Every finding on record at Patterson Healthcare Center

Based on interview and record reviews, the facility failed to accurately document the administration of a resident's medication for 1 (Resident #1) of 3 sampled residents reviewed for accurate documentation.Findings:Review of Resident #1's record revealed, in part, an order for Miconazole 2% cream (an antifungal medication) to be applied topically two times a day with a start date of 04/29/2026 and an end date of 05/09/2026.Review of Resident #1's April 2026 electronic Treatment Administration Record (eTAR) revealed, in part, Miconazole 2% cream was scheduled for administration from 04/20/2026 in the PM to 04/30/2026 in the PM. Further review of Resident #1's April 2026 eTAR revealed Miconazole 2% cream was not documented as administered on 04/20/2026 in the PM and 04/30/2026 in the PM.Review of Resident #1's May 2026 eTAR revealed, in part, Miconazole 2% cream was scheduled for administration from 05/01/2026 in the AM to 05/09/2026 in the AM. Further review of Resident #1's May 2026 eTAR revealed Miconazole 2% cream was not documented as administered on 05/02/2026 in the AM, 05/03/2026 in the AM, 05/04/2026 in the PM, 05/05/2026 in the PM, 05/07/2026 in the PM and 05/08/2026 in the PM.In an interview on 05/26/2026 at 2:36PM, S2Director of Nursing (DON) indicated Resident #1's Miconazole 2% cream was administered as ordered but was not documented as administered on the above documented dates, and should have been.

Based on interviews and record reviews, the facility failed to ensure a resident was administered medications per a physician's order for 1 (Resident #1) of 3 sampled residents investigated for medication administration. Findings:Review of Resident #1's April 2026 physician's orders revealed, in part, an order dated 09/30/2025 to administer Resident #1 one Levothyroxine Sodium 25 mcg tablet in the morning daily. Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1's Levothyroxine Sodium (a medication used to treat an underactive thyroid) 25 microgram (mcg) tablets were reordered by the facility on 03/30/2026. Review of facility's contracted pharmacy's Pharmacy Consolidated Delivery Sheet revealed, in part, S2Licensed Practical Nurse (LPN) had documented via her signature that Resident #1's Levothyroxine Sodium 25 mcg tablets were delivered to the facility on [DATE]. Review of Resident #1's April 2026 electronic medication administration record (eMAR) revealed, in part, no documented evidence Resident #1 was administered a Levothyroxine Sodium 25 mcg tablet on 04/04/2026 and 04/05/2026 by S2Licensed Practical Nurse. Further review revealed S2LPN had documented/indicated to see Resident #1's progress notes on 04/04/2026 and 04/06/2026. Review of Resident #1's progress note dated 04/04/2026 at 5:19AM revealed, in part, Resident #1's Levothyroxine is on order. Review of Resident #1's progress note dated 04/05/2026 at 5:33AM revealed, in part, Resident #1 was informed the Levothyroxine Sodium 25 mcg tablet was still on order. Further review revealed Resident #1 stated, I don't know how they didn't realize to order it before it ran out. In an interview on 04/06/2026 at 4:23AM, Resident #1 indicated she had not been administered Levothyroxine Sodium 25 mcg all weekend because the facility's staff said they were out of the medication. In an interview on 04/06/2026 at 4:46AM, S2LPN indicated she did not administer Resident #1's Levothyroxine Sodium 25 mcg tablets on 04/04/2026 and 04/05/2026. In a telephone interview on 04/07/2026 at 2:31PM, the pharmacy technician at the facility's contracted pharmacy indicated S2LPN had documented via her signature that Resident #1's Levothyroxine Sodium 25 mcg tablets had been delivered to the facility on [DATE] at midnight on the Consolidated Delivery Sheet. In an interview on 04/07/2026 at 2:40PM, S1Director of Nursing indicated if Resident #1's Levothyroxine Sodium 25 mcg tablets were available in the facility, it should have been administered to Resident #1 as ordered on 04/04/2026 and 04/05/2026.

Based on observations, interviews, and record reviews, the facility failed to ensure the menus approved by the facility's dietician were followed for 2 (04/02/2026 and 04/06/2026) of 3 days of observation of the facility's served meals. Findings:Review of the facility's dietician approved Week 1 menu revealed, in part, a biscuit was to have been served to residents on Mondays for breakfast. Review of the facility's dietician approved Week 5 menu revealed, in part, mock pecan pie was to have been served to residents on Thursdays for lunch. Review of the Menus Substitution Log with dates from 03/13/2026 to 04/08/2026 revealed, in part, there was no substitution listed for lunch menu items on 04/02/2026 and for breakfast menus items on 04/06/2026. Observation on 04/02/2026 (Thursday) at 9:50AM revealed pecan pie was the dessert listed on the facility's posted lunch menu. Observation on 04/02/2026 (Thursday) at 11:51AM revealed at least 37 of the residents eating in the facility's dining room were served a cake like dessert with a white icing and not mock pecan pie as noted on the facility's lunch menu for Thursday. In an interview on 04/06/2026 at 4:23AM, Resident #1 indicated for dinner on 04/03/2026, she was not served all of the items that were on the facility's menu. Observation on 04/06/2026 (Monday) at 7:41AM revealed the residents in the dining room were being served toast halves as part of their breakfast and not a biscuit as noted on the facility's breakfast menu for Monday. In an interview on 04/08/2026 at 1:27PM, S4Contracted Dietary Manger (DM) indicated the facility served the Week 1 menu on 04/06/2026 through 04/12/2026 and served the Week 5 menu last week on 03/30/2026 through 04/05/2026. S4Contracted DM further indicated a different dessert was served on Thursday 04/02/2026 because the mock pecan pie that was listed to be served on Thursdays of the Week 5 menu was something she could no longer get. S4Contracted DM further indicated she was not aware toast halves were served for breakfast on Monday 04/06/2026 and confirmed it was biscuits that were listed to be served for breakfast on Mondays of the Week 1 menu. S4Contracted DM further indicated the facility's dietician came to the facility on 4/07/2026. S4Contracted DM further indicated the process for making menu substitutions was when a substitution for a food item was made on the menu, the dietician would sign and approve the substitution/menu change on the dietary menu substitution log. S4Contracted DM confirmed the substitutions for the lunch dessert on 04/02/2026 and the breakfast toast on 04/06/2026 were not on the menu substitution log on 04/07/2026. In a telephone interview on 04/08/2026 at 1:41PM, S3Contracted [NAME] indicated he had prepared toast instead of biscuits for breakfast on 04/06/2026 because the facility was out of biscuits. In a telephone interview on 04/08/2026 at 2:00PM, S5Regional Dietician indicated it was the facility/company's process that if a substitution was made to a menu item, documentation of the substitution/menu change should be written on the menu substitution log and the substitution should be reviewed/signed by the facility's dietician when she visited the facility. S5Regional Dietician indicated if the above mentioned menu substitutions were made, documentation of the substitutions should have been added to the menu substitution log for the facility's dietician to review.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to a resident to prevent accidents for 1 (Resident #66) of 4 sampled resident investigated for accidents/hazards. Findings:Review of Resident #66's electronic medical record (EMR) revealed, in part, Resident #66 had diagnoses, which included, Alzheimer's disease, dementia, and an altered mental status. Review of Resident #66's Care Plan Conference summary dated 10/01/2025 revealed, in part, Resident #66 had Alzheimer's disease and was consuming non-food items which could cause harm to Resident #66. Further review revealed Resident #66 would possibly benefit from a butterfly unit facility (a facility that had a secured unit for residents that require more supervision due to their mental status/memory). Further review revealed Resident #66 had current and continuous incidents such as drinking shampoo and lotion that could possibly harm Resident #66. Further review revealed Resident #66 was highly active in the facility and was going in other resident's rooms. Review of Resident #66's Wander Data Collection form dated 11/05/2025 revealed, in part, Resident #66 was cognitively impaired with poor decision-making skills and was able to ambulate/perform locomotion independently. Further review revealed Resident #66 has wandered and significantly intruded on the privacy or activities of others. Review of Resident #66's progress note dated 07/03/2025 at 11:48a.m. revealed, in part, the nurse was summoned to the smoking patio and Resident #66 was noted to be digging in potting soil and eating it. Further review revealed Resident #66 was asked to spit out the soil, was brought to her room, had her mouth rinsed out, and had some vomitus substance noted. Review of Resident #66's progress note dated 09/21/2025 at 12:20p.m. revealed, in part, the nurse was notified by a Certified Nursing Assistant (CNA) that Resident #66 was found on Hall c drinking a bottle of skin and hair cleanser. Review of Resident #66's progress note dated 09/30/2025 at 11:58a.m. revealed, in part, the nurse was notified by a staff member that Resident #66 was found in another resident's room consuming a bottle of liquid soap. Review of Resident #66's progress note dated 10/08/2025 at 1:30p.m. revealed, in part, it was reported by staff that Resident #66 was outside on the smoking patio and attempted to drink out of other resident's coffee cups and attempted to dig in ashtrays. Observation on 12/09/2025 at 10:55a.m. revealed Resident #66 was sitting with a coffee mug in her hand that had a small amount of coffee at the bottom of the mug. Further observation revealed S13Transportation took the coffee mug from Resident #66 and indicated to Resident #66 she would get her a new coffee mug. In an interview on 12/09/2025 at 10:55a.m., S13Transportation indicated she had to get Resident #66 a new coffee mug because the coffee mug Resident #66 was holding was not hers, but was another resident's coffee mug. Observation on 12/09/2025 at 1:19p.m. revealed Resident #66 attempted to grab items off of the used lunch tray cart on Hall e. In an interview on 12/09/2025 at 1:22p.m., S14CNA confirmed Resident #66 was attempting to grab items off of the used lunch tray cart in the above observation. In an interview on 12/09/2025 at 3:03p.m., S15CNA indicated Resident #66's wanders. S15CNA further indicated Resident #66 would grab random things and try to put them to her mouth. S15CNA further indicated she had witnessed Resident #66 take other resident's coffee mugs and drink other residents' coffee. S15CNA also indicated Resident #66 had a history of putting the used cigarette butts of others to her mouth. In an interview 12/09/2025 3:07p.m., S16CNA, indicated the staff had to be careful because Resident #66 would pick up anything and start eating it. S16CNA indicated she had witnessed Resident #66 pick a leaf off of a flower arrangement in the facility's dining room and put it in her mouth. S16CNA further indicated Resident #66 had previously gone into Resident # 70's room and drank Resident #70s body wash. S16CNA further indicated Resident #66 drank out of other people's coffee mugs and will eat other resident's food. S16CNA further indicated Resident #66 had previously put either ashes or cigarettes butts into her mouth. S16CNA further indicated that Resident #66 would sometimes go into other residents' rooms. In an interview on 12/09/2025 at 3:17p.m., S10Licensed Practical Nurse (LPN) indicated Resident #66 went into the facility's dining area and would put food and drinks left on the tables in her mouth. In an interview on 12/09/2025 at 3:20p.m., S17LPN, indicated Resident #66 wanders in her wheelchair. S17LPN further indicated other residents informed her Resident #66 put potting soil in her mouth, and when she assessed Resident #66, it was confirmed Resident #66 had potting soil in her mouth. S17LPN further indicated Resident #66 would pick up people's drinks and would eat whatever she could get her hands on. In an interview on 12/09/2025 at 3:32p.m., S14CNA indicated Resident #66 was known to take others' food and drinks. In an interview on 12/09/2025 at 3:34p.m., S5Social Services Director (SSD) indicated if Resident #66 sees food she liked, she would grab it. S5SSD further indicated that she witnessed Resident #66 drink other residents' coffee and take other residents' food. In an interview on 12/09/2025 at 3:53p.m., S18CNA indicated Resident #66 wandered the halls and went from table to table trying to eat other residents' food. In an interview on 12/09/2025 at 3:58p.m., S19CNA indicated Resident #66 had attempted to put shampoo in her mouth. S19CNA further indicated when Resident #66 was getting wheeled out of the facility's dining room, she tried to grab other residents' food. In an interview on 4:31p.m., S2Director of Nursing (DON) indicated, if someone did not always have their eye on (constantly supervised) Resident #66, she had the potential to obtain things she was not supposed to have and put them into her mouth. S2DON further indicated, in her opinion, Resident #66 sometimes would require one on one supervision, and the facility could not provide that. S2DON indicated Resident #66 should not have been able to go into the other residents' rooms if the other residents did not want her in their room. S2DON further indicated Resident #66 should not have been able to take and drink out of other residents' cups. In an interview on 12/09/2025 at 4:50p.m., S1Administrator indicated she was made aware of the situation today of Resident #66 eating things she should not and going into other resident's rooms. S1Administrator further indicated, based off what she had read of Resident #66's behaviors, it appeared Resident #66's behaviors and continued residency in the facility were a safety issue.

Based on interviews and record reviews, the facility failed to ensure the verification of controlled substances count sheet was completed every shift. This deficient practice was identified for 2 (Medication Cart a, Medication Cart b) of 2 medication carts reviewed for controlled substance reconciliation. Findings:Review of facility's Controlled Substances policy, with a revision date of November 2022, revealed, in part, the nurse coming on duty and the nurse going off duty would count the controlled substances together and document the controlled substances count. Review of the facility's November 2025 Medication Cart a controlled substances count sheet revealed, in part, the following:-On 11/15/2025, there was no documented evidence S6Licensed Practical Nurse (LPN) verified the controlled substance count with the off-going nurse at 6:00p.m. or the on-coming nurse at 6:00a.m. -On 11/20/2025, there was no documented evidence S7LPN verified the controlled substance count with the off-going nurse at 6:00p.m. or the on-coming nurse at 6:00a.m. -On 11/29/2025, there was no documented evidence S6LPN verified the controlled substance with the off-going nurse at 6:00p.m. or the on-coming nurse at 6:00a.m. Review of the facility's November 2025 Medication Cart b controlled substances count sheet revealed, in part, the following:-On 11/02/2025 there was no documented evidence S10LPN verified the controlled substance count with the off-going nurse at 6:00a.m. or the on-coming nurse at 6:00p.m.-On 11/16/2025 there was no documented evidence S8LPN verified the controlled substance count with the off-going nurse at 10:00p.m. or the on-coming nurse at 6:00a.m.-On 11/23/2025 there was no documented evidence S6LPN verified the controlled substance count with the on-coming nurse at 6:00p.m.; and-On 11/30/2025 there was no documented evidence S8LPN verified the controlled substance count with the off-going nurse at 10:00p.m. or the on-coming nurse at 6:00a.m. In an interview on 12/09/2025 at 1:30p.m., S9LPN indicated the controlled substances count record should have had each nurse that is on-coming and off-going sign the controlled substance log each shift. S9LPN acknowledged the controlled substance log sheets were not signed on the above mentioned dates. In an interview on 12/09/2025 at 1:40p.m., S2Director of Nursing indicated the controlled substances count sheet did not have the signatures of the on-coming and off-going nurse on the above mentioned dates, and should have, as required.

Based on observations, interviews, and record reviews, the facility failed to ensure the walls of a resident's bathroom were in good repair for 1 (Bathroom f) of 1 bathrooms investigated for environmental concerns. Findings:Review of the facility maintenance log dated 11/01/2025 through 12/10/2025 revealed, in part, there were no entries regarding a hole in the wall of Bathroom f. Observation on 12/08/2025 10:32a.m. revealed Bathroom f had an approximately 8 inch (in) x 3.5 in hole near the bottom of the right wall. Observation on 12/09/2025 10:32a.m. revealed Bathroom f had an approximately 8 in x 3.5 in hole near the bottom of the right wall. Observation on 12/10/2025 8:31a.m. revealed Bathroom f had an approximately 8 in x 3.5 in hole near the bottom of the right wall. In an interview on 12/10/2025 at 8:52a.m., S1Administrator acknowledged the wall of Bathroom f should not be in disrepair.

Based on interviews the facility failed to ensure residents were able to access their personal funds on the weekends for 4 (Resident #12, Resident #57, Resident #61, Resident #72) of 4 residents investigated for access to personal funds. Findings:In an interview on 12/08/2025 at 10:11a.m., Resident #72 indicated she was unable to access her facility managed personal funds on weekends. In an interview on 12/10/2025 at 9:52a.m., S12Business Office Manager (BOM) indicated both she and S11HR did not work on the weekends and she does not know how the residents were able to access their funds on the weekends. In an interview on 12/10/2025 at 10:13a.m., Resident #12 indicated the residents in the facility were unable to get their personal funds on the weekend. In an interview on 12/10/2025 at 10:17a.m., Resident #61 indicated he knew no staff were here on the weekend with access to the facility's funds, so he made sure he got the money he needed before the weekend. Resident #61 further indicated neither S12BOM nor S11HR worked on the weekend, so there was no one that could access the residents' personal funds. In an interview on 12/10/2025 at 10:30a.m., Resident #57 indicated she had previously wanted to get money from her personal funds on the weekend, but was unable to get money from her personal funds. In an interview on 12/10/2025 at 10:33a.m., Resident #72 indicated she was not educated by the facility's staff on the process of notifying the weekend staff she wanted access her personal funds so that they could contact S11HR. In an interview on 12/10/2025 at 11:03a.m., S1Administrator indicated there was no signage posted prior to the entrance of the survey team to inform the facility's residents of the process for accessing their personal funds. S1Administrator further indicated the facility had not educated all the residents on the process for access their personal funds on the weekend.

