility failed to deliver mail to the residents on Saturdays for 10 of 10 residents who attended the resident council meeting. The facility identified 30 residents who resided in the facility. Findings: On 05/19/21 at 1:30 p.m., a resident council meeting was held with ten alert and oriented residents. The residents were asked if they received mail on Saturdays. All 10 of the residents stated they did not. One resident stated they only got mail on the days the activities director was working which was Monday through Friday. 05/19/21 at 2:02 p.m., the social services/activities director was asked if residents received mail on Saturdays. She stated, No. She stated she passed out the mail and she was not in the facility on Saturdays. On 05/26/21 at 3:05 p.m., the executive director was asked if the facility had a policy for mail delivery on Saturdays. She stated the mail was delivered to the facility on Saturday, but it was not passed out to residents on the weekends.

Based on observations and interviews, it was determined the facility failed to ensure controlled medications were locked in permanently affixed compartments for one of one medication room refrigerator observed. The administrator stated there were 29 residents in the facility. Findings. On 02/24/19 at 9:53 a.m., the medication room was observed to have a small white refrigerator sitting on the counter. The refrigerator had a clasp for a lock to secure the unit which was open. A small lock was observed sitting on top of the refrigerator. The refrigerator was not locked and there was no lock box inside the refrigerator. Licensed practical nurse #1 was asked if there were any narcotics stored inside the medication room. She stated there was one narcotic inside the refrigerator. The licensed practical nurse opened the refrigerator and handed the surveyor a small plastic bag. Inside the bag was a single syringe. The bag label documented resident #8 had an order to receive [MEDICATION NAME] 2 milligrams per milliliter give one milliliter at bed time and every six hours as needed. She was asked if the unit containing the [MEDICATION NAME] had been locked. She stated it had not been locked. She stated it should have been locked.

Based on interview and record review, it was determined the facility failed to ensure there was a registered nurse in the building for eight hours a day seven days a week for three (02/02/19, 02/09/19, and 02/10/19) of 14 days reviewed. The administrator stated there were 29 residents in the building. Findings: On 02/25/19 at 9:26 a.m., the nurses' punch date schedule for 01/28/19 through 02/10/19 were reviewed. The punch detail documented there had not been a registered nurse on duty on 02/02/19, 02/09/19, and 02/10/19. At 12:21 p.m., the director of nursing was asked if there had been a registered nurse working on 02/02/19, 02/09/19, and 02/10/19. She stated there had not been a registered nurse working on those dates. She stated the facility had requested a waiver regarding having a registered nurse in the building eight hours a day but had not received one as yet. The director of nursing stated the facility had been trying to hire a registered nurse but had been unsuccessful.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received care and services to prevent a decrease in functional range of motion (ROM) and/or provide restorative care for 3 (#1, #6, and #8) of 3 sampled residents whose records were reviewed for restorative care. The business office manager/restorative aide (BOM/RA) identified 9 residents resided in the facility who were on the restorative care program. The facility failed to: a) Assess, monitor, and intervene for resident #8 who had experienced decreased ROM to her left hand. This resulted in the development of contractures to both her left and right hand. b) Ensure resident #8 received her therapy ordered restorative care treatment to her lower extremities. This resulted in the resident's increased need for assistance with transfers and a decrease in resident #8's ability to ambulate. c) Provided restorative services for residents #1 and #6. The facility census and condition identified 2 residents who resided in the facility and who had contractures. Findings: 1. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 01-21-15, documented the resident was severely impaired cognitively, required limited assistance with most activities of daily living (ADLs) including transfers and ambulation, and had no limitations with ROM. A health status note, dated 05-18-15, documented, .3RD, 4TH, ET (and) 5TH DIGIT ON LEFT HAND BEGINNING TO BECOME CONTRACTED, WAS NOT ABLE TO FULLY EXTEND FINGERS ET FACIAL GRIMACE ET PAIN NOTED DURING AROM (active range of motion). HR (resident name deleted) STATES 'LEAVE THEM ALONE' . A health status note, dated 05-20-15, documented an order had been received regarding therapy for the contracture of resident #8's left hand. A physician's telephone order, dated 05-20-15, documented an order for [REDACTED]. The clinical record for resident #8 did not contain any documentation PT/OT had evaluated or treated resident #8's contractures per the 05-20-15 physician