Every finding on record at Piedmont Crossing

Based on record review, Resident Representative (RR), Hospital Case Manager, Hospice Hospital Liaison, Ombudsman and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for evaluation due to a resident-to-resident altercation for 1 of 2 resident reviewed for discharge (Resident #224). The findings included: Resident #224 was admitted to the facility on [DATE] under hospice care with diagnoses that included neurocognitive disorder with Lewy bodies, dementia with mood disturbance, and dementia with agitation. A progress note written by the Director of Nursing (DON) on 10/22/23 at 9:38 PM documented that she had received a call from Nurse Supervisor #1 and was informed Resident #224 had become aggressive with staff and had an altercation with another resident. The altercation resulted in the resident being pushed to the floor. The on-call provider was notified of the incident and received a verbal order to send Resident #224 to the hospital. Resident #224's family member was present in the facility at the time of the incident. Emergency Medical Service (EMS) was called to the facility, but the Resident Representative declined hospitalization . The DON and Nursing Supervisor #1 went to the local magistrate's office and received a court order to have Resident #224 sent to the hospital for evaluation. Resident #224 was sent to the hospital on 10/23/23 at approximately 1:00 AM. A progress note written by Social Worker #1 on 10/23/23 at 12:54 PM indicated the local Ombudsman was contacted and informed Resident #224 had been sent to the hospital under involuntary commitment due to aggressive behavior. The note also indicated that the facility had no plans to accept Resident #224 back. A review of the investigation report completed by Administrator #1 on 10/24/23 indicated a resident abuse investigation was completed and was not substantiated. The allegation details indicated Resident #224 entered another resident's room as NA #1 was walking that resident to the dining room. Resident #224 was noted to be walking with his stepdaughter at that time and he walked into another resident causing that resident to fall onto the floor. The report further indicated that neither was injured. The report included an attached summary signed by Administrator #1 on 10/24/23. The summary indicated Resident #224 was so severely impaired both physically and mentally and had absolutely no idea that he was walking into other individuals. Resident #224 was not capable of making willful decisions and the allegation of abuse was not substantiated. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #224 had an unplanned discharge to the hospital with return not anticipated. An interview was conducted with the local Ombudsman on 2/10/25 at 2:18 PM. The Ombudsman indicated that she did recall speaking to Social Worker #1 regarding Resident 224's hospitalization and that the facility did not plan to readmit him to the facility. An interview was conducted with the Resident Representative on 2/12/25 at 9:24 AM. She indicated that she did not want Resident #224 sent to the hospital as his behaviors were related to his diagnosis. The facility was insistent on him going to the hospital, but she declined the first attempt at hospitalization . She further revealed that she was made aware by the DON that the facility had received a court order to have Resident #224 sent to the hospital for an evaluation as they felt they could not meet his needs. She indicated she had reached out to hospital staff for support but once the facility obtained the court order for involuntary commitment, she could not stop the discharge. The Resident Representative indicated that an unnamed staff member told her at the time of discharge to the hospital that the facility was selective in the type of residents they took and that they could not meet Resident #224's needs. She further revealed that she was not offered a bed hold option or an offer to readmit Resident #224 even though he was documented to be stable at the hospital. An interview was conducted with the Hospice Hospital Liaison on 02/14/25 8:29 AM. The liaison recalled the Hospital Case Manger contacted her to let her know the facility would not allow Resident #224 to readmit and would need to seek alternate placement. She further revealed that she had spoken with the Resident Representative and the family did want Resident #224 to be admitted back to the facility, but she was told the facility could not meet Resident #224's needs. An interview was conducted with the Hospital Case Manager on 2/14/25 at 11:08 AM. She indicated she was the case manager assigned to Resident #224 and attempted to have him admitted back to the facility. She recalled contacting Administrator #1 when Resident #224 was cleared to return to the facility. Administrator #1 indicated the facility would not readmit resident #224 because the facility could not meet the resident's needs. Resident #224 was placed at another skilled nursing facility. An interview was conducted with the DON on 2/13/25 at 4:37 PM. She stated Resident #224 was involved in an incident where he walked into another resident and the resident fell to the floor. The DON further indicated she did not feel this was intentional and that Resident # 224 had no safety awareness. The Resident Representative denied the initial attempt at hospitalization and therefore she consulted with the local law enforcement and was directed to seek involuntary commitment (IVC) from the local magistrate's office. She indicated that she and Nursing Supervisor #1 presented their request to the local magistrate, and it was granted. The DON returned to the facility and explained the IVC process to the family. EMS and law enforcement arrived at the facility approximately 1:00 AM on 10/23/23 and transported Resident #224 to the local hospital. She further revealed that she did not have any discussion with the family or hospital staff regarding readmission status. An interview was conducted with Administrator #1 on 2/14/25 at 11:24 AM. She indicated that after Resident #224 was sent to the hospital, the facility team felt they could not permit Resident #224 to return to the facility due to his behavior.