Based on interviews and record reviews, the facility failed to complete a care plan meeting for 1 (Resident #1) of 1 resident investigated for participation in care planning. Findings:Review of Resident #1's clinical record revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/14/2025 revealed, in part, Resident #1 had a Brief Interview Mental Status Score of 14, which indicated Resident #1 was cognitively intact. In an interview on 12/10/2025 at 10:15 a.m., Resident #1 indicated she never attended a care plan meeting since her admission to the facility. On 12/10/2025 at 12:20 p.m., Surveyor requested documentation of Resident #1's most recent care plan meeting from S5Social Services Director. On 12/10/2025 at 12:24 p.m., S5Social Services Director presented surveyor with documentation of Resident #1's most recent care plan meeting, which was conducted on 08/14/2025. On 12/10/2025 at 2:24 p.m., Surveyor requested documentation of a care plan meeting that was held after 08/14/2025 from S5Social Services Director. In an interview on 12/10/2025 at 2:25 p.m., S5Social Services Director indicated there was no documentation of a care plan meeting for Resident #1 that occurred after 08/14/2025. On 12/10/2025 at 2:26 p.m., Surveyor requested, documentation of a care plan meeting for Resident #1 that occurred after 08/14/2025 from S4MDS Nurse. In an interview on 12/10/2025 at 2:36 p.m., S4MDS Nurse indicated she did not have documentation of a care plan meeting for Resident #1 that occurred after 08/14/2025. S4MDS Nurse further indicated Resident #1 was overdue for a quarterly care plan meeting. On 12/10/2025 at 2:45 p.m., Surveyor requested documentation of a care plan meeting for Resident #1 that occurred after 08/14/2025 from S3Corporate Compliance Nurse. In an interview on 12/10/2025 at 2:50 p.m., S3Corporate Compliance Nurse confirmed Resident #1 did not have a care plan meeting held quarterly as required.

Based on interviews and record reviews the facility failed to obtain laboratory test results for 1(Resident #45) of 1 resident reviewed for laboratory services. Findings:Review of Resident #45's nurse's note dated 10/08/2025 revealed, in part, S10Licensed Practical (LPN) received a verbal order from Resident #45's medical provider to obtain a urine specimen for a urinalysis (UA) and culture and sensitivity (C&S). Review of Resident #45's nurse's note dated 10/09/2025 revealed the S10LPN collected a urine specimen for a UA and C&S. Review of Resident #45's medical record revealed no documented evidence the facility obtained the results of the UA and C&S from the 10/09/2025 urine specimen collection. On 12/09/2025 at 2:03p.m. the surveyor requested the lab results from Resident #45's 10/09/2025 urine specimen collection from S2Director of Nursing (DON) In an interview on 12/09/2025 at 4:10p.m., S2DON indicated Resident #45's lab results were not obtained from the urine specimen collected on 10/09/2025. S2DON further indicated the lab did not have any record of receiving Resident #45's urine specimen collected on 10/09/2025. S2DON further indicated a new specimen should have been collected and was not. In an interview on 12/10/2025 at 8:45a.m., Resident #45's medical provider confirmed she gave a verbal order to obtain a urine specimen for a UA and C&S for Resident #45 on 10/08/2025. Resident #45 medical provider further indicated she had not received the results as of 10/13/2025 and requested the specimen be re-collected.

Based on interviews and record reviews, the facility failed to ensure documentation was complete and accurate for residents' activities of daily living (ADL) for 3 (Resident #1, Resident #2, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for ADLs. Findings: Review of the facility's Charting and Documentation policy, dated July 2017, revealed, in part, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Resident #1 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2025 revealed Resident #1 required supervision and set up help with transfer. Further review of Resident #1's MDS revealed Resident #1 required partial to moderate assistance with personal hygiene. Review of Resident #1's Care Plan with a documented goal date of 06/19/2025 revealed, in part, Resident #1 had an ADL self-care performance deficit. Further review revealed Resident #1 required supervision or touch assistance with chair/bed-to-chair transfers and partial to moderate assistance with personal hygiene. Review of Resident #1's March 2025 Documentation Survey Report revealed, in part, the following: -Personal Hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shift on 03/21/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shifts on 03/12/2025, 03/13/2025, 03/21/2025, or on the 6:00PM - 6:00AM shifts on 03/13/2025, 03/14/2025, and 03/31/2025. Review of Resident #1's April 2025 Documentation Survey Report revealed, in part, the following: -Personal hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shifts on 04/02/2025 or on the 6:00PM - 6:00AM shift on 04/05/2025 and 04/11/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shift on 04/01/2025, or on the 6:00PM - 6:00AM shifts on 04/04/2025 and 04/11/2025. In an interview on 06/09/2025 at 2:55PM, S3MDS Coordinator confirmed Resident #1's transfer and personal hygiene assistance was not documented as provided on the above mentioned dates. S3MDS Coordinator further indicated the Certified Nursing Assistants (CNAs) were responsible for documentation of assistance provide to Resident #1 for transfers and personal hygiene. Resident #2 Review of Resident #2's MDS with an ARD of 05/23/2025 revealed Resident #2 was dependent for transfers. Further review of Resident #2's MDS revealed Resident #2 required partial to moderate assistance with personal hygiene. Review of Resident #2's Care Plan with a documented goal date of 08/29/2025 revealed, in part, Resident #2 had an ADL self-care performance deficit. Further review revealed Resident #2 required total assistance of 2 staff persons for transfers. Review of Resident #2's May 2025 Documentation Survey Report revealed, in part, the following: -Personal Hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shifts on 05/02/2025, 05/16/2025, 05/17/2025, 05/18/2025, and 05/31/2025 or on the 6:00PM - 6:00AM on 05/21/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shifts on 05/02/2025, 05/16/2025, 05/17/2025, 05/18/2025, and 05/31/2025 or on the 6:00PM - 6:00AM shift on 05/21/2025. Review of Resident #2's June 2025 Documentation Survey Report revealed, in part, the following: -Personal Hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shifts on 06/04/2025 and 06/05/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shifts on 06/04/2025 and 06/05/2025. Resident #3 Review of Resident #3's MDS with an ARD of 03/21/2025 revealed Resident #3 was dependent for transfers and personal hygiene. Review of Resident #3's Care Plan with a documented goal date of 06/30/2025 revealed, in part, Resident #3 had an ADL self-care performance deficit and required assistance with transfers and personal hygiene. Review of Resident #3's May 2025 Documentation Survey Report revealed, in part, the following: -Personal Hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shifts on 05/03/2025, 05/12/2025, 05/13/2025, 05/16/2025, 05/17/2025, 05/21/2025, 05/22/2025, 05/26/2025, 05/27/2025, 05/30/2025 or on the 6:00PM - 6:00AM shifts on 05/20/2025, 05/30/2025, and 05/31/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shifts on 05/03/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/21/2025, 05/22/2025, 05/26/2025, 05/27/2025, and 05/30/2025 or on the 6:00PM - 6:00AM shifts on 05/02/2025, 05/20/2025, 05/30/2025, and 05/31/2025. Review of Resident #3's June 2025 Documentation Survey Report revealed, in part, the following: -Personal Hygiene: no documented evidence personal hygiene assistance was provided on the 6:00AM - 6:00PM shifts on 06/1/2025 and 06/04/2025; and, -Transfers: no documented evidence transfer assistance was provided on the 6:00AM - 6:00PM shifts on 06/01/2025 and 06/04/2025. In an interview on 06/10/25 at 11:29AM, S2Director of Nursing (DON) indicated the CNA staff were responsible for ADL documentation. S2DON confirmed Resident #1's, Resident #2's, and Resident #3's transfer and personal hygiene assistance was not documented as provided on the above mentioned dates and should have been documented.

Based on observations, interviews, and record reviews, the facility failed to provide a diet to meet a resident's needs for 1 (Resident #3) of 2 (Resident #2, and Resident #3) sampled residents observed during dining. Findings: Review of the facility's Therapeutic Diet policy and procedure last reviewed on 06/12/2024 revealed, in part, therapeutic diets were prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Review of the facility's Assistances with Meals policy and procedure reviewed on 05/21/2024 revealed, in part, a resident shall receive assistance with meals in a manner that meets the individual needs of each resident. Further review revealed residents who could not feed themselves will be fed with attention to safety, comfort, and dignity. Review of Resident #3's Electronic Medical Record (EMR) revealed, in part, Resident #3 had a diagnosis of oropharyngeal phase dysphagia (a swallowing problem that occurs in the mouth and throat.) Review of Resident #3's Speech Therapy evaluation dated 04/23/2025 revealed, in part, the speech therapist made diet recommendations, which included, Resident #3 was to receive heavily iced liquids. Review of Resident #3's Diet Order and Communication form dated 04/23/2025 revealed, in part, Resident #3 was to receive heavily iced liquids. Review of Resident #3's May 2025 Physician's orders revealed, in part, an order dated 02/14/2025 for Resident #3 to receive a regular diet with heavily iced liquids. Observation on 05/05/2025 at 12:06PM revealed S9Certified Nursing Assistant (CNA) offered Resident #3 a sip of an unknown yellow liquid that contained no ice. Further observation revealed after swallowing a sip of the unknown yellow liquid, Resident #3 cleared her throat and made a slight cough. Observation on 05/05/2025 at 12:10PM revealed S9CNA offered Resident #3 a sip of an unknown yellow liquid that contained no ice. Further observation revealed after swallowing a sip of the unknown yellow liquid, Resident #3 coughed once and cleared her throat. Observation on 05/05/2025 at 12:12PM with S10Speech Therapist (ST) revealed Resident #3's above mentioned glass with an unknown yellow liquid contained no ice. In an interview on 05/05/2025 at 12:12PM, S10ST confirmed Resident #3's above mentioned glass with an unknown yellow liquid was not heavily iced as ordered, and should have been as per Resident #3's prescribed diet. In an interview on 05/05/2025 at 12:18PM, S11Licensed Practical Nurse (LPN) indicated staff should be following a resident's physician's prescribed diet order. In an interview on 05/06/22025 at 9:39AM, S3Registered Dietician (RD) indicated Resident #3 should have received heavily iced liquids on 05/05/2025 as ordered by Resident #3's physician. In an interview on 05/06/2025 at 2:10PM, S2Director of Nursing (DON) indicated S9CNA should have been following the physician's prescribed diet order.

Based on observations and interview, the facility failed to post nurse staffing information at the beginning of each shift daily as required. Findings: Observation on 05/06/2025 at 10:45PM revealed the facility's posted nurse staffing information was dated 05/05/2025. Observation on 05/06/2025 at 3:02PM revealed the facility's posted nurse staffing information was dated 05/05/2025. Observation on 05/08/2025 at 9:28AM revealed the facility's posted nurse staffing information was dated 05/07/2025. Observation on 05/08/2025 at 11:32AM revealed the facility's posted nurse staffing information was dated 05/07/2025. In an interview on 05/08/2025 at 11:33AM, S2Director of Nursing (DON) S2DON acknowledged the nurse staffing information should have been posted on 05/06/2025 and 05/08/2025 as required.

Based on observations, interviews, record reviews, and facility document review, it was determined the facility failed to ensure a resident that was cognitively impaired and had a high risk of falls had appropriate interventions to prevent future falls for 1 (Resident #12) of 2 residents reviewed for accidents. Findings included: The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/2024 revealed, in part, Resident #12 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #12 had moderate cognitive impairment, and was dependent on staff for toileting transfers. Further review revealed, prior to admission, Resident #12 had a previous history of falls and one fall which resulted in a fracture. Review of Resident #12's NSG: Morse Fall Scale Evaluation - V1 dated 09/25/2024 revealed Resident #12 had a previous history of falls, used a wheelchair, and overestimated and often forgot his limitations. Further review revealed Resident #12's score was 55, which indicated Resident #12 was a high risk for falls. Review of the facility's incident report titled Incident by Incident Type revealed, in part, Resident #12 had fall without injury on 09/25/2024, fall with injury on 10/23/2024 and 11/22/2024, and an unwitnessed fall on 12/09/2024. Review of Resident #12's Care Plan revealed, in part, Resident #12 had a risk for falls related to abnormal gait, muscle weakness, and a previous fall which resulted in a fracture. Further review revealed the following dated staff interventions: -On 09/25/2024, educate Resident #12 to call for assistance with transfers; -On 10/01/2024, encourage Resident #12 to use the call bell system; -On 10/23/2024, educate Resident #12 to call for assistance with bed mobility and transfers; -On 11/22/2024, re-educate Resident #12 to call for assistance when needing an adult brief and bed linen change; and, -On 12/09/2024, re-educate Resident #12 on the importance of calling for assistance with transfers and demonstrate the proper use of the facility's call bell system. During an interview on 12/11/2024 at 3:30PM, S15Minimum Data Set Coordinator (MDSC) indicated Resident #12 was cognitively impaired, and to educate and re-educate Resident #12 to use the call bell system for assistance, were not appropriate interventions for a resident with cognitive impairment. S15MDS further indicated Resident #12's fall care plan interventions should have been updated with new appropriate interventions. In an interview on 12/11/2024 at 3:55PM, S16Licensed Practical Nurse (LPN) indicated Resident #12 was admitted from another facility with a history of frequent falls. S16LPN further indicated to use the call bell system was not an appropriate fall care plan intervention for Resident #12 because of his cognitive impairment.

Based on record reviews and interviews, it was determined that the facility failed to monitor for the effectiveness and potential side effects of hypnotics, antidepressants, anti-anxiety medications, antipsychotics, and opioids for 1 (Resident #4) of 5 residents reviewed for unnecessary medications. Findings identified: Resident #4's Electronic Medical Record (EMR) revealed, in part, Resident #4 was admitted to the facility on [DATE] with diagnoses, in part, of unspecified dementia, anxiety disorder, depression, restlessness and agitation Review of Resident #4's November 2024 and December 2024 Physician's Orders revealed the following orders: - Haloperidol lactate (a medication used to treat psychosis) oral concentrate 2 milligrams (mg)/milliliter (ml), give 0.5 mls by mouth two times a day related to restlessness and agitation beginning on 11/13/2024 - Trazodone hydrochloride (a medication used to treat depression and/or anxiety) 50 mg oral tablet, give 2 tablets by mouth at bedtime for insomnia beginning 11/04/2024 - Morphine sulfate (a medication used to treat pain) oral solution 20 mg/5 ml, give 0.5 mls every 2 hours as needed for shortness of breath related to chronic obstructive pulmonary disease with a start date of 10/17/2024 - Lorazepam (a medication used to treat anxiety) oral tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for anxiety disorder beginning on 10/17/2024 - Zoloft (a medication used to treat depression) 25 mg tablet, give 25 mg by mouth 1 time a day related to depression beginning on 10/18/2024 Review of Resident #4's November 2024 and December 2024 Electronic Medication Administration Record revealed no documented evidence and the facility failed to present any documented evidence Resident #4 was monitored for the effectiveness and possible side effects of the previous mentioned medications. Review of Resident #4's Electronic Medical Record did not reveal any documented evidence and the facility was unable to present any documented evidence Resident #4 was monitored for the effectiveness and possible side effects of the previous mentioned medications. In an interview on 12/11/2024 at 3:08 PM, S2Director of Nursing confirmed Resident #4 was not monitored for the effectiveness and possible side effects of the previous mentioned medications and should have been. In an interview on 12/11/2024 at 3:50 PM, S20Corporate Clinical Specialist confirmed Resident #4 was not monitored for the effectiveness and possible side effects of the previous mentioned medications and should have been.

Based on interviews and observations, it was determined that the facility failed to: 1. Ensure the facility's hood fan was kept clean and sanitary; 2. Ensure the facility's double fryer was kept clean and sanitary; 3. Ensure stored foods in the facility's cooler were properly contained and had an open date for 1 (cooler d) of 2 coolers observed; 4. Ensure a dietary cook wore a proper hair restraint during food handling and preparation; and, 5. Ensure Auto-Chlor test strips were not expired. Findings included: 1. Observation on [DATE] at 8:28 AM revealed the facility's hood fan had an unknown white and orange/red substance on the outside surface of the hood fan. In an interview on [DATE] at 10:14 AM, S1Administrator indicated the facility's hood fan should not have an unknown white and orange/red substance on the outside surface and should have been kept in a sanitary manner. 2. Observation on [DATE] at 10:15 AM revealed the facility's double fryer had a white substance on the outside of the fryer; and an unknown brown substance on the back ledge of the fryer. In an interview on [DATE] at 10:16 AM, S1Administrator indicated the facility's double fryer should not have had an unknown white substance on the outside and an unknown substance on the back ledge and should have been kept clean and in a sanitary manner. 3. Observation on [DATE] at 8:30 AM of cooler d revealed: -a bag of frozen fish with no open date; -a bag of sliced turkey, not contained, open to air, and with no open date; and, -a bag of shredded lettuce, not contained, open to air, and with no open date. In an interview on [DATE] at 8:30 AM, S22Dietary Manager (DM) indicated the bag of frozen fish in cooler d should have had an open date, the bag of sliced turkey in cooler d should have been contained and had an open date, and the bag of shredded lettuce in cooler d should have been contained and had an open date. 4. Observation on [DATE] at 8:30 AM revealed S23Cook was prepping lunch in the facility's kitchen without a hair restraint covering his beard. In an interview on [DATE] at 8:31 AM, S22DM indicated S23Cook should have worn a proper hair restraint to cover his beard while he handled and prepped food. 5. Observation on [DATE] at 11:55 AM revealed the facility's Auto-Chlor test strips for the facility's dishware and the facility's 3 compartment sanitization sink had an expiration date of ,d+[DATE]. In an interview on [DATE] at 11:55AM, S22DM indicated the facility's Auto-Chlor test strips were expired and should not have been.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess a resident for self-administration of a medication for 1 (Resident #25) of 2 residents observed for accidents/hazards. Findings included: Review of the facility's policy titled, Medication Administration, dated 07/08/2024, revealed resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident #25's Quarterly Minimum Data Set with an Assessment Reference Date of 10/03/2024 revealed, in part, Resident #25 had a Brief Interview of Mental Status score of 15, which indicated Resident #25 was cognitively intact. Review of Resident #25's December 2024 Physician's Orders revealed an order dated 01/21/2023 for Flonase Sensimist Nasal Suspension (a nasal spray used to treat stuffy/itchy nose, and sneezing) 1 spray in each nostril one time a day for allergic rhinitis (inflammation in the nose). Further review revealed no evidence Resident #25 had a physician's order to self-administer medications. Review of Resident #25's Care Plan revealed, in part, no evidence Resident #25 had been care planned to address the self-administration of medications. Observation on 12/09/2024 at 10:29 AM, revealed Resident #25 had a bottle of Flonase Sensimist Nasal Suspension at her bedside. In an interview on 12/09/2024 at 10:29 AM, Resident #25 indicated she had an order for Flonase nasal spray to be administered daily, but she had been self-administering the nasal spray as needed. Resident #25 further indicated the last time she self-administered the nasal spray was one day last week. In an interview on 12/10/2024 at 3:53 PM, S5Licensed Practical Nurse (LPN) indicated Resident #25's should not have been self-administering nasal spray. In an interview on 12/10/2024 4:30 PM, S15Minimum Data Set (MDS) Coordinator indicated Resident #25 did not have a physician's order or was care planned for self-administration of medications. In an interview on 12/10/2024 at 4:30 PM, S20Clinical Nurse Specialist indicated Resident #25 should not have been self-administering nasal spray. In an interview on 12/10/2024 at 4:23 PM, S2Director of Nursing (DON) indicated Resident #25 did not have a physician's order for self-administration of medications, and was not care planned for self-administration of medications. S2DON confirmed Resident #25 should not have been self-administering nasal spray.