order. A physician's telephone order, dated 06-09-15, documented an order for [REDACTED]. A physical therapy certification note, dated 06-09-15, documented resident #8 had decreased ROM in both lower extremities. The note documented resident #8 had decreased upper extremity ROM and contractures in both hands. The note documented to refer the resident to occupational therapy services at that time. A PT daily note, dated 06-11-15, documented the restorative nurse aide and the resident had been instructed on the treatment plan for the restorative nursing program. The note documented the restorative program was for maintaining and/or increasing the resident's lower extremity ROM and strength for contracture management. A quarterly assessment, dated 07-09-15, documented the resident was severely impaired cognitively, required extensive assistance with all ADLs, no longer ambulated, and had no limitations with range of motion. A nursing restorative care program document, dated 06-24-15, documented the goals for resident #8 were to maintain lower extremity ROM for contracture management. The program documented to perform ROM to the lower extremities times ten repetitions to each leg. The program documented to perform the exercises three times a week for twelve weeks. The document recorded restorative exercises had been performed three times out of eight opportunities. A nursing restorative care program document, dated 07-01-15, documented the goals for resident #8 were to maintain lower extremity ROM for contracture management. The program documented to perform ROM to the lower extremities ten repetitions to each leg. The program documented to perform the exercises three times a week for twelve weeks. The document recorded restorative exercises had been performed two times and had been refused three times out of thirty-one opportunities. There was no restorative care documentation after July 2015. A care plan, dated 07-25-15, documented resident #8 needed extensive assistance related to debility and cognitive deficit. The care plan documented to refer to therapy as needed. The care plan did not contain documentation of the resident having a contracture or a restorative treatment plan. On 09-09-15 at 11:10 a.m., resident #8 was observed sitting in a geri chair in the dining room with her eyes closed. The resident's hands were both observed to be contracted. On 09-09-15 at 4:15 p.m., licensed practical nurse (LPN) #4 was asked about resident #8's contractures. She stated she had first observed the contracture of resident #8's left hand on 05-18-15. She stated at that time she had faxed the physician and received an order for [REDACTED]. LPN #4 was asked if she thought resident #8's contractures could have been prevented. She stated yes. On 09-09-15 at 4:30 p.m., the director of nursing (DON) was asked about resident #8's contractures. She stated they had tried therapy and ROM but it was too painful for the resident so it was discontinued. When asked if the facility should be doing something for the contractures she stated yes. She stated they needed to evaluate the resident again. She stated they should try using heat packs and medicating the resident prior to ROM procedures. The DON was asked if the limited ROM should have been documented on the resident's quarterly assessment and the care plan. She stated yes, it should have been documented on both. On 09-10-15 at 08:40 a.m., the business office manager/restorative aide (BOM/RA) was asked if she provided any restorative care for resident #8. She stated yes, just on her legs. She stated she had never received instructions to do ROM on the resident's hands. She stated she had stopped doing ROM on the resident's lower extremities because the resident complained of pain. The RA was asked if she had reported this to anyone. She stated yes, the DON. The RA was asked if there was any evidence of decline in resident #8's hand contractures. She stated yes her hand contractures had gotten worse. On 09-10-15, at 1:10 p.m., LPN #4 was asked about the PT/OT order that was obtained on 05-20-15 and why had the resident not been evaluated until 06-09-15. She stated she had told PT/OT about the order on 05-20-15, and she did not know why there had been a delay. On 09-10-15 at 1:45 p.m., the physical therapist assistant (PTA), was asked if she was aware of a referral for OT for resident #8 as documented in the PT certification note dated 06-09-15. The PTA stated she would have to look for that documentation. The PTA returned later and stated she could not find any documentation of a referral for OT for resident #8. On 09-10-15 at 2:35 p.m., certified nursing assistant (CNA) #2 was asked how long resident #8's hands had been contracted. She stated the resident's hands had been contracted approximately two months. She stated the resident's hands used to be ok. She stated that now the resident is unable to grip or hold a cup. On 09-10-15 at 3:05 p.m., the physical therapist (PT) was asked about the referral she had made to OT services on 06-09-15 for resident #8. She stated she had sent a text message to OT regarding the referral. She stated referrals were usually initiated by calling or texting the OT services. She stated that she had not followed up to ensure that OT services had been initiated for the resident. She stated they normally do not follow up with OT after a referral had been made. 