Based on observations and interviews, it was determined the facility failed to ensure shower rooms were maintained in a safe and sanitary manner for 2 (shower room y and shower room z) of 3 shower rooms reviewed for physical environment. Findings included: Review of Resident #82's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 revealed, in part, Resident #82 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #82 was moderately impaired. Observation of shower room y on 12/10/2024 at 8:50 AM revealed shower stalls were in use and had an unknown black/brown substance on the surface and around the edges of the shower tiles. Observation of shower room z on 12/10/2024 at 8:55 AM revealed 3 shower stalls were in use and had an unknown black/brown substance on the surface and around the edges of the shower tiles. In an interview on 12/10/2024 at 9:06 AM, S14Housekeeping Manager indicated the housekeeper assigned to the hall was responsible for cleaning the shower room on that hall. In an interview on 12/10/2024 at 9:20 AM, S17Housekeeper indicated she was responsible for cleaning shower room z. S17Housekeeper confirmed the shower stalls in shower room z had a black/brown unknown substance on the tiles and should have been cleaned. In an interview on 12/10/2024 at 9:30 AM, Resident #82 indicated the facility's shower rooms were not kept clean by the housekeeping staff. Resident #82 further indicated he showered in the front left stall of shower room z a couple of days ago and noticed mildew along the surface and cracks of the tiles. In an interview on 12/10/2024 at 9:40 AM, S14Housekeeping Manager indicated the shower stalls in shower room y and shower room z were not clean and should not have a black/brown unknown substance on the surface of the shower stalls. Observation on 12/10/2024 at 10:11 AM, of shower room y revealed a sharps container mounted to the wall which was overflowing and had 3 used shaving razors on top of the sharps container. Further review revealed a red/brown substance had dripped down the lid of the sharps container. During an interview on 12/10/2024 at 10:14 AM, S19License Practical Nurse (LPN) indicated she did not know who was responsible for replacing the full sharps container located in shower room y. S19LPN further indicated the used shaving razors overflowing from the sharps container was definitely not, safe or sanitary. During an interview on 12/10/2024 at 10:18 AM, S3Assistant Director of Nursing (ADON) indicated the sharps container located in shower room y should not have been overflowing with used shaving razors.

Based on record review and interview, it was determined that the facility failed to implement recommendations from the Office of Behavioral Health (OBH) for a resident with a mental health diagnosis for 1 (Resident #39) of 2 sampled residents reviewed for Pre-admission Screening and Resident Review (PASARR). Findings included: Review of Resident #39's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses, in part, of anxiety disorder, depression, and schizophrenia. Review of Resident #39's Level II PASARR with an authority period of 04/09/2024 through 04/08/2025 revealed Resident #39 was referred to OBH for recommendations of psychiatric treatment. Review of Resident #39's OBH's recommendations dated 04/09/2024 revealed, in part, a recommendation for a comprehensive psychiatric evaluation. Review of Resident #39's EMR revealed no documented evidence, and the facility did not present any documented evidence that Resident #39 had a comprehensive psychiatric evaluation completed. In an interview on 12/11/2024 at 10:10 AM, S20Corporate Clinical Specialist confirmed Resident #39 did not have a comprehensive psychiatric evaluation completed as recommended by OBH.

Based observations, interviews, record reviews, facility document review, and facility policy review, it was determined that the facility failed to ensure a resident was involved in the development and revision of the resident's Comprehensive Care Plan for 1 (Resident 58) of 2 residents reviewed for involvement in their Comprehensive Care Plan. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed November 2024, indicated the care planning process would facilitate resident and/or representative involvement. The interdisciplinary team must review and update the care plan when there was a significant change in the resident's condition, when the desired outcomes are not met, when the resident was readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. Review of Resident #58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/2024 revealed, in part, Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #58 was cognitively intact. Review of the facility's document indicated Resident #58 had an annual MDS assessment review dated 05/12/2024, quarterly MDS assessment review dated 08/12/2024, an entry MDS assessment review dated 09/25/2024, and a quarterly MDS assessment review dated 10/03/2024. In an interview on 12/09/2024 at 11:07AM, Resident #58 indicated he had not participated in and was not notified of his care plan meetings during the time of the above mentioned assessments. In an interview on 12/10/2024 at 9:23AM, S19Social Worker (S19SW) indicated Resdient #58 was his own responsible party. In an interview on 12/11/2024 at 11:55AM, S19SW indicated she had no documented evidence, and the facility could not produce any documented evidence that Resident #58 participated in and/or was notified of his care plan meetings for the above mentioned care plan assessments.

Based on observation, interviews, and record review, facility document review, and facility policy review, it was determined the facility failed to provide nail care to a dependent resident for 1 (Resident #76) of 5 residents reviewed for activities of daily living (ADL). Findings included: Review of the facility's Admission Record revealed the facility admitted Resident #76 on 10/27/2023 with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) followed by a cerebral infarction affecting Resident #76's right dominant side. Review of Resident #76's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/2024 revealed Resident #76 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #76 was cognitively intact. Further review revealed Resident #76 required supervision and assistance with personal hygiene. Review of Resident #76's Care Plan initiated on 11/06/2024 revealed Resident #76 had an ADL self-care performance difficulty related to hemiplegia and required assistance and supervision with personal hygiene. Review of the facility's policy titled Care of Fingernails/Toenails last revised February 2018 revealed, nail care included daily cleaning, regular trimming, and the documentation thereof should be in the resident's medical record. Observation on 12/09/2024 at 9:44 AM revealed Resident #76 had half inch long nails to his left ring and middle fingers and one fourth inch long nails to all fingers on his right hand. Observation on 12/10/2024 at 9:04 AM revealed Resident #76 had half inch long nails to his left ring and middle fingers and on fourth inch long nails to all fingers on his right hand. There was no documented evidence, and the facility could not produce any documented evidence Resident #76 was provided nail care. In an interview on 12/10/2024 at 9:05 AM, Resident #76 indicated he had asked staff to trim his nails, but staff had not trimmed his nails. Resident #76 further indicated he was bothered that his fingernails on both his hands were long. In an interview on 12/10/2024 at 9:12 AM, S2Director of Nursing (DON) indicated Resident #76's nails should have been trimmed by staff when resident #76 requested nail care. In an interview on 12/10/2024 at 9:33 AM, S3Assistant Director of Nursing (ADON) indicated staff should have trimmed Resident #76's when requested nail care.

Based on observations, interviews and record reviews, the facility failed to have a system in place to ensure staff increased supervision to prevent elopement for severely cognitively impaired residents who displayed exit seeking behaviors for 2 (#1 and #3) of 7 (#1-#7) sampled residents to prevent elopement. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. when Resident #1, a severely cognitively impaired resident, eloped from the facility without the facility staff's knowledge. On 08/01/2023 at approximately 1:00 a.m., Resident #1 climbed through his bedroom window and exited the facility grounds through the unlocked fence located at the end of Hall W. Resident #1 walked approximately 1 mile, crossed a set of railroad tracks and a busy four lane highway, and stopped at a friend's house. According to the facility's incident report, the facility did not discover Resident #1 was missing from the facility until 08/01/2023 at approximately 8:00 a.m. Resident #1 was later found on 08/01/2023 at approximately 2:51 p.m. when S24Driver arrived at a local hospital and recognized Resident #1 in the lobby of the hospital. S24Driver then notified local authorities and S2Director of Nursing (DON). Resident #1 returned to the facility assisted by local police at approximately 4:00 p.m. on 08/01/2023. An order was received on 08/02/2023 to transport Resident #1 to the hospital for an inpatient psychiatric visit. The immediate jeopardy ended when Resident #1 was placed on 1 on 1 supervision until Resident #1 was transported to the hospital on 08/02/2023 at 3:09 p.m. The Immediate Jeopardy continued for Resident #3, a severely cognitively impaired resident, who began displaying exit seeking behaviors on 02/24/2023 and staff supervision was not increased. S5Regional [NAME] President of Operations (RVPO) was notified of the Immediate Jeopardy on 08/03/2023 at 4:23 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 4:33 p.m. as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice had the likelihood to cause more than minimum harm to the remaining 4 residents identified (#1, #3, #4, and #8) identified as elopement risks. Findings: Review of the facility's policy for Wanderer Management, Monitoring System and Resident Elopement Protocol revealed, in part, an elopement risk was determined by the use of the Wander Data collection tool. Review revealed the assessment should also include review of the resident's medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. Review revealed the Wander Data collection tool was to be completed on admission, quarterly, upon change of condition, or after an elopement incident. Review revealed, an elopement risk binder would be maintained in a central area and would contain a current picture of the resident and a current face sheet. Further review revealed, after an elopement incident the interdisciplinary team must review the resident's plan of care to determine changes that may be warranted. The family must be included to assure that all areas are addressed. The facility would provide proper psychosocial support to the resident and/or family. The facility may assess the resident to determine if alternate placement was necessary to assure the resident's safety. The facility's Quality Assurance Performance Improvement Team shall review facility system to evaluate if all systems are working appropriately. On 08/02/2023, review of the facility's elopement risk binder revealed Resident #1 and Resident #4 were identified as an elopement risk. Review of the facility's Staffing, Sufficient and Competent Nursing policy revealed, in part, licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting, and reporting resident changes of conditions consistent with their scope of practice and responsibilities. Resident #1 Review of the facility's incident report entered on 08/01/2023, revealed an incident description which read at approximately 8:00 a.m. staff discovered Resident #1 was missing from the facility. The facility completed the following: search of the facility to include all rooms, restrooms, closets, the facility grounds, and staff was deployed to search the surrounding community and local hospitals were notified. A silver alert was issued with the local police to assist with the search. Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Unspecified Psychosis, Major Depressive Disorder, Dementia with other behavioral disturbances, and Anxiety Disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/2023 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated Resident #1 had severe cognitive impairment. Further review revealed, Resident #1 was independent with walking and did not use a wander/elopement alarm daily. Review of Resident #1's Comprehensive Care Plan revealed, in part, a focus that included Resident #1 was at risk for elopement related to his impaired safety awareness with an initiation date of 01/06/2023. Further review revealed no documented evidence and the facility did not present any documented evidence of having interventions implemented to prevent elopement before 08/02/2023. Resident #1's Care Plan also revealed he had impaired cognitive function with an initiation date of 11/07/2022. Further review revealed Resident #1's interventions with an initiated date of 11/07/2022 that staff should cue, reorient, and supervise Resident #1 as needed. Review of Resident #1's Physician's Orders from January 2023- August 2023 revealed, in part, an order with a start date of 01/02/2023 and a status of discontinued that read wander bracelet r/t wandering/exit seeking behaviors 2nd to psychosis. Review of Resident #1's Wander Data Collection form with a completion date of 01/05/2023, revealed, in part, Resident #1 was cognitively impaired, displayed wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place, was able to ambulate independently, verbally expressed the desire to go home, had a visual, auditory, and/or communication deficits, and was searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed as being at high risk for wandering. Review of Resident #1's Wander Data Collection form with a completion date of 02/06/2023, revealed, in part, Resident #1 was cognitively impaired and did not display wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place. Further review revealed Resident #1 was able to ambulate independently, did not verbally express the desire to go home, did not have any visual, auditory, or communication deficits, and was not searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed for being at low risk for wandering. Review of Resident #1's Wander Data Collection form with a completion date of 05/05/2023, revealed, in part, Resident #1 was not cognitively impaired and did not display wandering behaviors that put Resident #1 at a significant risk of getting to a potentially dangerous place. Further review revealed Resident #1 was not able to ambulate independently, did not verbally express the desire to go home, did not have any visual, auditory, or communication deficits, and was not searching and/or seeking to find a spouse and/or family member. Further review Resident #1 was assessed for being at low risk for wandering. Review of Resident #1's nurse's notes dated 05/30/2023 at 7:07 a.m. written by S28LPN revealed, in part, that Resident #1 was at the facility's lobby door and wanted to leave to go to a job in Texas. Further review, revealed Resident #1 became upset after the nurse attempted to redirect him and went to his room to pack his belongings. Review revealed an additional nurse's note with a date of 07/13/2023 at 3:45 p.m. written by S31LPN which stated Resident #1 was at the facility's nurse's station and stated he wished he could go run off on the highway and get hit by a car. Review also revealed an additional nurse's note with a date of 08/01/2023 at 9:24 a.m. written by S2DON which stated at approximately 8:30 a.m. S2DON was notified by staff Resident #1 was not able to be located. In an interview on 08/02/2023 at 9:15 a.m. S5RVPO stated he was currently serving as the administrator of the facility. S5RVPO stated in the last 6 months the facility had two incidents of elopement. S5RVPO stated the first incident occurred on 05/27/2023 when, a cognitive resident, Resident #2 climbed out of his window and was found shortly after, still on facility grounds, by a staff member and was brought back into the facility. The second incident occurred on 08/01/2023 when Resident #1 climbed out of his window and left the facility grounds. In an interview on 08/02/2023 at 10:04 a.m. Resident #1 stated he eloped from the facility on 08/01/2023 shortly after midnight. Resident #1 stated throughout the day on 08/01/2023 and into the evening he had been telling staff he was going to leave the facility. Resident #1 stated he opened his window, placed his right leg out of the window, placed his left leg out of the window, climbed out of the window, walked around the building to the fence located at the end of Hall W, and walked out of the unlocked gate. Resident #1 stated he then walked up the road that led to the facility towards the highway, crossed the railroad tracks, crossed the four lane highway, and kept walking until he got to his friend's house that he was going to do a job with. Resident #1 stated it took him about 45 minutes to get to his destination, but he does not remember the address of where he went. Resident #1 stated his friend and he later arrived at a local hospital for his girlfriend's medical care and during that time a staff member from the facility recognized him. Resident #1 stated he then was brought back to the facility by the police. Observation on 08/02/2023 at 10:06 a.m. revealed Resident #1 in his room lying in his bed. Observation further revealed Resident #1's window was able to be unlocked and opened. In an interview on 08/02/2023 at 10:09 a.m. S29CNA stated she works for the facility full time on the night shift. S29CNA further stated she worked on the night of 07/31/2023, which led into the morning of 08/01/2023. S29CNA stated residents who wander are identified by their wander guard bracelets. S29CNA stated she was not notified that Resident #1 was an elopement risk prior to this incident. S29CNA stated she is not aware of any residents in the facility that are elopement risks at this time. In an interview on 08/02/2023 at 10:30 a.m. S9MDS Nurse stated she was assigned to Resident #1. S9MDS Nurse stated Wander Data Collection forms were completed on admission, readmission, when status changes occur, and quarterly. S9MDS Nurse stated in order to complete a Wander Data Collection forms, she gathers information from the floor nurse that was taking care of the resident. S9MDS Nurse stated Resident #1 was an elopement risk as of 01/06/2023 when he began displaying exit seeking behaviors. S9MDS Nurse stated Resident #1 used to wear a wander guard bracelet, but it was discontinued and she did not remember why. S9MDS Nurse further stated prior to the incident on 08/01/2023 she had not been notified Resident #1 was displaying exit seeking behaviors. In an interview on 08/02/2023 at 10:45 a.m. S2DON stated Resident #1 has had exit seeking behaviors since he was admitted to the facility. S2DON stated Resident #1 had a wander guard bracelet in place, but he kept removing the wander guard bracelet so the facility discontinued it. S2DON further stated she was not notified on 05/30/2023 or 07/31/2023 Resident #1 displayed exit seeking behaviors. S2DON further stated the facility identified on 07/26/2023, they could not meet Resident #1's needs due to his suicidal ideations and exit seeking behaviors. S2DON further stated Resident #1 was not placed on 1 on 1 monitoring until after the elopement incident on 08/01/2023. Observation on 08/02/2023 at 10:50 a.m. revealed the windows in Room a, Room b, Room c, Room d, Room e, Room f, Room g, Room h, Room I, Room j, and Room k on Hall Z was able to be unlocked and slide open to access the front of the facility that was not gated and faced the road. In an interview on 08/02/2023 at 11:00 a.m. S6Regional Maintenance Director stated all of the windows in the facility were not secured. S6Regional Maintenance Director stated the windows were able to be locked from the inside, but can be easily opened at any time from the inside. S6Regional Maintenance Director stated half of the facility's windows opened to the back of the facility that was fenced in, but the other half opened to the road. S6Regional Maintenance Director stated Resident #1's window had been sealed, but nothing was keeping him or any other resident from entering another resident's room and crawling out of their window. In an interview on 08/02/2023 at 11:20 a.m. S7Unit Manager stated she completed Resident #1's a Wander Data Collection form on 01/05/2023. S7Unit Manager stated Resident #1 was labeled as an elopement risk because he was cognitively impaired, frequently displayed exit seeking behaviors, and was always looking for his daughter. In an interview on 08/02/2023 at 12:45 p.m. S28Licensed Practical Nurse (LPN) stated she was the nurse on 05/30/2023 when Resident #1 said he wanted to leave to go to a job in Texas. S28LPN further stated she did consider this behavior exit seeking behavior. S28LPN further stated she notified S2DON, but she did not increase supervision for Resident #1. In an interview on 08/02/2023 at 2:45 p.m. S3Assistant Director of Nursing (ADON) stated she was never notified by staff on the evening of 07/31/2023 that Resident #1 was displaying exit seeking behaviors. In an interview on 08/02/2023 at 2:50 p.m. S10Quality Assurance (QA) Nurse stated Resident #1 had been to the psychiatric hospital from 07/19/2023- 07/26/2023 for suicidal ideations. S10QA Nurse stated upon returning to the facility, the IDT team had discussed the facility could not meet Resident #1's needs and he needed alternate placement. S10QA Nurse stated she was not notified Resident #1 was displaying exit seeking behavior, only that he desired to go to another facility. In an interview on 08/02/2023 at 3:00 p.m. S24Driver stated she was the staff member that found Resident #1 at a local hospital. S24Driver stated she arrived at the hospital to deliver labs and Resident #1 was sitting in the lobby. S24Driver stated she notified authorities and Resident #1 was brought back to the facility around 4:00 p.m. S24Driver stated Resident #1 had left the facility and went to an address which was approximately 1-2 miles from the facility. S24Driver stated she knew the address of the location in which Resident #1 went to because he spoke about going to this address since he was admitted to the facility. S24Driver stated Resident #1 displayed exit seeking behaviors often. Review of the global positioning system revealed when walking from the facility to the address Resident #1 walked to after eloping from the facility was approximately 1 mile. Further review revealed, in order to reach the destination a set of train tracks and a four lane highway had to be crossed. Observation on 08/03/2023 at 12:50 p.m. revealed the windows in Room l, Room m, Room n, Room o, Room p, Room q, Room r, Room s, Room t, Room u, Room v, and Room w were able to be unlocked and slide open to access the front of the facility that was not gated and faced the road. In an interview on 08/03/2023 at 2:33 p.m. Resident #1's Responsible Party (RP) stated S10QA Nurse called and notified her on 08/01/2023 around 9:48 a.m. that Resident #1 was missing and the facility was unaware of his location. Resident #1's RP stated she was currently on vacation out of state and she had no idea where Resident #1 could have went at the time. Resident #1's RP stated she was very concerned because prior to Resident #1 being admitted to the facility, he would wander into random people's homes due to his diagnosis of dementia. Resident #1's RP stated she informed the facility prior to his admission of the above and that was the reason she was admitting him to the facility. Resident #1's RP stated Resident #1 had a wander guard bracelet around his ankle, but he removed it multiple times so the facility chose to leave it off. Resident #1's RP further stated she received a second call from the facility stating they had located Resident #1, he was in no distress, and he would be transferred to a psychiatric facility for evaluation between 08/01/2023 and 08/02/2023. In an interview on 08/04/2023 at 9:30 a.m. S1Administrator stated it was determined Resident #1 got out of the backyard fencing because the gate was left unlocked by the contracted lawn company. S1Adminsitrator stated normal practice of the facility was for himself or S30Maintenance Director to ensure the fence was locked when yard work was completed. S1Administrator stated at the time of the incident himself and S30Maintenance Director were both on leave and was unable to ensure the gate was locked after the lawn company left the facility. In an interview on 08/04/2023 at 10:04 a.m. S2DON stated staff should have immediately recognized Resident #1's behavior as exit seeking and implemented increased supervision. S2DON further stated if staff had notified her of Resident #1's behavior earlier in the shift, she would have been able to implement 1 on 1 monitoring and Resident #1 would've never been able to elope from the facility. In an interview on 08/04/2023 at 10:07 a.m. S1Administrator stated two residents had used the same tactic to elope from the facility through a window. S1Adminstrator further stated if the facility had implemented the above stated interventions after the first time a resident left the facility through a window on 05/27/2023, all residents would have been assessed properly for elopement, appropriate interventions would have been implemented for each resident, and Resident #1's elopement would have been prevented. In a phone interview on 08/04/2023 at 1:02 p.m. S25Certified Nursing Assistant (CNA) stated she was the CNA assigned to Resident #1 the night he eloped from the facility. S25CNA stated the last time she had seen Resident #1 was around 10:00 p.m. at the beginning of her shift on 07/31/2023 when Resident #1 requested he be left alone to go to sleep. S25CNA stated she was not notified by the facility that Resident #1 was an elopement risk. S25CNA stated the facility had not ever educated her or communicated to her who the wandering residents in the facility were. S25CNA further stated if the facility had notified her Resident #1 was displaying exit seeking behaviors she would have provided 1 on 1 monitoring and Resident #1 would not have eloped from the facility. In an interview on 08/04/2023 at 1:15 p.m. S9MDS Nurse stated Resident #1's Wander Assessments completed on 02/06/2023 and 05/05/2023 were completed incorrectly, which was the reason Resident #1 was assessed as being at low risk for wandering. S9MDS Nurse further stated Resident #1 should have had a wander assessment completed after each change in condition when he began displaying exit seeking behaviors. S9MDS Nurse further stated Resident #1 should have had interventions put into place prior to 08/02/2023 address his exit seeking behaviors. Resident #3 Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date(ARD) of 05/23/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated that he was severely cognitively impaired. Further review revealed, Resident #3 required supervision with one-person physical assistance for locomotion on the unit, locomotion and required supervision with set up help only for transfer, walking in the room, and walking in the corridor. Review of Resident #3's physician progress note dated 01/19/2023 revealed, in part, Resident #3 was adamant about going home. Review of Resident #3's progress note dated 02/23/2023 revealed, in part, Resident #3 wanted to go home and did not have any transportation, but insisted on going home. Review of Resident #3's progress note dated 03/23/2023 revealed, in part, Resident #3 wanted to go home. Review of Progress Note dated 04/26/2023 revealed, in part, Resident #3 complained of wanting to go home and wanting his truck. Review of Resident #3's progress note dated 05/18/2023 revealed, in part, Resident #3 still wanted to go home. Review of Resident #3's psychiatric progress note dated 06/01/2023 revealed, in part, staff was reporting Resident #3's was exit seeking and was increasingly confused as dementia was progressing. Review of Resident #3's progress note dated 07/27/2023 revealed, in part, Resident #3 wanted to go home. Review of Resident #3's nurse's note dated 02/24/2023 at 9:53 a.m., revealed, in part, Resident #3 was in the front lobby screaming and attempting to leave the facility. Further review revealed, Resident #3 stated my truck is outside, and I am leaving out this god damn place Review of Resident #3's nurse's note dated 02/24/2023 at 12:24 p.m., revealed, in part, Resident #3 refused to stay in his room where he was on isolation for COVID-19. Further review revealed, resident swore at staff, attempted to push his walker over staff, and demanded to be let out of the front door to get his car to go home. Further review revealed, Resident #3 had also packed all of his belongings in a large suitcase in his room. Review of Resident #3's nurse's note dated 03/26/2023 revealed, in part, Resident #3 noted with agitation related to attempting to leave facility to get back to his car. Further review revealed, resident pulled on the door and demanded to, and resident paced up and down the hall while yelling at staff very aggressively. Review of Resident #3's nurse's note dated 03/27/2023 revealed, in part, Resident #3 continued to request to leave the facility. Further review revealed, staff attempted to redirect, but Resident #3 returned minutes later with identical behavior. Review of Resident #3's nurse's note dated 03/29/2023 revealed, in part, Resident #3 was noted with increased agitation, attempted to leave the facility, slammed doors, and cussed at the staff. Review of Resident #3's nurse's note dated 04/05/2023, revealed, in part, Resident #3 had been increasingly agitated and seeking to go home. Review of Resident #3's nurse's note dated 04/07/2023 revealed, in part, Resident #3 was noted with increased agitation in the front lobby and stated, I need to go to [NAME] City, and somebody stole my truck. Further review revealed staff reoriented frequently, but Resident #3 later continued with the same behavior. Review of Resident #3's nurse's note dated 06/18/2023 revealed, in part, Resident #3 ambulated around the hall with the use of a walker and was hard of hearing. Further review revealed, Resident #3 had a large suitcase packed and talked constantly of going home to see about his house and truck. Review of Resident #3's Wander Data Collection report dated 02/22/2023 revealed, in part, Resident #3 was assessed as being at low risk for wandering. Review of Resident #3's Wander Data Collection report dated 05/23/2023 revealed, in part, Resident #3 was assessed as being at low risk for wandering. Further review revealed, the answer no was indicated for questions related to if Resident #3 was cognitively impaired, if Resident #3 wandered, did the resident have any auditory deficits, and did the resident verbally express the desire to go home or pack up their belonging to leave. Further review of Resident #3's Wander Data Collection report revealed assessments related to Resident #3's wandering or exit seeking was performed on 02/24/2023, 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023. Observation on 08/02/2023 at 1:57 p.m., revealed Resident #3 was lying in the bed without staff present in his room or within the line of sight of staff. Observation revealed, Resident #3's window was able to be opened at this time. Further observation revealed, Resident #3 without a wander guard bracelet in place. In an interview on 08/02/2023 at 1:28 p.m. Resident #3 stated he wanted to get out of this place and go home. Resident #3 further stated he was going to figure out a way to leave this facility. In an interview on 08/03/2023 at 11:20 a.m., S1Administrator stated if a resident was having wandering or exit seeking behaviors, the facility's procedure was that a wandering assessment should be completed on the resident exhibiting those behaviors. Observation on 08/03/2023 at 8:42 a.m., revealed Resident #3's door to his room was closed and no staff was present to supervise Resident #3. Further observation upon entering room revealed, Resident #3 sitting on the side of his bed. Further observation revealed, Resident #3's window was able to be opened, and a large suitcase was in the middle of Resident #3's room. Observation on 08/03/2023 at 10:57 a.m., revealed Resident #3's door to his room was closed and no staff was present to supervise Resident #3. Further observation upon entering room revealed, Resident #3 lying in bed. Further observation revealed, Resident #3's window was able to be opened, and a large suitcase was in the middle of Resident #3's room . In an interview on 08/03/2023 at 10:57 a.m., Resident #3 stated that he had his suitcase out because it was packed for him to take home. Resident #3 stated that he needed to get out of the facility to go and check on his truck. In an interview on 08/03/2023 at 11:02 a.m., S7Unit Manager stated all resident's wandering evaluations should be completed on admission, quarterly, and as needed when residents displayed wandering or exit seeking behaviors such as trying to leave the facility and having a plan to go home. In an interview on 08/03/2023 at 11:05 a.m., S21Certified Nursing Assistant (CNA) stated she saw Resident #3 try to go out into the facility's parking lot and try to get out of the facility on multiple occasions. S21CNA further stated Resident #3 packed his luggage constantly to try to leave with his stuff. In an interview on 08/03/2023 at 11:05 a.m., S23CNA confirmed that Resident #3 has wandered and tried to get out of the building, but stated she was unsure if Resident #3 was a wandering or elopement risk. S23CNA further stated she had witnessed Resident #3's had packed luggage to leave with, and Resident #3 was constantly worried about getting to his truck. In an interview on 08/03/2023 at 11:13 a.m., S24Driver stated Resident #3 constantly asked to go outside or to leave the facility, including this morning, 08/03/2023, at 10:00 a.m. In an interview on 08/03/2023 at 12:00 p.m., S9MDS Nurse stated she had not realized that Resident #3 was displaying wandering or exit seeking behaviors on 02/24/2023, 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023. S9MDS Nurse further stated a wandering assessment should have been conducted for each new behavior noted on the above dates, and Resident #3's care plan should have been updated to reflect his exit seeking and wandering behaviors. In an interview on 08/03/2023 at 2:30 p.m., S8MDS Nurse stated when completing a quarterly wandering assessment, staff assess for wandering or exit seeking behaviors noted in a seven-day lookback period. S8MDS Nurse further stated that this practice was not adequate, because Resident #3's assessments were only being done every quarter. S8MDS nurse also stated that staff should have reported any new wandering or exit seeking behavior done by Resident #3 and a new wandering assessment should have been performed. In an interview on 08/03/2023 at 2:40 p.m. S7Unit Manager stated that she was unaware that Resident #3 had exit seeking behaviors since 02/24/2023. S7Unit Manager further stated each time Resident #3 started exhibiting wandering or exit seeking behaviors, a new wandering evaluation should have been performed, and Resident #3 should have possibly had increased supervision. S7Unit Manager further stated that Resident #3 now has a wander guard bracelet on, but that this device would not alert if resident attempted to exit the building via window. In a phone interview on 08/04/2023 at 9:54 a.m., S20Licensed Practical Nurse (LPN) stated her nurse's note on 04/07/2023 was related to Resident #3's dementia behaviors. S20LPN further stated that Resident #3 was able to ambulate around the facility with his walker, and that on 02/24/2023 Resident #3 attempted to leave the facility with his Guitar packed. S20LPN also stated that Resident #3 always has his luggage packed to go home. In an interview on 08/04/2023 at 10:01 a.m., S3Assistant Director of Nursing (ADON) stated it was important for staff to complete new wandering assessments when residents start exhibiting new wandering or exit seeking behaviors because these assessments give facility information to help keep the residents safe. A phone interview on 08/04/2023 at 10:19 a.m., S22LPN stated she had noted Resident #3 talking about wanting to get out of the facility and packing and unpacking his bag, but was unaware if he had ever attempted to get out of the facility. S22LPN further stated she did not specifically report the behaviors noted above to S2DON or Resident #3's physician because Resident #3 had been having these behaviors and everyone in the facility was aware. In an interview on 08/04/2023 at 10:50 a.m., S2Director of Nursing stated that when she noted Resident #3 was having exit seeking behaviors and packing a bag on 02/24/2023, a wandering assessment should have been completed. S2DON further stated that when Resident #3's was displaying wandering or exit seeking behaviors on 03/26/2023, 03/27/2023, 03/29/2023, 04/05/2023, 04/07/2023, and 06/18/2023, a wandering assessment should have been completed and Resident #3's care plan should have been updated. In an interview on 08/04/2023 at 2:31 p.m., S7Unit Manager stated she was not thorough when completing Resident #3's wandering assessment on 08/03/2023, and should have assessed him fully for wandering behaviors, exit seeking behaviors, verbalizing wanting to go home, or packing a bag. S7Unit Manager further stated that she was in-serviced on correctly completing a wandering evaluation.

The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to provide supervision to keep a resident free from elopement for 2 (#1 and #3) of 7 (#1 - #7) sampled residents. The facility failed to: 1. Ensure Resident #1, a severely cognitively impaired resident, who was care planned for wandering, was accurately assessed and/or adequately supervised when exit seeking behaviors were displayed; and 2. Ensure Resident #3, a severely cognitively impaired resident, was accurately assessed and adequately supervised when exit seeking behaviors were displayed. The Immediate Jeopardy situation began on 08/01/2023 at approximately 1:00 a.m. when Resident #1, a severely cognitively impaired resident, eloped from the facility without the facility staff's knowledge. On 08/01/2023 at approximately 1:00 a.m., Resident #1 climbed through his bedroom window and exited the facility grounds through the unlocked fence located at the end of Hall W. Resident #1 walked approximately 1 mile, crossed a set of railroad tracks and a busy four lane highway, and stopped at a friend's house. According to the facility's incident report, the facility did not discover Resident #1 was missing from the facility until 08/01/2023 at approximately 8:00 a.m. Resident #1 was later found on 08/01/2023 at approximately 2:51 p.m. when S24Driver arrived at a local hospital and recognized Resident #1 in the lobby of the hospital. S24Driver then notified local authorities and S2Director of Nursing (DON). Resident #1 returned to the facility assisted by local police at approximately 4:00 p.m. on 08/01/2023. An order was received on 08/02/2023 to transport Resident #1 to the hospital for an inpatient psychiatric visit. The immediate jeopardy ended when Resident #1 was placed on 1 on 1 supervision until Resident #1 was transported to the hospital on 08/02/2023 at 3:09 p.m. The Immediate Jeopardy continued for Resident #3, a severely cognitively impaired resident, who began displaying exit seeking behaviors on 02/24/2023 and staff supervision was not increased. S5Regional [NAME] President of Operations (RVPO) was notified of the Immediate Jeopardy on 08/03/2023 at 4:23 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 4:33 p.m. as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice had the likelihood to cause more than minimum harm to the remaining 4 residents identified (#1, #3, #4, and #8) identified as elopement risks. Findings: Cross Reference F-689. In an interview on 08/04/2023 at 10:04 a.m. S2DON stated staff should have immediately recognized Resident #1's behavior as exit seeking and implemented increased supervision. S2DON further stated if staff had notified her of Resident #1's behavior earlier in the shift, she would have been able to implement 1 on 1 monitoring and Resident #1 would've never been able to elope from the facility. In an interview on 08/04/2023 at 10:07 a.m. S1Administrator stated two residents had used the same tactic to elope from the facility through a window. S1Adminstrator further stated if the facility had implemented the above stated interventions after the first time a resident left the facility through a window on 05/27/2023, all residents would have been assessed properly for elopement, appropriate interventions would have been implemented for each resident, and Resident #1's elopement would have been prevented. In an interview on 08/04/2023 at 2:00 p.m., S5RVPO stated he completed an in-service with S1Administrator, S2DON, S3ADON, S10QA Nurse, S8MDS Nurse, S9MDS Nurse, S16Maintenance Assistant, S7Unit Manager, S15Housekeeping and Laundry Supervisor, S17Business Office Manager, S18Human Resources, S14Therapy Director, and S11Social Services Director that covered all elements listed in the plan for the above stated deficiencies and discussed listed interventions to ensure continued compliance. S5RVPO further stated he will be coming monthly to ensure all the above stated audits and education is completed by the administrative staff.