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07-10-15, documented the resident was cognitively intact, required limited to extensive assistance with activities of daily living (ADLs), and had no limitations with range of motion (ROM). A Nursing Restorative Care Program document, dated 07-30-15, documented the goals for resident #1 were to maintain independence with transfers and gait training and to increase and/or maintain lower extremity strength. The program documented to perform exercises and ambulation six to seven times a week for twelve weeks. There was no documentation the exercises or ambulation had been done. On 09-08-15 at 10:08 a.m., resident #1 was observed in her room. She was unable to answer questions when asked. 3. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06-03-15, documented the resident was severely cognitively impaired, required limited assistance with ADLs, and had no limitations with ROM. A Nursing Restorative Care Program document, dated 08-01-15, documented the goals for resident #6 were to maintain gait training and to maintain or increase both upper and lower extremity strength. The program documented to perform strengthening exercises and ambulation three times a week for twelve weeks. There was no documentation the exercises or ambulation had been done. On 09-08-15 at 12:55 p.m., resident #6 was observed lying in bed with his eyes closed. On 09-10-15 at 4:00 p.m., the BOM/RA was asked about the restorative care program. She stated she had been doing restorative care off and on since 2012. The BOM/RA stated during that time she would frequently have to work the floor as a certified nursing assistant (CNA). The BOM/RA was asked who performed restorative care during the times she worked as a CNA. She stated no one. She stated she had been made the business office manager about one month ago. The BOM/RA was asked who was responsible for performing restorative care now. She stated there had not been anyone doing restorative care until about a week ago. On 09-10-15 at 4:30 p.m., the director of nursing (DON) was asked about the facility's restorative care program. She stated the program was something they had recently been working on. She stated therapy was working with the CNAs on how to perform restorative exercises and how to document them. The DON stated she had recently assigned restorative duties to a couple of CNAs.

Based on observation, interview, and record review, it was determined the facility failed to supervise to prevent accidents for one (#7) of 3 sampled residents whose records were reviewed for elopement. The facility failed to provide adequate supervision to prevent a resident from eloping which resulted in a fall with injury for resident #7. The resident was taken to the emergency room . The emergency room "Physician Note," dated 09-30-14, documented the resident had been treated for [REDACTED]. The assistant director of nursing (ADON) identified five residents who resided in the facility who were an elopement risk. The facility census and condition identified 31 residents resided in the facility. Findings: 1. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05-10-14, documented the resident was severely impaired cognitively, had behaviors such as delusions, resisting care, and wandering, and required supervision with set up for most activities of daily living (ADL) including ambulation. An annual assessment, dated 08-09-14, documented the resident was moderately impaired cognitively, had short and long term memory loss, had behaviors such as delusions, resisting care, and wandering, required limited assistance of one staff member for most ADLs including ambulation. The assessment documented resident #7's wandering did not place her at a significant risk of getting to a potentially dangerous place. A care plan, dated 08-13-14, documented resident #7 was at risk for falls due to visual impairment, cognitive impairment, and psychotropic drug therapy. The care plan documented the resident had a wanderguard bracelet to alert staff of unescorted attempts to leave the facility. The care plan documented staff was to encourage the resident to wear the wanderguard bracelet and to check it daily to make sure it was in good working order. The care plan documented resident #7 had a problem of wandering and attempts to leave. The care plan documented due to resident #7's non-compliance with leaving the wanderguard on, a pretty pin had been made for the resident to wear which contained a wanderguard. A hand written note, undated, on the care plan documented, "...Takes "pin" c (with) wander guard off and leaves in various places..." A facility incident report, dated 08-30-14, documented resident #7 had been found by an off duty staff member across the street from the facility sitting on the ground. The report documented the resident had removed her wanderguard and placed it in her