Based on observation, record review and interview the facility failed to ensure that residents receives adequate supervision to prevents falls for 2 (#93, #45) of 3 (#93,#45, #28. The facility further failed to: 1. Investigate the cause of the fall when resident # 45 was found on the floor after being left in the room alone. 2. Update the care and initiate new interventions after falls for 2 (#93, #45) of 3 (#93,#45, #28) This failed practice resulted in an actual harm on 8/9/15 at 7:00 a.m. when Resident # 45 was found on the floor face down in the main lobby. Further review revealed that the resident had a laceration to her forehead and the area was indented. A review of the Hospital Emergency Record dated 8/9/15 revealed that the resident was assessed as having pain and that she had a laceration to her forehead that required sutures and a [DIAGNOSES REDACTED]. FINDINGS: 1. Resident #45: During an interview with S4, LPN during Stage I of the survey process, she reported that the resident had sustained falls on 8/8/15 and 8/9/15. She added that Resident #45 sustained a fractured neck during the fall on 8/9/15. A record review of the facility's Fall Log revealed that Resident #45 only sustained 1 fall during the month of August, 2015 and that it occurred on 8/9/15. An observation was made of Resident #45 on 8/17/15 during the lunch meal and she was seated up in a wheelchair with a soft cervical collar in place. Resident #45 was not interviewable due to a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. A record review revealed that Resident #45 was admitted to the facility on [DATE]. Resident #45 had [DIAGNOSES REDACTED]. A review of Resident #45's Minimum Data Set ((MDS) dated [DATE] revealed that she required extensive assistance for bed mobility and transfers, and that she required total assistance for dressing, and toileting. Resident #45 was unable to ambulate, she utilized a wheelchair and she required total assistance of staff with locomotion. Resident #45 had experienced no pain during the look back period. Resident #45 was incontinent of bowel and bladder. A review of Resident #45's clinical record revealed that Fall Risk Assessments were completed, the most recent on 11/13/14, and that she was at risk for falls with a score of 12. A review of Resident #45's Care Plan revealed that she was care planned at risk for falls due to Osteoporosis and a history of falls. Resident #45 had not had falls since admit on 1/7/12. An intervention included to monitor for changes in condition that would warrant increased supervision/assistance and to notify her physician. Resident #45's Care Plan was not updated after the fall on 8/8/15. A review of Resident #45's Incident Report dated 8/9/15 revealed that she was found on the floor face down at 7:00 a.m. in the main lobby. Further review revealed that the resident had a laceration to her forehead and that the area was indented and that the resident complained of pain to the forehead. Resident #45 was sent out to the hospital emergency department for evaluation. The Incident Report was completed by S5, LPN. A review of one Witness Statement dated 8/9/15 was provided by the facility and it revealed that it was completed by S6, LPN. The Witness Statement revealed that the resident was seated in a chair and that the resident fell face first. There was no other documentation included in the blanks to indicate what the staff noticed about the area where the incident occurred, who she reported it to, if anyone else witnessed the incident, and who else may have witnessed the incident. A review of the Neurological Record completed after the 8/9/15 fall revealed that neurological checks were initiated after Resident #45 returned from the hospital at 1:40 p.m. Further review revealed that blood pressures were not completed from 3:10 PM to 5:10 p.m. and that the pupil responses were not completed from 2:40 p.m. to 12 a.m. on 8/10/15. A review of Resident #45's Nurse's Notes dated 8/9/15 at 1:36 p.m., completed by S5, LPN revealed that while she was passing medications, she heard a thump and that she found the resident on the floor face down. Resident #45 was noted to have a bleeding laceration to the forehead. A review of Resident #45's Nurse's Notes dated 8/9/15 at 1:54 p.m., completed by S9, RN, Tx Nurse, revealed that the resident, fell out of her chair, and was found lying with her face/forehead on the floor. Further review revealed that the resident was bleeding profusely from the laceration to her forehead. Resident #45 complained of pain to the forehead area when the compression dressing was applied. Resident #45 was taken by ambulance to the hospital emergency department. A review of the Hospital Emergency Record dated 8/9/15 revealed that the resident was assessed as having pain and that she had a laceration to her forehead that required sutures and a [DIAGNOSES REDACTED]. Further review of the hospital emergency department record revealed that the resident was capable of localizing pain and that she was assessed as having pain. A review of Resident #45's Nurse's Notes revealed that the resident also sustained a fall on 8/8/15. Further review of the note revealed that the resident was left in her room unattended after the evening meal and that when the staff CNA (Certified Nursing Assistant) went back to prepare her for bed, that she was found on the floor. Further review revealed that the resident had a skin tear to her right forearm and an abrasion to both of her knees. There were no Nurse's Notes for the 8/8/15 night shift of 10 p.m. to 6 a.m. on 8/9/15. A request was made to S1, RN, DON for all incident reports for this resident on 8/19/15 and she reported that she only had one in August, 2015, and that it was for the fall on 8/9/15. An interview was conducted with S1, RN, DON on 8/20/15 at 6:10 p.m. and she stated that she had located another Incident Report dated 8/8/15 and that it included information to indicate that Resident #45 had sustained a fall on the evening shift of 8/8/15. She stated that the Incident Report had not showed up on the facility log because the staff had not included a date that the incident occurred in the computer system. She stated that she was not aware that the resident had sustained a fall on 8/8/15 and that it was not investigated. She provided a copy of the 8/8/15 Incident Report that indicated that the resident sustained [REDACTED]. S1, RN, DON stated that she had not read Resident #45's Nurse's Notes that indicated that the resident had sustained a fall on 8/8/15. A review of the Incident Report dated 8/8/15 revealed that the resident had slid out of her wheelchair onto the floor. Further review revealed that the CNA had placed the resident in her room until she would go back to put her into bed. Resident #45 was found laying on her right side and was noted to have a skin tear on her right forearm, and abrasions to both knees. Further review of the document revealed that the resident's physician was notified (not specific as to how he was notified), and the date that the contact was initiated as 8/8/15, and there was no information in the section for the time that the physician responded. There were no witness statements included with this Incident Report. A review of the Neurological Record initiated after the 8/8/15 fall revealed that the resident's pupil responses were not completed from 8/8/15 at 7:10 p.m. to 10:00 p.m. An interview was conducted with S5, LPN on 8/20/15 at 11:30 a.m. and she confirmed that she was present when Resident #45 fell on [DATE] at 7:00 a.m. and that she completed the Incident Report. She stated that the resident was seated in the front lobby near the door to the dining room when the incident occurred and that she had been there since she arrived for work at approximately 6:00 a.m. S5, LPN stated that the resident was seated upright in her wheelchair and that when the incident occurred, that there were other staff seated at the nurse's station nearby, including the off going nurse from the 6:00 a.m. shift. She stated that the off going nurse had informed her that the resident had fallen the night before but that she had not provided her with any information about what happened and how she fell because it was unwitnessed. She stated that the resident was seated near the dining room door, lined up with a row of other residents that were awaiting the CNA staff to arrive for the residents that required feeding at the feeding tables. An interview was conducted with S1, RN, DON on 8/20/15 at 12:35 p.m. and she stated that she was responsible for investigating all incidents, including falls. She stated that she did not investigate the fall on 8/8/15 because she was not aware that it had occurred. An interview was conducted with S10, Administrator on 8/20/15 at 3:00 p.m. who reviewed the documentation of the investigation provided on the 8/9/15 incident in which the resident was found on the floor in the lobby by staff. He confirmed that there was only one Witness Statement completed by S6, LPN. He stated that this would be considered an incomplete investigation into this incident. He stated that he would expect witness statements from all other employees that were anywhere around the incident. A phone interview was conducted with S11, LPN on 8/21/15 at 11:33 a.m. and she confirmed that she was present when Resident #45 was found on the floor in her room on 8/8/15 by S12, CNA. She confirmed that she completed the Incident Report and she added that she had S12, CNA complete a witness statement and put it in S1, RN, DON's box herself. S11, LPN stated that she sent an oral message via another staff member, unable to recall name, to notify S1, RN, DON that the incident had occurred but that she did not speak to her in person during the evening shift on 8/8/15. She stated that she notified S1, RN, DON in person on 8/9/15 in the am, but was unable to recall the time. S11, LPN stated that S12, CNA should not have left Resident #45 alone in the room while up in her wheelchair and that she instructed her not to leave her unattended in the chair in her room again. She confirmed that she notified S1, RN, DON on the a.m. of 8/9/15, that she had completed an Incident Report in the computer regarding the fall from previous evening on 8/8/15. She denied having updated the care plan after the fall on 8/8/15 and stated that she did not know if she had access to the care plans. She stated that she was not aware that she should have updated the care plan and/or added new interventions for the oncoming staff to put into place after the fall on 8/8/15 at 6:00 p.m. S11, LPN stated that she did not know Resident #45 well enough to know if her behavior during the 2:00 p.m. to 10:00 p.m. shift on 8/8/15 was normal for her in order to report her being ill or her behavior being any different than normal. S11, LPN denied having investigated the condition of Resident #45's wheelchair after she slid out of it on 8/8/15 at 6:00 p.m. S11, LPN confirmed that she was also present when Resident #45 sustained another fall on 8/9/15 at 7:00 a.m. She stated that the fall was unwitnessed and that it occurred in the front lobby near the dining room door. She added that the resident was seated outside the dining room awaiting staff to bring her in for breakfast. S11, LPN stated that other nursing staff, S5, LPN and S9, RN were present at the nursing station when the incident occurred. She added that S5, LPN, S9, RN and herself lifted the resident and brought her to her room after the incident. S11, LPN stated that she thought the other staff decided to move her before the ambulance service arrived because there was no much blood and they were concerned about the other residents that were in the lobby would be traumatized. S11, LPN denied updating the care plan after the fall on 8/8/15 6 p.m. fall. She stated that she did not know if she had access to the care plan and that she did not know that she had to update the care plan and/or add new interventions She stated that the only thing she did was tell the CNA her shift not to leave her alone in her room up while up in her wheelchair. An interview was conducted with S5, LPN on 8/21/15 PM who confirmed that she completed the 8/9/15 Incident Report involving Resident #45. She stated that the resident was seated up in her wheelchair awaiting to be pushed into the dining room for breakfast when she was found on the floor. She stated that she was aware of the fall on 8/8/15 and that she was surprised that the resident had fallen because she had no history of recent falls and that this was out of her normal behavior. S5, LPN stated that she assisted S9, RN and S11, LPN to put her up into her wheelchair and brought her to her room to await the ambulance. A review of the Incident and Accident Prevention System Policy provided by the facility revealed that the facility would conduct an investigation of all incidents involving residents of the facility. Further review revealed that all incidents/accidents should have been reported immediately to the supervisor or director of nursing. Further review also revealed that witness forms should have been completed by all persons who witnessed and by all persons who were thought to have witnessed the incident. The Investigation Form must have been initiated by the department supervisor or charge nurse and completed by the Administrator or Director of Nursing. Neuro checks were to be completed per neuro check sheet if applicable. Further review of the revised Neuro Check Protocol section dated 7/27/15 revealed that neuro checks were to be completed q (every) 30 minutes x 4 hours, q 1 hour x 4 hours, q 4 hours x 24 hours and q 8 hours x 72 hours. The charge nurse must have immediately initiated an investigation to determine the circumstances of the incident/accident. Documentation in the medical record to include in part, names of witnesses, actions to take to prevent a re-occurrence and follow up documentation regarding the resident's treatment and condition. Further review revealed that the Witness Forms, Incident Report and Investigation Report were to be submitted to the Director of Nurses/Designee upon their completion and he/she then should complete the investigation follow up on the Investigation Report form to come to a reasonable conclusion regarding the causative factors surrounding the incident and the actions necessary to prevent further incidents/accidents. All forms completed as a result of an incident/accident should have been filed together, by resident, by month in a binder in the Administrator/DON/Designee's office. 2. Resident #93: Resident #93 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Fall Risk evaluation dated 7/14/15 revealed he had a score of 19. Further review of the evaluation revealed that a score of greater than 10 was considered high risk. The procedure was to initiate a fall prevention program and place on the care plan. A review of the nurse's notes revealed the following: 7/17/15 at 7:27 p.m. by S14LPN: Res found on floor in front of w/c (wheelchair) by CNA (Certified Nursing Assistant) (___). 0 injuries denies pain. Fall was unwitnessed neuro checks in progress. Son (___) was notified. Dr. (___) was faxed and will continue to monitor. 7/19/15 at 11:42 a.m. by S4LPN: Late entry: 7/18/15 at 10:20 AM Resident noted on floor in dining area sitting upright on his buttocks resident stated 'I was walking and I slipped .' (Sic) 8/7/15 at 6:11 p.m. by S4LPN: Informed by the CNA that resident fell in dining room at 12:30pm while attempting to get out of his W/C . 8/15/15 at 11:07 p.m. by S11LPN: While on the medicine cart on the hall I observed res (resident) slowly place himself on the floor and lye down . (Sic) A review of the Care Plan revealed that a problem was identified on 7/21/15 for falls. ****I had a fall on 6/28/15 no injury noted, family notified, MD notified. ***I also had a fall on 7/18/15 and 7/17/15 no injuries . Further review revealed no information regarding the falls on 8/7/15 or 8/15/15 and had no updates or revisions for the multiple falls. On 8/19/2015 at 2:58 p.m., an interview was conducted with S8LPN, Care Plan nurse. She verified that Resident #93 had a fall on 6/28/15 that she did not care plan until 7/21/15 and that she did not update the care plan after each his falls on 7/17/15 and 7/18/15. She stated that she was unaware of the falls on 8/7/15 and 8/15/15. She stated that usually found out about falls during their start-up meeting in the mornings and then she would go to the computer and find the incident reports and then proceed to care plan the problem and make revisions when necessary. She stated that she must not have been present for the start-up meetings in which those falls were discussed. She confirmed that she did not have a system in place to catch problems if she did not attend a start-up meeting. On 8/19/15 at 3:30 p.m., an interview was conducted with S1DON. She reviewed Resident #93's Care Plan and verified that there were no new interventions for fall prevention with each of his falls. She stated that S8LPN should have known about the falls and should have addressed them in the care plan. She stated that she could have pulled up the incident reports herself even if she did not make it to their morning meeting. She verified that there was a system failure for revision of care plans. On 8/21/15 at 2:00 p.m., Resident #93 's care plan was provided which had comments hand written on the side which included: 7/17/15: Pain assessment MD and RP (responsible party) notified. 7/18/15: Neuro checks initiated fly. (family) and MD notified per staff. 8/7/15: Resident assessed for injuries and pain, V/S (vital signs) obtained, RP and MD notified. 8/15/15: Dr. (doctor) notified, fly. Notified V/S obtained. On 8/21/15 at 2:30 p.m., another interview was conducted with S1DON. She reviewed the care plan and verified that the new comments for 7/17/15, 7/18/15, 8/7/15, and 8/15/15 were not on the care plan prior to the interview with S8LPN. She further verified that the comments still did not address new interventions to prevent further falls for Resident #93.

Based on observation, record review and interview, the facility was not administered in a manner that enabled it to use its resources effectively to maintain the highest physical well-being. The Facility failed to: 1. Provide Resident #4 with physician ordered (ordered on 3-30-12) bolster pads, landing pads, and a bed alarm from 3-30 through 4-19-12. 2. Provide Resident #5 with physician ordered hipsters on 2-4-12 and care planned bed alarm dated 11-2-11, or to monitor Resident by the nursing station during waking hours as per his care plan dated 12-22-11. 3. Follow their incidents and accidents prevention system policy and procedure which included ensuring each resident's care plan was being followed, accurate level of assistance communicated on ADL flow sheet/CNA communication sheets, and review of current equipment available for appropriateness of device for Residents #4 and #5, 4. Supervise staff to ensure each Resident's safety devices were in place for Residents #4 and #5. 5. Ensure Resident #5 received weight bearing one person physical assistance when ambulating as per his MDS assessment dated [DATE]. 6. Identify trends in regards to Resident #5's falls by the Quality Improvement team. The Immediate Jeopardy situation began on 3-26-12 when resident #4 fell out of bed, and the facility failed to implement their documented safety interventions (Landing Strips, bed alarm and bolster pads) to prevent injuries by falling. The Administrator S1 was notified of the Immediate Jeopardy situation on 4-19-12 at 4:55 PM. The Immediate Jeopardy situation ended on 4-20-12 at 2:35 PM, when a system was put into place to ensure all residents requiring safety devices had them in place and would be monitored daily by supervisory staff, a review was conducted of each Resident's documented safety interventions to ensure they were in place, and all staff were inservice regarding each resident's safety needs. The deficient practice remains at an actual harm level for Resident #4, with the potential for more than minimal harm for any Resident at risk for falls requiring safety devices (#4 and #5). This occurred in 2 of 5 sampled residents of 72 residents requiring personal safety devices in the facility. Findings: 1. Record review revealed Resident #4 was a [AGE] year old female that was admitted to the facility on 8-22-09. Her accumulative [DIAGNOSES REDACTED]. The MDS dated 4-15-12 revealed the resident had memory problems, Cognitive skills for daily decisions was moderately impaired, Delusional with disorgagnized thinking that fluctuates, and the resident rejects care on a daily bases. A record review of the Incident/Accident reports for Resident #4 revealed the following: - Report on 3-26-12 at 7:20 AM: Resident #4 rolled out of bed in her room and was found on floor. The cause was resident unaware during sleep. The new interventions to prevent further falls documented was to use bolsters pads x 2 and Landing strips x 2. - Report on 3-27-12 at 3:30 AM: Resident #4 found lying in her room on the floor next to bed. The cause was lost balance while changing clothes. The new intervention to prevent falls documented was to use bed alarm. Past interventions were bolsters and landing strips X 2. - On 4-1-12 at 04:00 AM, Resident #4 found in her room on the floor with laceration and swelling to right eye. Description of situation was Resident #4 found on the floor with a laceration and swelling to the right eye. A trail of blood led from the foot of the bed to the resident. Resident was obviously semi-sedated. The cause of fall was resident was tangled in her clothing. Summary of Investigation: Bed Alarm not in Place. Past Intervention Attempted 3-27-12 Bed alarm, 3-26-12 Bolsters and Landing Strips x 2. Investigation: Bed Alarm Not in Place. Intervention: Ensure bed alarm is in place and working properly. - Report on 4-7-12 at 2:30 AM: Resident #4 found lying on the floor besides her bed. The cause of fall was from generalized weakness. A review of Resident #4's Nurses notes dated 4-1-12 at 4:35 AM, revealed the resident was sent to the emergency room via ambulance. A review of Resident #4's discharge summary with an admitted [DATE] revealed the final [DIAGNOSES REDACTED]. A Physician order [REDACTED]. On 4-19-12 at 09:40 AM, an observation was made of Resident #4's room. There was no bed alarm, no landing strips, and no bolsters on her bed. Also, there was no sign in her room or on the door to direct the use of landing strips, bolsters or bed alarm. On 4-19-12 at 09:45 AM, an interview was conducted with CNA S5. CNA S5 indicated she had been working with Resident #4 since she had been admitted . She revealed that Resident #4 never had a bed alarm or bolster pads on her bed. Also, there had never been any landing strips on the floor. On 4-19-12 at 09:50 AM, an interview was conducted with LPN S6. She stated that Resident #4 never had a bed alarm, bed bolsters, or landing strips. On 4-19-12 at 10:20 AM, RN DON S2 was asked how the CNAs determined what safety devices a resident required, and she stated that each hall had a supervisor that does "start up" in the mornings, and they all do it a little bit different, so she was not sure. Some put the care needs and safety devices needed on the wall and door, but not all, so each supervisor would need to be asked. On 4-19-12 at 10:55 AM, an interview was conducted with RN DON S2 regarding Resident #4's safety devices. She revealed that maintenance had placed an order for [REDACTED]. On 4-19-12 at 11:20 AM, LPN MDS coordinator S4 revealed that when Resident #4 fell out of bed on 4-1-12 and fractured her right orbital strut, she returned from the hospital on 4-6-12, and the Physician orders [REDACTED]. The previous orders were discontinued. "I don't think that was a good idea to discontinue her bed alarm". We were always told we had to have a doctor's order for bed alarms. It would have been a prudent nursing judgement to continue the bed alarm/bolster pads. If we would have continued the bed alarm/bolster pads, it could have prevented the fall on 4-7-12." On 4-19-12 at 12:00 PM, an interview was conducted with RN ADON S3. She revealed she was the supervisor over the LPNs and CNAs, and that LPN MDS Coordinator S4 performed the supervisory reviews of Resident #4's hall during "start up" each morning to ensure that the residents had their safety equipment in place. On 4-19-12 at 12:05 PM, an interview was conducted with LPN MDS Coordinator S4. She confirmed she does the supervisory "start up" on Resident #4's hall. "I go down the hall two times a day. I help the LPN make sure things are going smoothly. I don't know if Resident #4 had bed alarms and bolsters on the bed. The staff (C.N.A's) know through the LPN." "I am to supervise that the staff put the bed alarms and bolster pads on the residents' beds." At this time, a review of the CNAs computerized charting system was performed. There was no information regarding what care needs or safety devices each resident should receive, it gave multiple generic options to choose from to indicate what was observed in use. After reviewing Resident #4's computerized documentation, LPN MDS Coordinator S4 confirmed there was no documented evidence bolster pads, landing pads, or a bed alarm were utilized between 3-30-12 and 4-19-12. On 4-19-12 at 4:40 PM, RN DON S2 confirmed that there was no continuity between supervisors in the system to communicate to the CNAs what kind of care each resident is to receive including safety measures. There was no facility wide system to ensure that CNAs are informed on what type of care each resident requires. According to the incidents and accidents prevention system policy and procedure provided by the facility, they are to review Resident incident outcomes at the weekly clinical standards meeting to determine compliance and needs to update, specific interventions will be implemented to minimize falls and avoid repeat falls and minimize falls resulting in significant injury. The expectations of assessment and communication indicated to ensure the accurate level of assistance was communicated, the charge nurse will notify the current floor staff providing care; write information on the ADL flow sheet/CNA communication sheets or any additional facility specific communication process such as visual identifiers, and participants in the clinical standards will review current equipment available for appropriateness of devices. The Quality Improvement process included review of fall prevention program and effectiveness, review resident's care plan reflective of fall risk and interventions, and if resident was identified as fall risk - is the care plan being followed. According to the clinical standards reference guide provided, trends would be identified and acted upon and visual identifiers would be in place. 2. Resident #5 was a [AGE] year old male with [DIAGNOSES REDACTED]. A review of Resident #5's comprehensive care plan with a goal date of 5/2012 revealed 19 falls occurred between 12/7/11 and 4/8/12. Eleven of those falls were outside of his room or outside of the building. A new intervention was added to his care plan on 2/8/12 of hipsters X 2 to prevent serious injury. On 2/16/12, 3/9/12, 3/28/12, and 4/8/12, the intervention to address falls was repeated - to ensure the hipsters were being placed on the Resident. On 4/19/12 at 10:15 AM, CNA S7 was observed bringing Resident #5 to his room to change his diaper. She was asked if he had hipsters on, and she pulled his pants down and revealed he did not have hipsters in place. CNA S7 stated she was not sure if Resident #5 was supposed to have the hipsters on. She indicated that he used to wear them, but she had been gone for about a month and it was her second day back working with him. "Usually they will have a sign or something to tell me if he has special needs like that." CNA S7 looked around the room and did not find a sign to indicate Resident #5 was to wear the hipsters. She did find a pair of hipsters in his drawer, but she did not know if he still wore them and would have to ask someone. CNA S7 confirmed she was the person who got him dressed yesterday and today and had not put the hipsters on him either day. She also confirmed there was no bed alarm in place. (Hipsters looked like bicycle shorts with the pads on the sides) On 4/19/12 at 10:20 AM, RN DON S2 was asked how the CNAs knew if a resident had to wear hipsters, and she stated she was not sure, but the RN ADON S3 had two residents wearing them, and she would know how the aides know. RN DON S2 revealed that each hall had a supervisor that does "start up" in the mornings and they all do it a little different. Some put the care needs and safety devices needed on the wall and door, but not all." She indicated that RN ADON S3 was the supervisor of Resident #5's hall. On 4/19/12 at 10:25 AM, RN ADON S3 was asked how she communicated Resident safety device needs to the CNAs, specifically the hipsters Resident #5 was to wear, and she stated the information was on the ADL sheets in the computer, and she told them. She confirmed that Resident #5 should wear hipsters. On 4/19/12 at 10:28 AM, CNA S7 was asked to review the computerized ADL sheets Resident #5's. This review revealed that hipsters were not listed as an option on the ADL sheet. On 4/19/12 at 10:30 AM, RN ADON S3 was informed that hipsters was not an option to choose on the ADL sheets, and she confirmed they were not on the ADL sheets. RN ADON S3 stated that the CNAs should have known Resident #5 was to wear the hipsters, because after his accident, she told them he was to wear them. She also confirmed there was no sign or any other means of communication to inform the CNAs that Resident #5 was to wear hipsters. On 4/19/12 at 12:00 PM, RN ADON S3 explained that "Start up" was performed every morning by each hall's supervisor to ensure things are in place like personal safety devices. A review of Resident #5's MDS dated [DATE] revealed his functional status for walking in corridor was 3/2 which indicated he needed extensive assistance - resident involved in activity, staff provide weight bearing support with one person physical assist. Resident #5's Comprehensive Care Plan with a problem of falls revealed on 12/22/11, he was found lying in the front flower bed on his right side, and he had cigarette butts in his hand. The intervention initiated was monitor resident by nursing station during waking hours. After this intervention was initiated, Resident #5 fell on [DATE] - Resident laying on right side with pants down around ankles, diaper off lying on the grass outside back; 1/30/12 - Resident found lying outside on left side. Resident's pants down around ankles causing resident to fall; 2/8/12 - Resident attempting to sit down in chair in front of building and fell ; 2/24/12 - fell outside on back patio. Abrasion noted to left elbow; 3/9/12 - Found on ground outside, head on cement; and 3/26/12 - Resident was found lying in flower bed at front of building. There was no documented evidence Resident #5 was being supervised/monitored by the nursing station when these accidents/falls occurred, or that one person physical assist was being provided as per his MDS assessed needs. Care Plan review revealed Resident #5 ha Potential for falls related to a history of falls, Impaired balance and unsteady gait. His Fall score assessment was 21. Meaning he was a high risk for falls. The facilities approach for this problem read, "Analyze previous falls by resident to determine whether pattern/trend can be addressed." On 4/19/12 at 11:00 AM, while standing at the nursing station, CNA S8 was heard calling for staff to attend to Resident #5. This surveyor looked into the dinning area and noted there was no staff in the full dinning room and Resident #5 was on the ground with the dinning chair on it's side. Maintenance S9 was then seen going into the dinning area to stop a visitor from assisting Resident #5 off of the ground before a nurse could assess him. The resident was complaining of right hip pain. CNA S8 stated she and a restorative aide had helped Resident #5 walk into the dinning room and helped him sit at the table. She then went back to the nurses station. CNA S8 indicated the staff had been going in and out of the dinning room bringing the residents in for lunch. She stated they were getting the residents in the dinning room early because activities was having a volunteer luncheon, and they wanted the residents in there early. CNA S8 indicated they do not normally start bringing the residents into the dinning room until after 11:00 AM for lunch, but today they were almost all in the dinning room by that time. "That is really the time that the aides take their breaks." She stated getting help when an incident occurred was second nature because a lot of times she is at the nurse's station by herself, because the aides are always down the hall charting on the computers. Resident #5 was sent to the emergency room . On 4/19/12 at 12:15 PM, Maintenance S9 confirmed he was the first staff member to assist Resident #5 when he fell in the dinning room at 11:00 AM. He stated he was outside of the dinning room and heard someone say that Resident #5 had fallen, "I turned and looked through the glass into the dinning room and saw him on the floor with the chair flipped over and one of the visitors was trying to get him up off of the floor, so I ran in there." He confirmed there was no staff in the dinning room when Resident #5 fell , he ran in because there was no one in there to stop the visitor from getting him up. A review of Resident #5's emergency room discharge instructions dated 4/19/12 indicated he had a hip contusion. A prescription for [MEDICATION NAME] 10 mg (pain medication) was given to the resident. On 4/20/12 at 09:20 AM, Resident #5 was observed walking unassisted from the dinning room to the nurses station to request a cigarette. Social Service Director S10 told Resident #5 she had his cigarettes and to go outside. He walked unassisted to the back smoke area while the Social Service Director S10 got his cigarettes from the desk. Resident #5 was noted to walk out the back door and immediately pick up a used cigarette butt from the ash tray and put it in his mouth. Social Service Director S10 ran through the door and grabbed the butt from him, sat him down and went back in for the smoke apron. At 09:40 AM, he had completed his cigarette, and walked back inside to the dinning room without weight bearing physical assistance. A review of Resident #5's Comprehensive Care Plan revealed on 11/2/11, a bed alarm was initiated. On 12/7/11, Resident #5 was lying in bed and rolled out of bed, and a scoop mattress and bolsters X 2 were initiated. A review of Resident #5's Incident/Accident witness form dated 3/9/12 had a quote from the resident which read: "I'm all right I just slipped out my bed.." On 4/20/12 at 09:50 AM, RN ADON S3 was observed performing the morning start up supervisory review of Resident #5's hall. She had a list of every Resident's care needs and safety devices. She indicated they had reviewed all of the Residents' safety device needs and updated the list, and now she was using that updated information to perform her morning start up review. At that time, RN ADON S3 was walking into Resident #5's room. Bolster pads were in place and a landing pad was on the floor. The bed had been moved against the wall. According to the updated list, the resident was to have a scoop mattress. RN ADON S3 confirmed Resident #5 did not have a scoop mattress and that was an incorrect order on the list because you could not have bolsters with a scoop mattress. She confirmed there was no bed alarm on Resident #5's bed and stated that he was not supposed to have a bed alarm. On 4/20/12 at 10:40 AM, LPN MDS Coordinator S4 confirmed that Resident #5 had bed alarm listed as an intervention on his comprehensive care plan, and after reviewing his clinical record, the bed alarm had not been discontinued (d/c'd) as far as she could tell. LPN MDS Coordinator S4 confirmed that Resident #5 was coded 3/2 (extensive assist/one person physical assist) for locomotion in the corridor. She reviewed the worksheet used to complete this assessment and revealed that he had a lot of 0/0 (no assistance) during the morning shifts with just a couple of 3/2s, but Resident #5 had a lot more 3/2s during the evening shift. On 4/20/12 at 11:58 AM, an interview was conducted with RN DON S2 regarding the facility's Quality Improvement (QI) review of Resident #5's falls. She was asked if they had seen any trends in Resident #5's falls, and she revealed they have a fall tracking form to see if there was a particular time or place that the falls were occurring. She provided this form that had been documented with Resident #5's falls from 1/25/12 - 4/8/12. She indicated they had not seen a pattern in his falls, just that he falls all of the time. After reviewing the information provided, this surveyor noticed that 8 out of 10 falls, including the fall on 4/19/12 at 11:00 AM, which occurred in locations outside of his room, were between the 10:45 AM and 2:30 PM. She indicated she had not noticed that, and did not know why, but it seems he falls during the busiest time of the day. There was no evidence the QI team reviewed Resident #5's MDS worksheet used to assess his ambulation needs/function showing the majority of 0/0 (no assistance) occurred during the morning/day shift, or time of falls to determine trends in causes of his falls. There was also no evidence the QI team followed their policy and procedure to identify if his care plan was being followed. Also, the QI team failed to ensure the clinical standard of visual identifiers would be in place.

Based on record review and staff interview, the facility failed to ensure services provided met professional standards of quality as evidenced by Resident #2 receiving 80 milligrams of another resident's [MEDICATION NAME] by accident. This error led to Resident #2 being sent to the emergency room for nausea, vomiting, constricted pupils and elevated blood pressure for 1 of 16 sampled Resident's reviewed. Based upon the Louisiana Revised Statutes, Section 961 of Chapter 11 reads: A Licensed Practical Nurse must practice practical nursing in accordance with the standards normally expected... This would include following the rights of medication administration - right patient, right medication, right dosage, and right time. This deficient practice has the potential to effect all Residents receiving medication. An Immediate Jeopardy situation began on 1/17/12 at 5:30 PM, when the nurse gave the wrong medication and was lifted on 1/18/12 at 4:55 AM, when Resident #2 was sent to the emergency room . The Administrator S1 was notified of the Immediate Jeopardy situation on 2/3/12 at 3:15 PM. The deficient practice remains at an actual harm level for Resident #2, and the potential for more than minimal harm for any resident receiving medications. Findings: Resident #2 is a [AGE] year old male with [DIAGNOSES REDACTED]. He has a pacemaker/defibrillator in place. According to his most recent MDS, he had a BIMS score of 15, indicating he is cognitively intact. A review of Resident #2's nurses notes dated 1/18/12 at 04:00 AM read summoned to resident's room per CNA stating resident complained of "not feeling right." Upon exam, resident noted with elevated blood pressure of 166/104, respirations 20, oxygen saturation 98%, and pulse of 60. He complained of feeling lightheaded and "drunk", nausea and vomiting, dry mouth and pupils constricted. Stated he started feeling bad around 12:00 AM but went back to sleep. Gait unsteady, three trips to bathroom with complaint of not being able to urinate. Patient questioned about night medications and stated he took his night sleeping pills ([MEDICATION NAME] two 15 mg tablets). Writer recalled count was off for this medication which was over by 2 tablets. Also, count for another resident was off by 2 making count for [MEDICATION NAME] 80 mg short. DON S2 notified of suspicion resident was given [MEDICATION NAME] by mistake instead of [MEDICATION NAME]. 04:10 AM, blood pressure recheck 184/106. Lungs clear. Primary care Physician paged two times with no return call received. 04:40 AM, RN DON S2 notified and instructed to send Resident #2 to the emergency room . 04:55 AM, Resident #2 left facility via stretcher per ambulance with continued nausea, vomiting and complaints of lethargy. Resident #2's Ambulance report, with no date documented, read patient woke up complaining of nausea and vomiting. He is also complaining of being tired and falling asleep while trying to use the restroom. Nursing home staff believe to have had a medication error and given 80 mg of [MEDICATION NAME]. Awake and alert, tired and dizzy, pupils constricted. Blood pressures listed: 190/116, 179/110, 174/111, and 172/104. A review of Resident #2's emergency room nurses notes dated 1/18/12 at 05:16 AM read nursing home reports that patient was given 80 mg of [MEDICATION NAME] instead of nightly dose of [MEDICATION NAME]. A review of Resident #2's Physician's Progress Notes dated 1/24/12 read feeling well now. Had accidental overdose of [MEDICATION NAME] at nursing home. ([MEDICATION NAME] is time released [MEDICATION NAME]) On 1/27/12 at 4:00 PM, an interview was conducted with Resident #2. He stated that after he received his night time medications on 1/17/12, he felt horrible, started projectile vomiting and turning red. He indicated he had a pace maker and thought he was having another [MEDICAL CONDITION]. Resident #2 stated he had to go to the emergency room , his pupils were constricted and blood pressure was way up. He also said he could not urinate. He would try to go and could not. He did not want to get the nurse in trouble, but felt when she stands in the hallway and prepares medications, she talks and visits, and does not pay attention to what she is doing. He stated that it took him several days to get back to normal. He also stated that when he went to his cardiology appointment on 1/24/12, he had to tell him what had happened. The cardiologist told Resident #2 that the [MEDICATION NAME] "can act as a vasoconstrictor and could have killed me with the way my heart is, and that they absolutely should have notified him." Resident #2 indicated he was still very upset about what happened and is worried about his care and the bill for the ambulance and emergency room . On 1/27/12 at 4:30 PM, an interview was conducted with the RN DON S2 and RN ADON S3. She indicated she had been notified at 4:00 AM regarding the incident with Resident #2 on 1/17/12-1/18/12. "I knew right when they told me that they were over by 2 [MEDICATION NAME] and short 2 [MEDICATION NAME], that Resident #2 got the 2 [MEDICATION NAME]. It was a no brainer, that he(Resident #2) had gotten Resident #17's [MEDICATION NAME]." When asked if the staff performed assessments on Resident #2, after it was discovered the [MEDICATION NAME] was missing, she stated no, not according to their documentation. At that time, LPN S5 was called into the room, and revealed they had not done any assessments on Resident #2 because they did not know what had happened to the medication. She was just so worried that they did not know what happened to the [MEDICATION NAME] that she did not think about who it went to. LPN S5 stated she tried to call the RN ADON S3, but could not get her by phone, so she called the Administrator S1. He said he would take care of it in the morning. When asked what the [MEDICATION NAME] looked like and how they could have been mistaken for [MEDICATION NAME], the RN DON S2 stated the pills were similar in size and shape, but one is yellow and one is white. LPN S5 stated she must not have been paying close attention and just gave the wrong medication. The RN DON S2 stated she wished they would have called her at 10:00 PM, she would have known right off the bat what happened and would have had them assess Resident #2. A review of a disciplinary action Record in LPN S5's personnel record dated 1/18/12 read: Rule infracted: Improper Medication Administration on 1/17/12. Facts regarding incident: Improper Medication Administration - nurse gave Resident #17's [MEDICATION NAME] 80 mg (2-40mg) instead of giving Resident #2's correct medication [MEDICATION NAME]. Also, medications were given at 5:30 PM instead of 9:00 PM, causing the resident to go to the emergency room because of side effects of the medication. Expectations: Proper drug administration and follow nine rights of drug administration. Will follow proper policy and procedures concerning drug administration. Employee inserviced on medication administration. A statement was attached to the form written per LPN S5 on 1/18/12 which stated the following: This writer gave Resident #2 his medication after his dinner. He requested his night time medication early so that he could go to his room and watch TV. At this time, medications were given. We had several resident who needed my attention. This writer gave Resident #2 the wrong medication. This error was not noted until the -- of my shift at medication count. When this error of the count was off, this writer called the nursing home Administrator. This is the best of what I could remember. Also attached was the signed Rights of Medication Administration in-service which included the following rights: right patient, right medication, right dosage, right route, right time, right documentation, resident education if applicable, right to refuse, right assessment, and right evaluation. According to the facility's general medpass guidelines indicated staff was to read, read, read carefully during med pass to avoid errors.