nightstand. The report documented the resident had re-opened an old skin tear on her right arm and there were no other injuries. The report documented steps to prevent recurrence were to replace the wanderguard on the resident's left wrist and to encourage her to use her wheelchair at all times for locomotion. A facility nurse's note, dated 08-31-14 at 11:15 a.m., documented the resident had attempted to exit the facility two times so far that shift. The note documented a wanderguard had been placed in the resident's pocket that morning and was in working order. The note documented the resident had been redirected by staff to engage in various activities with little success and they would continue to monitor the resident. A facility nurse's note, dated 08-31-14 at 6:15 p.m., documented the resident frequently removed her wanderguard and placed it in her bedside table. A handwritten note by the administrator, dated 09-03-14, documented (name deleted) construction had been called to order a magnetic door as soon as possible. A facility nurse's note, dated 09-03-14 at 8:56 p.m., documented resident #7 had tried to exit the front door two times and had to be redirected by the staff. A facility nurse's note, dated 09-06-14 at 3:19 p.m., documented resident #7 had been alert and pleasant with staff, and her wanderguard had been attached to her shirt and was in proper working order. A care plan update, dated 09-15-14, documented, "...Hourly observation checks initiated. Staff cont. to find wanderguard pin in various places Please replace pin to my clothing PRN (as needed)..." A facility in-service training class report, dated 09-15-14, documented the subject of the class was "Elopement Risk." The report documented to do hourly observations of resident #7 and to document and sign hourly. A facility one hour close observation report, documented the facility had started one hour observation checks daily on 09-15-14 for resident #7. The report documented resident #7 had last been observed by staff at 5:30 a.m. on 09-30-14. A facility incident report, dated 09-30-14, documented resident #7 had been found by a facility staff member that morning at 5:58 a.m. lying on the ground in front of the facility as she was coming to work. The report documented resident #7 had a bump on the left side of her forehead, blood on the bridge of her nose and face, and skin tears to her right arm. The report documented emergency medical services (EMS) had been called and the resident had been transferred to the hospital for evaluation and treatment at 6:50 a.m. The report documented the resident did not have a wanderguard on. An emergency room "Physician Note," dated 09-30-14, documented the resident had been treated for [REDACTED]. The note documented resident #7 had been discharged from the emergency room to another nursing facility per the resident's daughter's request. A facility in-service training class report, dated 10-01-14, documented the subject of the class was wanderguards. The report documented staff was to only remove the wanderguards during bathing if not waterproof; the wanderguards were to be on the resident at all times even while in bed; if a resident did not have their wanderguard on the staff were to contact the administrator, the director of nursing, and the assistant director of nursing; and the resident was to have one on one by a staff member until the wanderguard could be replaced. On 10-21-14 during the survey the surveyors observed new doors being installed in the front and back of the facility. On 10-22-14 at 7:40 a.m., licensed practical nurse (LPN) #4 was asked about the incident with resident #7 on 09-30-14. LPN #4 stated she and two other certified nursing assistants had been working the 11-7 shift. She stated the staff had been doing hourly checks on resident #7 during the shift. She stated resident #7 had last been seen sleeping at 5:30 a.m. LPN #4 stated after observing resident #7 at 5:30 a.m. she had gone to the nurses' station and then to the restroom. She stated at 6:00 a.m. a staff member came into the facility and told her resident #7 was outside lying on the ground. LPN #4 stated she immediately assessed the resident and called EMS to transport the resident to the emergency room due to the "goose egg" on the resident's forehead. LPN #4 was asked if resident #7 had a wanderguard on at the time of her elopement. She stated no. She stated the resident frequently took it off at night. She stated the resident had refused to wear it that night because she did not want to mess up her "pretty pin." LPN #4 stated the wanderguard had been placed in the resident's bedside drawer. On 10-22-14 at 5:20 p.m., the administrator was asked what steps she had put in place after resident #7 had eloped on 08-30-14 to prevent it from happening again. She stated they had: a) in-serviced the staff b) started hourly checks c) made the resident's wander guard into a pin she could wear on her shirt d) placed a wanderguard on the resident's walker, wheel chair, and in her purse e) updated the care plan f) ordered new doors that would alarm when the doors were opened without the use of a wanderguard.