Based on record review and staff interview, the facility failed to ensure each resident was free from significant medication errors as evidenced by a failure to follow professional standards of practice resulting in Resident #2 receiving 80 milligrams of another resident's [MEDICATION NAME] by accident. This led to Resident #2 being sent to the emergency room for nausea, vomiting, constricted pupils and elevated blood pressure for 1 of 16 sampled Resident's reviewed. This deficient practice has the potential to effect all Residents receiving medication. An Immediate Jeopardy situation began on 1/17/12 at 5:30 PM, when the nurse gave the wrong medication and was lifted on 1/18/12 at 4:55 AM, when Resident #2 was sent to the emergency room . The Administrator S1 was notified of the Immediate Jeopardy situation on 2/3/12 at 3:15 PM. The deficient practice remains at an actual harm level for Resident #2, and the potential for more than minimal harm for any resident receiving medications. Findings: Resident #2 is a [AGE] year old male with [DIAGNOSES REDACTED]. He has a pacemaker/defibrillator in place. According to his most recent MDS, he had a BIMS score of 15, indicating he is cognitively intact. A review of Resident #2's nurses notes dated 1/18/12 at 04:00 AM read summoned to resident's room per CNA stating resident complained of "not feeling right." Upon exam, resident noted with elevated blood pressure of 166/104, respirations 20, oxygen saturation 98%, and pulse of 60. He complained of feeling lightheaded and "drunk", nausea and vomiting, dry mouth and pupils constricted. Stated he started feeling bad around 12:00 AM but went back to sleep. Gait unsteady, three trips to bathroom with complaint of not being able to urinate. Patient questioned about night medications and stated he took his night sleeping pills ([MEDICATION NAME] two 15 mg tablets). Writer recalled count was off for this medication which was over by 2 tablets. Also, count for another resident was off by 2 making count for [MEDICATION NAME] 80 mg short. DON S2 notified of suspicion resident was given [MEDICATION NAME] by mistake instead of [MEDICATION NAME]. 04:10 AM, blood pressure recheck 184/106. Lungs clear. Primary care Physician paged two times with no return call received. 04:40 AM, RN DON S2 notified and instructed to send Resident #2 to the emergency room . 04:55 AM, Resident #2 left facility via stretcher per ambulance with continued nausea, vomiting and complaints of lethargy. Resident #2's Ambulance report, with no date documented, read patient woke up complaining of nausea and vomiting. He is also complaining of being tired and falling asleep while trying to use the restroom. Nursing home staff believe to have had a medication error and given 80 mg of [MEDICATION NAME]. Awake and alert, tired and dizzy, pupils constricted. Blood pressures listed: 190/116, 179/110, 174/111, and 172/104. A review of Resident #2's emergency room nurses notes dated 1/18/12 at 05:16 AM read nursing home reports that patient was given 80 mg of [MEDICATION NAME] instead of nightly dose of [MEDICATION NAME]. A review of Resident #2's Physician's Progress Notes dated 1/24/12 read feeling well now. Had accidental overdose of [MEDICATION NAME] at nursing home. On 1/27/12 at 4:00 PM, an interview was conducted with Resident #2. He stated that after he received his night time medications on 1/17/12, he felt horrible, started projectile vomiting and turning red. He indicated he had a pace maker and thought he was having another [MEDICAL CONDITION]. Resident #2 stated he had to go to the emergency room , his pupils were constricted and blood pressure was way up. He also said he could not urinate. He would try to go and could not. He did not want to get the nurse in trouble, but felt when she stands in the hallway and prepares medications, she talks and visits, and does not pay attention to what she is doing. He stated that it took him several days to get back to normal. He also stated that when he went to his cardiology appointment on 1/24/12, he had to tell him what had happened. The cardiologist told Resident #2 that the [MEDICATION NAME] "can act as a vasoconstrictor and could have killed me with the way my heart is, and that they absolutely should have notified him." Resident #2 indicated he was still very upset about what happened and is worried about his care and the bill for the ambulance and emergency room . ([MEDICATION NAME] is time released [MEDICATION NAME]) On 1/27/12 at 4:30 PM, an interview was conducted with the RN DON S2 and RN ADON S3. The RN DON S2 stated there was no incident and accident report and had not sent anything to the state or to the state board of nursing. She indicated she had been notified at 4:00 AM regarding the incident with Resident #2 on 1/17/12-1/18/12. "I knew right when they told me that they were over by 2 [MEDICATION NAME] and short 2 [MEDICATION NAME], that Resident #2 got the 2 [MEDICATION NAME]. It was a no brainer, that he had gotten Resident #17's [MEDICATION NAME]." When asked if the staff performed assessments on Resident #2, after it was discovered the [MEDICATION NAME] was missing, she stated no, not according to their documentation. At that time, LPN S5 was called into the room, and revealed they had not done any assessments on Resident #2 because they did not know what happened to the medication. She was just so worried that they did not know what happened to the [MEDICATION NAME] that she did not think about who it went to. LPN S5 stated she tried to call the RN ADON S3, but could not get her by phone, so she called the Administrator S1. He said he would take care of it in the morning. When asked what the [MEDICATION NAME] looked like and how they could have been mistaken for [MEDICATION NAME], the RN DON S2 stated the pills were similar in size and shape, but one is yellow and one is white. LPN S5 stated she just must not have been paying close attention and just gave the wrong medications. At that time, Administrator S1 was called into the room, and he stated that the staff called him and told him the count was off around 10:00 PM, and he told them he would take care of it in the morning. He did not call the DON or ADON. The RN DON S2 stated she wished they would have called her at 10:00 PM, she would have know right off the bat what happened and would have had them assess Resident #2. The RN ADON S3 stated they only called her one time on her cell phone that night and not on her house phone. The call schedule at that time was by word of mouth and since this incident, they have a call schedule in writing. A review of a disciplinary action Record in LPN S5's personnel record dated 1/18/12 read: Rule infracted: Improper Medication Administration on 1/17/12. Facts regarding incident: Improper Medication Administration - nurse gave Resident #17's [MEDICATION NAME] 80 mg (2-40mg) instead of giving Resident #2's correct medication [MEDICATION NAME]. Also, medications were given at 5:30 PM instead of 9:00 PM, causing the resident to go to the emergency room because of side effects of the medication. Expectations: Proper drug administration and follow nine rights of drug administration. Will follow proper policy and procedures concerning drug administration. Employee inserviced on medication administration. A statement was attached to the form written per LPN S5 on 1/18/12 which stated the following: This writer given Resident #2 his medication after his dinner that he request his night time medication early so that he could go to his room and watch TV. At this time, medications were give. We had several resident who needed my attention. This writer gave Resident #2 the wrong medication. This error was not noted until the -- of my shift at medication count. When this error of the count was off, this writer called the nursing home Admistrator. This is the best of what I could remember. According to the facility's general medpass guidelines indicated staff was to read, read, read carefully during med pass to avoid errors. Any discrepancies on the narcotic count should be immediately reported to the DON. On 1/27/12 at 5:11 PM, an interview was conducted with RN DON S2. She was asked what she would have done if they would have called her instead of the Administrator on 1/17/12 when there was a discrepancy in the narcotic count. "I would have told them they could not leave, we need to find out what happened, and when they would have told me that they were 2 over ([MEDICATION NAME]) and 2 under ([MEDICATION NAME]), I would have known that Resident #2 got the medication, and would have taken steps - assessments, etc." When they did not get the ADON on the phone, they should have called the DON and not the Administrator." "He is not clinical and should not be taking care of clinical issues. I told him next time call me so that I can take care of the situation."

Based on record review and interviews the facilty failed to notify the physician of a significant change in the resident's physical condition. This was evident by resident #1 having severe rectal pain for 4 days so that he was unable to sleep at night and was sent to a local hospital to remove an impaction. This occured in 1 of 5 sampled residents. Findings: Record review of Resident #1 face sheet revealed he was admitted to the facility on [DATE]. He was an [AGE] year old male. His Accumulative [DIAGNOSES REDACTED]. The Responsible party was his Son. Record review of the nurses notes for Resident #1 for the following dates read, 10-19-11 Resident alert and verbally responsive. Complained of severe pain at 800 a.m.. Complained of upset stomach at 900 a.m. [MEDICATION NAME] given as needed. 10-22-11 at 930 A.M., [MEDICATION NAME] given times one for constipation . Resident in bed with call bell in reach. 10-23-11 1:00 p.m. resident in bed, head of bed up, "moaning", resident stated he was having sharp pains in his rectum. Also stated that he didn't sleep last night because of these rectal pains . Will notify the doctor per fax. 10-24-11 5 p.m. fax prepared for doctor. requesting change in pain medications. also requesting medication for [MEDICAL CONDITION]. 10-25-11 945 a.m. resident complaining of "Labor Pain" in his rectum. Complained of his feces not being able to come out. appears he does not have the strength to push it out. left message with doctor awaiting return call. 2:30 p.m.. Resident continued to complain of rectal spasms. awaiting response from doctor. 430 p.m. fax returned per doctor for new orders. Orders read [MEDICATION NAME] 15 mg orally daily for [MEDICAL CONDITION], 2. [MEDICATION NAME] give one tablespoon in 8 oz of water for complaint of rectal pain. 10-26-11 10:00 a.m. friend of resident very adamant that resident needs to go to the emergency room for rectal spasms. Resident also requested to go to hospital. Nurse spoke to Responsible party and he Ok'd for resident to go to local hospital emergency department due to rectal spasms. Sent resident to hospital because #1's rectal spasms was new Responsible party. Record review of faxed document to MD's (Medical Doctor) office from the nursing home dated 10-23-11 read, " (Resident #1) complained of sharp rectal Pains to external Hemorrhoids noted. Resident had 1 gram BM last night. Also complained of not sleeping well at night. Any New orders?" Fax response from MD read, " [MEDICATION NAME] 1 table spoon in 8 ounces of water every day." Record review of Resident #1's Emergency Department visit dated 10-26-11 at 12:03 p.m. read, "This [AGE] year old white male presents to emergency room via wheel chair with complaints of severe rectal pain-spasm. Resident interview revealed the symptoms began 3 days ago. Patient revealed Excruciating rectal pain for the past 3 days. Fecal disimpaction procedure was performed, with a large amount of stool expressed. Radiology KUB (Kidney Ureter and Bladder) report revealed findings consistent with functional obstruction. On 11-4-11 at 2:20 p.m. an interview with S6 LPN revealed she worked with Resident #1 on 10-25-11 to 10-26-11. She stated the nurse she relieved on 10-25-11 did not report to her that #1 was having rectal pain. She revealed she read the nurses notes to find out this information. She revealed that on 10-25-11 #1 complained to her that he was having pain that felt like "Labor Pains". S6 LPN stated she told the DON about #1's rectal pain. She further stated that a fax was sent on 10-23-11 to the Doctor about #1's rectal pain and they received a return fax from the doctor on 10-25-11 for [MEDICATION NAME] for rectal pain and [MEDICATION NAME] for [MEDICAL CONDITION]. On 11-3-11 at 3:30 p.m. an interview with S6 LPN revealed the resident never had hemorrhoids when he went to the hospital on 10-26-11. She further revealed that Resident #1 went to the hospital for a fecal impaction. She further revealed #1 could not evacuate his lower bowels. On 11-4-11 at 3:20 p.m. an interview with S2 DON revealed she did not have a Policy for Fecal Impaction. On 11-3-11 at 11:20 a.m. a visit was made to local hospital where resident was transported. An interview with Resident #1 revealed he had rectal pain that was not from hemorrhoids. He stated that last time he was in this hospital he was so constipated they had to dig it out of him. He further revealed he was screaming for around 4 days. He revealed he did not sleep all night due to the pain. Record review of Care plan read, "Problem onset: I am at risk for constipation, related to poor nutritional and fluid intake, Goal: I will maintain normal bowel function. Approaches; Assess me for constipation/Impaction.

Based on record review and interviews, the facility failed to 1. Assess resident #1 for 4 days for a fecal impaction and repeated complaints of severe rectal pain resulting in a hospitalization for the removal of an impaction. 2. Assess Resident #1 for his ability to push his button-type call light to call for pain medication when he did not have the upper body strength to push it resulting in delayed response for administration of pain medication. This occurred in 1 of 5 sample residents. Findings 1. Record review of Resident #1 face sheet revealed he was admitted to the facility on [DATE]. He was an [AGE] year old male. His Accumulative [DIAGNOSES REDACTED]. The Responsible party was his Son. Record review of the nurses notes for Resident #1 for the following dates read, 10-19-11 Resident alert and verbally responsive. Complained of severe pain at 800 a.m.. Complained of upset stomach at 900 a.m. [MEDICATION NAME] given as needed. 10-22-11 at 930 A.M., [MEDICATION NAME] given times one for constipation . Resident in bed with call bell in reach. 10-23-11 1:00 p.m. resident in bed, head of bed up, "moaning", resident stated he was having sharp pains in his rectum. Also stated that he didn't sleep last night because of these rectal pains . Will notify the doctor per fax. 10-24-11 5 p.m. fax prepared for doctor. requesting change in pain medications. also requesting medication for [MEDICAL CONDITION]. 10-25-11 945 a.m. resident complaining of "Labor Pain" in his rectum. Complained of his feces not being able to come out. appears he does not have the strength to push it out. left message with doctor awaiting return call. 2:30 p.m.. Resident continued to complain of rectal spasms. awaiting response from doctor. 430 p.m. fax returned per doctor for new orders. Orders read [MEDICATION NAME] 15 mg orally daily for [MEDICAL CONDITION], 2. [MEDICATION NAME] give one tablespoon in 8 oz of water for complaint of rectal pain. 10-26-11 10:00 a.m. friend of resident very addiment that resident needs to go to the emergency room for rectal spasms. resident also requested to go to hospital. Nurse Spoke to Responsible party and he Ok'd for resident to go to local hospital emergency department due to rectal spasms that was new to him. Record review of faxed document to MD (Medical Doctor) office from the nursing home dated 10-23-11 read, " Resident #1 Complained of Sharp rectal Pains to external Hemorrhoids noted. Resident had 1 gram BM last night. Also complained of not sleeping well at night. Any New orders?" Fax response from MD read, " [MEDICATION NAME] 1 table spoon in 8 ounces of water every day." Record review of Resident #1's Emergency Department visit dated 10-26-11 at 12:03 p.m. read, "This [AGE] year old white male presents to emergency room via wheel chair with complaints of severe rectal pain-spasm. Resident interview revealed the symptoms began 3 days ago. Resident #1 revealed Excruciating rectal pain for the past 3 days. Fecal disimpaction procedure was performed, with a large amount of stool expressed. Radiology KUB (Kidney Ureter and Bladder) report revealed findings consistent with functional obstruction. On 11-4-11 at 2:20 p.m. an interview with S6 LPN revealed she worked with Resident #1 on 10-25-11 to 10-26-11. She stated the nurse she relieved on 10-25-11 did not report to her that #1 was having rectal pain. She revealed she read the nurses notes to find out this information. She revealed that on 10-25-11 #1 complained to her that he was having pain that felt like "Labor Pains". S6 LPN stated she told the DON about #1's rectal pain. She further stated that a fax was sent on 10-23-11 to the Doctor about #1's rectal pain and they received a return fax from the doctor on 10-25-11 for [MEDICATION NAME] for rectal pain and [MEDICATION NAME] for [MEDICAL CONDITION]. On 11-3-11 at 3:30 p.m. an interview with S6 LPN revealed the resident never had hemorrhoids when he went to the hospital on 10-26-11. She further revealed that Resident #1 went to the hospital for a fecal impaction. She further revealed #1 could not evacuate his lower bowels. On 11-4-11 at 3:20 p.m. an interview with S2 DON revealed she did not have a Policy for fecal Impaction. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed he had rectal pain that was not from hemorrhoids. He stated that last time he was in this hospital he was so constipated they had to dig it out of him. He further revealed he was screeming for around 4 days. He revealed he did not sleep all night due to the pain. Record review of Care plan read, "Problem onset: I am at risk for constipation, related to poor nutritional and fluid intake, Goal: I will maintain normal bowel function. Approaches; Assess me for constipation/Impaction. 2. On 11-2-11 at 3:00 p.m. an observation revealed Resident #1 sitting up in his bed. Sensitive touch call light on bedding. Record review of Physicians Orders dated October 2011 read, "[MEDICATION NAME] 10/325 milligrams 1 by mouth every 4 hours as needed for pain." Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. His pain averaged from 6-10 on a pain scale of 1-10 (1 least and 10 worst pain). On 11-3-11 at 10:00 a.m. an interview with S6 LPN revealed Resident #1 was transported and admitted to a local hospital because he was very weak an had Shortness of breath. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed that he was transported to the hospital because he was weak and short of breath. #1 revealed the facility does not always give him pain medication. He revealed that he has to call for his pain medication. He further revealed it is not easy when he can't move. He further revealed his pain level is usually an 8 out of 10 in his neck and shoulders. He states that sometimes it takes hours before he gets his pain medications because he couldn't push the button-type call light. On 11-4-11 at 12:40 p.m. an interview with S4 Maintenance Supervisor revealed he changed Resident #1's call light from the button-type, that was in his room since admission on 10-12-11, to the sensitive type on 11-2-11 at the request of administration because his wife said he had a hard time pushing the button-type call light. On 11-4-11 at 1:00 p.m., an interview with S1 Administrator revealed he had S4 Maintenance Supervisor change Resident #1's button-type call light that he had in his room since admission to a Sensitive-type call light. He further revealed the reason he had this type of call light put in was to satisfy the request of a family member. On 11-4 -11 at 10:56 a.m., an interview with S8, OT- Rehab Director revealed Resident #1 could not push the button-type call light because he didn't have upper body strength. She further revealed that if #1 was in pain, he would not be able to push the button type call light. On 11-4-11 at 10:58 an interview with S9 LPN-MDS Coordinator revealed the doctor reduced #1's pain medication because she thought he was over medicated with pain medication. She revealed he needed extensive assistance with ADL's, transfers, eating, personal hygiene and toileting. She revealed he was too weak to get up to the toilet. She further revealed she did not assess the resident if he could push the call light. She further revealed she did not know that he had a touch sensitive call light. On 11-4-11 at 1:30 p.m. an interview with Resident #1' Responsible Party (Son) revealed that his father had problems pushing the call light to request pain medication. On 11-3-11 at 11:20 am, an interview with a significant family friend revealed the facility had changed resident # 1's call light from the button-type to the sensitive-type on 11-2-11 because resident #1 did not have the strength to push the button-type call light. On 11-3-11 at 11:20 am, an interview with Random # 3 revealed the facility had changed resident # 1's call light from the button-type to the sensitive-type on 11-2-11 because resident #1 did not have the strength to push the button-type call light. On 11-4-11 at 11:25 a.m. an interview with S2 DON revealed that LPN's and C.N.A.'s did not inform her that Resident #1 could not push his call light. She also stated that Resident #1 was "totally in pain." Record review of Resident #1's Care Plan read, "Problem: Pain, Goal: resident will be as pain free as possible, Will verbalize pain relief. Approaches: Keep call light within easy reach. Encourage resident to report pain at onset." Record review of MDS dated [DATE] revealed under section J. resident #1 was on a continual pain medication, Resident has pain almost constantly, Resident has limited day to day activity because of pain.

Based on observation, record review, interviews and Registered Nurse Practice act the facility failed to arrange for services by a DON to meet professional standard of quality. This was evident by the facility failed to; 1. Assess resident #1 for 4 days for a fecal impaction and repeated complaints of severe rectal pain resulting in a hospitalization for removal of an impaction. 2. Assess Resident #1 for his ability to push his button-type call light to call for pain medication when he did not have the upper body strength to push it resulting in delayed response for administration of pain medication. This occurred in 1 of 5 sample residents. Findings 1. Record review of Resident #1 face sheet revealed he was admitted to the facility on [DATE]. He was a [AGE] year old male. His Accumulative [DIAGNOSES REDACTED]. The Responsible party was his Son. Record review of the nurses notes for Resident #1 for the following dates read, 10-19-11 Resident alert and verbally responsive. Complained of sever pain at 800 a.m.. Complained of upset stomach at 900 a.m. [MEDICATION NAME] given as needed. 10-22-11 at 930 A.M., [MEDICATION NAME] given times one for constipation . Resident in bed with call bell in reach. 10-23-11 1:00 p.m. resident in bed, head of bed up, "moaning", resident stated he was having sharp pains in his rectum. Also stated that he didn't sleep last night because of these rectal pains . Will notify the doctor per fax. 10-24-11 5 p.m. fax prepared for doctor. requesting change in pain medications. also requesting medication for [MEDICAL CONDITION]. 10-25-11 945 a.m. resident complaining of "Labor Pain" in his rectum. Complained of his feces not being able to come out. appears he does not have the strength to push it out. left message with doctor awaiting return call. 2:30 p.m.. Resident continued to complain of rectal spasms. awaiting response from doctor. 430 p.m. fax returned per doctor for new orders. Orders read [MEDICATION NAME] 15 mg orally daily for [MEDICAL CONDITION], 2. [MEDICATION NAME] give one tablespoon in 8 oz of water for complaint of rectal pain. 10-26-11 10:00 a.m. friend of resident very addiment that resident needs to go to the emergency room for rectal spasms. resident also requested to go to hospital. Nurse Spoke to Responsible party and he Ok'd for resident to go to local hospital emergency department due to rectal spasms that was new to him. Record review of faxed document to MD (Medical Doctor) office from the nursing home dated 10-23-11 read, " Resident #1 Complained of Sharp rectal Pains to external Hemorrhoids noted. Resident had 1 gram BM last night. Also complained of not sleeping well at night. Any New orders?" Fax response from MD read, " [MEDICATION NAME] 1 table spoon in 8 ounces of water every day." Record review of Resident #1's Emergency Department visit dated 10-26-11 at 12:03 p.m. read, "This [AGE] year old white male presents to emergency room via wheel chair with complaints of severe rectal pain-spasm. Resident interview revealed the symptoms began 3 days ago. Resident #1 revealed Excruciating rectal pain for the past 3 days. Fecal disimpaction procedure was performed, with a large amount of stool expressed. Radiology KUB (Kidney Ureter and Bladder) report revealed findings consistent with functional obstruction. On 11-4-11 at 2:20 p.m. an interview with S6 LPN revealed she worked with Resident #1 on 10-25-11 to 10-26-11. She stated the nurse she relieved on 10-25-11 did not report to her that #1 was having rectal pain. She revealed she read the nurses notes to find out this information. She revealed that on 10-25-11 #1 complained to her that he was having pain that felt like "Labor Pains". S6 LPN stated she told the DON about #1's rectal pain. She further stated that a fax was sent on 10-23-11 to the Doctor about #1's rectal pain and they received a return fax from the doctor on 10-25-11 for [MEDICATION NAME] for rectal pain and [MEDICATION NAME] for [MEDICAL CONDITION]. On 11-3-11 at 3:30 p.m. an interview with S6 LPN revealed the resident never had hemorrhoids when he went to the hospital on 10-26-11. She further revealed that Resident #1 went to the hospital for a fecal impaction. She further revealed #1 could not evacuate his lower bowels. On 11-4-11 at 3:20 p.m. an interview with S2 DON revealed she did not have a Policy for fecal Impaction. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed he had rectal pain that was not from hemorrhoids. He stated that last time he was in this hospital he was so constipated they had to dig it out of him. He further revealed he was screaming for around 4 days. He revealed he did not sleep all night due to the pain. Record review of Care plan read, "Problem onset: I am at risk for constipation, related to poor nutritional and fluid intake, Goal: I will maintain normal bowel function. Approaches; Assess me for constipation/Impaction. 2. On 11-2-11 at 3:00 p.m. an observation revealed Resident #1 sitting up in his bed. Sensitive touch call light on bedding. Record review of Physicians Orders dated October 2011 read, "[MEDICATION NAME] 10/325 milligrams 1 by mouth every 4 hours as needed for pain." Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. His pain averaged from 6-10 on a pain scale of 1-10 (1 least and 10 worst pain). On 11-3-11 at 10:00 a.m. an interview with S6 LPN revealed Resident #1 was transported and admitted to a local hospital because he was very weak an had Shortness of breath. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed that he was transported to the hospital because he was weak and short of breath. #1 revealed the facility does not always give him pain medication. He revealed that he has to call for his pain medication. He further revealed it is not easy when he can't move. He further revealed his pain level is usually an 8 out of 10 in his neck and shoulders. He states that sometimes it takes hours before he gets his pain medications because he couldn't push the button-type call light. On 11-4-11 at 12:40 p.m. an interview with S4 Maintenance Supervisor revealed he changed Resident #1's call light from the button-type, that was in his room since admission on 10-12-11, to the sensitive type on 11-2-11 at the request of administration because his wife said he had a hard time pushing the button-type call light. On 11-4-11 at 1:00 p.m., an interview with S1 Administrator revealed he had S4 Maintenance Supervisor change Resident #1's button-type call light that he had in his room since admission to a Sensitive-type call light. He further revealed the reason he had this type of call light put in was to satisfy the request of a family member. On 11-4 -11 at 10:56 a.m., an interview with S8, OT- Rehab Director revealed Resident #1 could not push the button-type call light because he didn't have upper body strength. She further revealed that if #1 was in pain, he would not be able to push the button type call light. On 11-4-11 at 10:58 an interview with S9 LPN-MDS Coordinator revealed the doctor reduced #1's pain medication because she thought he was over medicated with pain medication. She revealed he needed extensive assistance with ADL's, transfers, eating, personal hygiene and toileting. She revealed he was too weak to get up to the toilet. She further revealed she did not assess the resident if he could push the call light. She further revealed she did not know that he had a touch sensitive call light. On 11-4-11 at 1:30 p.m. an interview with Resident #1' Responsible Party (Son) revealed that his father had problems pushing the call light to request pain medication. On 11-3-11 at 11:20 am, an interview with a Significant family Friend revealed the facility had changed resident # 1's call light from the button-type to the sensitive-type on 11-2-11 because resident #1 did not have the strength to push the button-type call light. On 11-3-11 at 11:20 am, an interview with Random # 3 revealed the facility had changed resident # 1's call light from the button-type to the sensitive-type on 11-2-11 because resident #1 did not have the strength to push the button-type call light. On 11-4-11 at 11:25 a.m. an interview with S2 DON revealed that LPN's and C.N.A.'s did not inform her that Resident #1 could not push his call light. She further revealed Resident #1 was totally in pain. Record review of Resident #1's Care Plan read, "Problem: Pain, Goal: resident will be as pain free as possible, Will verbalize pain relief. Approaches: Keep call light within easy reach. Encourage resident to report pain at onset." Record review of MDS dated [DATE] revealed under section J. resident #1 was on a continual pain medication, Resident has pain almost constantly, Resident has limited day to day activity because of pain. Job Description review for LPN Charge nurse read, "The Primary Purpose of your job description is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times." further review review under Nursing Care Functions read, "Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition." Job Description review for the Director of Nursing Services read, "The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times." Further review revealed under Duties and Responsibilities of administrative function read, "Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities., Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request., Ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives." Review of Law Governing the Practice of Nursing for Registered Nurses, under Chapter 11. Nurses, Part I. Registered Nurses, 911. Legislative findings: intent; Purpose of part. read, "A. The legislature finds that the practice of nursing by qualified individuals is necessary to protect the public health, safety, and welfare of the citizens of this state." under 913. Definitions (14) , read, "Registered nursing" Means the practice of the scope of nursing which is appropriate to the individuals education level, knowledge, skills and abilities including: (a) Assess the health status of an individual or group of individuals. (b) Establishing a nursing [DIAGNOSES REDACTED]. (c.) establishing goals to meet identified health care needs. (d) Planning nursing care measures. (e) Implementing nursing care through such services as case finding, health instruction, health counseling, providing care supportive to or restorative of life and well-being, and executing health care regimes as prescribed by licensed physicians, dentists, optometrists, or other authorized prescribers. (f)) Delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the board. (g) Maintaining nursing care rendered directly or indirectly. (h) evaluating human response to interventions. (i)Teaching the theory and practice of nursing. (j) Managing and supervising the practice of nursing. (k) Collaborating with licensed physicians, dentists, optometrists, and other health care providers in the management of health care. (l) Performing additional acts which are recognized within the standards of nursing practice and which are authorized by the board."

Based on record review and interviews, the facility failed maintain resident #1's highest practicable physical, mental and psychosocial well-being. This was evidenced by the facility failing to; 1. Assess resident #1 for 4 days for a fecal impaction and repeated complaints of severe rectal pain resulting in a hospitalization for removal of an impaction. 2. Assess Resident #1 for his ability to push his button-type call light to call for pain medication when he did not have the upper body strength to push it resulting in delayed response for administration of pain medication. This occurred in 1 of 5 sampled residents. Findings 1. Record review of Resident #1 face sheet revealed he was admitted to the facility on [DATE]. He was an [AGE] year old male. His Accumulative [DIAGNOSES REDACTED]. The Responsible party was his Son. Record review of the nurses notes for Resident #1 for the following dates read, 10-19-11 Resident alert and verbally responsive. Complained of sever pain at 800 a.m.. Complained of upset stomach at 900 a.m. [MEDICATION NAME] given as needed. 10-22-11 at 930 A.M., [MEDICATION NAME] given times one for constipation . Resident in bed with call bell in reach. 10-23-11 1:00 p.m. resident in bed, head of bed up, "moaning", resident stated he was having sharp pains in his rectum. Also stated that he didn't sleep last night because of these rectal pains . Will notify the doctor per fax. 10-24-11 5 p.m. fax prepared for doctor. requesting change in pain medications. also requesting medication for [MEDICAL CONDITION]. 10-25-11 945 a.m. resident complaining of "Labor Pain" in his rectum. Complained of his feces not being able to come out. appears he does not have the strength to push it out. left message with doctor awaiting return call. 2:30 p.m.. Resident continued to complain of rectal spasms. awaiting response from doctor. 430 p.m. fax returned per doctor for new orders. Orders read [MEDICATION NAME] 15 mg orally daily for [MEDICAL CONDITION], 2. [MEDICATION NAME] give one tablespoon in 8 oz of water for complaint of rectal pain. 10-26-11 10:00 a.m. friend of resident very addiment that resident needs to go to the emergency room for rectal spasms. resident also requested to go to hospital. Nurse Spoke to Responsible party and he Ok'd for resident to go to local hospital emergency department due to rectal spasms that was new to him. Record review of faxed document to MD (Medical Doctor) office from the nursing home dated 10-23-11 read, " Resident #1 Complained of Sharp rectal Pains to external Hemorrhoids noted. Resident had 1 gram BM last night. Also complained of not sleeping well at night. Any New orders?" Fax response from MD read, " [MEDICATION NAME] 1 table spoon in 8 ounces of water every day." Record review of Resident #1's Emergency Department visit dated 10-26-11 at 12:03 p.m. read, "This [AGE] year old white male presents to emergency room via wheel chair with complaints of severe rectal pain-spasm. Resident interview revealed the symptoms began 3 days ago. Resident #1 revealed Excruciating rectal pain for the past 3 days. Fecal disimpaction procedure was performed, with a large amount of stool expressed. Radiology KUB (Kidney Ureter and Bladder) report revealed findings consistent with functional obstruction. On 11-4-11 at 2:20 p.m. an interview with S6 LPN revealed she worked with Resident #1 on 10-25-11 to 10-26-11. She stated the nurse she relieved on 10-25-11 did not report to her that #1 was having rectal pain. She revealed she read the nurses notes to find out this information. She revealed that on 10-25-11 #1 complained to her that he was having pain that felt like "Labor Pains". S6 LPN stated she told the DON about #1's rectal pain. She further stated that a fax was sent on 10-23-11 to the Doctor about #1's rectal pain and they received a return fax from the doctor on 10-25-11 for [MEDICATION NAME] for rectal pain and [MEDICATION NAME] for [MEDICAL CONDITION]. On 11-3-11 at 3:30 p.m. an interview with S6 LPN revealed the resident never had hemorrhoids when he went to the hospital on 10-26-11. She further revealed that Resident #1 went to the hospital for a fecal impaction. She further revealed #1 could not evacuate his lower bowels. On 11-4-11 at 3:20 p.m. an interview with S2 DON revealed she did not have a Policy for fecal Impaction. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed he had rectal pain that was not from hemorrhoids. He stated that last time he was in this hospital he was so constipated they had to dig it out of him. He further revealed he was screeming for around 4 days. He revealed he did not sleep all night due to the pain. Record review of Care plan read, "Problem onset: I am at risk for constipation, related to poor nutritional and fluid intake, Goal: I will maintain normal bowel function. Approaches; Assess me for constipation/Impaction. 2. On 11-2-11 at 3:00 p.m. an observation revealed Resident #1 sitting up in his bed. Sensitive touch call light on bedding. Record review of Physicians Orders dated October 2011 read, "[MEDICATION NAME] 10/325 milligrams 1 by mouth every 4 hours as needed for pain." Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. His pain averaged from 6-10 on a pain scale of 1-10 (1 least and 10 worst pain). On 11-3-11 at 10:00 a.m. an interview with S6 LPN revealed Resident #1 was transported and admitted to a local hospital because he was very weak an had Shortness of breath. On 11-3-11 at 11:20 a.m. a visit was made to Local hospital where resident was transported. An interview with Resident #1 revealed that he was transported to the hospital because he was weak and short of breath. #1 revealed the facility does not always give him pain medication. He revealed that he has to call for his pain medication. He further revealed it is not easy when he can't move. He further revealed his pain level is usually an 8 out of 10 in his neck and shoulders. He states that sometimes it takes hours before he gets his pain medications because he couldn't push the button-type call light. On 11-4-11 at 12:40 p.m. an interview with S4 Maintenance Supervisor revealed he changed Resident #1's call light from the button-type, that was in his room since admission on 10-12-11, to the sensitive type on 11-2-11 at the request of administration because his wife said he had a hard time pushing the button-type call light. On 11-4-11 at 1:00 p.m., an interview with S1 Administrator revealed he had S4 Maintenance Supervisor change Resident #1's button-type call light that he had in his room since admission to a Sensitive-type call light. He further revealed the reason he had this type of call light put in was to satisfy the request of a family member. On 11-4 -11 at 10:56 a.m., an interview with S8, OT- Rehab Director revealed Resident #1 could not push the button-type call light because he didn't have upper body strength. She further revealed that if #1 was in pain, he would not be able to push the button type call light. On 11-4-11 at 10:58 an interview with S9 LPN-MDS Coordinator revealed the doctor reduced #1's pain medication because she thought he was over medicated with pain medication. She revealed he needed extensive assistance with ADL's, transfers, eating, personal hygiene and toileting. She revealed he was too weak to get up to the toilet. She further revealed she did not assess the resident if he could push the call light. She further revealed she did not know that he had a touch sensitive call light. On 11-4-11 at 1:30 p.m. an interview with Resident #1' Responsible Party (Son) revealed that his father had problems pushing the call light to request pain medication. On 11-3-11 at 11:20 am, an interview with a Significant family Friend revealed the facility had changed resident # 1's call light from the button-type to the sensitive-type on 11-2-11 because resident #1 did not have the strength to push the button-type call light. On 11-4-11 at 11:25 a.m. an interview with S2 DON revealed that LPN's and C.N.A.'s did not inform her that Resident #1 could not push his call light. She further revealed Resident #1 was totally in pain. Record review of Resident #1's Care Plan read, "Problem: Pain, Goal: resident will be as pain free as possible, Will verbalize pain relief. Approaches: Keep call light within easy reach. Encourage resident to report pain at onset." Record review of MDS dated [DATE] revealed under section J. resident #1 was on a continual pain medication, Resident has pain almost constantly, Resident has limited day to day activity because of pain.