Based on record review, and Resident Representative and staff interviews, the facility failed to provide the resident representative with a written notification of the bed hold policy upon a resident's transfer to the hospital for 1 of 2 residents (Resident #224) reviewed for discharge. Findings included: Resident #224 was admitted to the facility on [DATE] with the Resident Representative listed as his legal representative according to the medical record. A review of the baseline care plan dated 10/20/23 revealed Resident #224 was cognitively impaired. The discharge Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] revealed Resident #224 was discharged to the hospital. Further review of the medical record revealed there was no written notice of the bed hold policy provided to the resident or resident representative when he was transferred to the hospital on 10/23/23. An interview was conducted with the Resident Representative on 2/12/25 at 9:24 AM. She indicated she was not provided with a written notice of the bed hold policy upon the resident's transfer to the hospital. An attempt was made to interview Nurse #1 who was assigned to Resident #224 at the time of discharge, but attempts were not successful. An interview was conducted with Administrator #1 on 2/14/25 at 11:24 AM. She indicated after Resident #224 was sent to the hospital, the facility team felt they could not permit Resident #224 to return to the facility due to his behaviors, and the resident was not offered a bed hold option.

Based on observation, record review and staff interviews, the facility failed to label, date, and/or remove expired food items stored for use in 1 of 1 reach-in prep coolers, 1 of 1 reach-in storage coolers and 1 of 1 walk-in freezer units. The facility failed to prevent the potential for cross-contamination when soiled dishware was stored on a shelf designated for clean dishware and failed to ensure plastic storage containers were dry before stacking. These practices had the potential to affect food served to residents. Findings included: During the initial tour of the kitchen on [DATE] at 11:27 am through 12:05 pm, the Director of Dining Service was present during the inspection, the following was observed: a. The food prep cooler was observed with a covered container of diced pimentos dated [DATE]. b. The food prep cooler was observed with a covered container of sauerkraut dated [DATE]. c. The food storage cooler was observed with 3 unopened ,d+[DATE] gallon containers of buttermilk with an expiration date of [DATE]. d. The walk-in freezer was observed with an opened, partially full, re-sealed package of ground pepperoni that had an illegible date written on the package in black marker. The date was smeared and only the number 10 could be read. e. A clean dish storage shelf was observed with 3 stacked serving trays with crumb like particles scattered over the tray surfaces and one plate cover with dried food product on the edges. The Director of Dining Services was interviewed during the initial tour on [DATE] from 11:27 am through 12:05 pm. He stated that staff were trained on food storage to include dating, labeling, and discarding outdated foods. He further stated that the refrigerated coolers were checked daily for outdated foods and outdated foods should be discarded at that time. Opened foods were to be marked with the date opened and should have been discarded 3 days after that date and expired foods should have been discarded on the expiration date. In response to the frozen ground pepperoni, he indicated that that if staff could not read the date that they could ask a supervisor to read it. He stated that he could not definitively read the date on the package. He stated that dirty dishes or containers should not have been placed on the storage rack with the clean dishes. He disposed of the food items listed above and removed the dirty dishes from the clean storage rack. A follow-up kitchen inspection on [DATE] at 3:00 pm revealed: a. Four (4) 3.5 qt plastic food storage containers nested and stacked together on a metal dish storage shelf. All 4 were observed to be wet on the inside. [DATE] at 3:00 pm An interview with the Director of Dining Services, who was present during the inspection, indicated that the food storage containers should not have been stacked together to dry. He then separated the containers. Interview with facility Administrator on [DATE] at 3:28 pm revealed she was unaware of the concerns in the kitchen and would address them with the Director of Dining Services. She further stated that she believed the discard date for opened refrigerated foods was 7 days beyond the opened date.

Based on resident and staff interviews and record review, the facility failed to provide any scheduled activities on the weekends. This was for 3 (Resident #1, Resident #22 and Resident #4) of 3 residents reviewed for activities. The findings included: 1. Resident #1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 activities care plan initiated 6/21/21 read she participated in group activities and individual pursuits. Her quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact. Review of Resident #1's Social assessment dated [DATE] indicated she participated in the assessment and she was cognitively intact. She enjoyed individual pursuits such as needlework, social media and watching television. She also stated she was very social and participated in group activities. Review of the activity calendar for July, August and September 2022 revealed activities Monday through Friday. The calendars for Saturdays read family and friend visits and for Sundays included a picture of a church. An interview was completed on 9/8/22 at 4:15 PM with Resident #1. She stated there were no activities on the weekends. Observed in her room was a copy of the September 2022 activity calendar. When questioned about what the calendar read for Saturdays regarding family and friend visits, she stated it meant the only thing for that day was hopefully the residents would have a visitor come see them. When questioned about the picture of a church on Sundays, she stated it didn't mean anything. It was just a picture and that there were no services on Sundays but rather on Mondays. An interview was completed on 9/9/22 at 9:05 AM with Activity Director (AD) #1. She stated she was the AD for the 200 hall and AD #2 was responsible for 400 and 500 halls. AD #1 stated AD #2 had been doing activities for a long time and she assisting with her training. She stated she worked Monday through Friday and AD #2 came in Monday through Friday at 11:00 AM. AD #1 stated AD #2 was responsible for the activity calendar each month and that to her knowledge, there were no scheduled activities on the weekends. When asked about Saturdays family and friends visits, it was a day for families to visit. When asked what the picture of a church meant on Sundays, she stated she thought it meant that there were church services on Sundays but she never inquired. An interview was completed on 9/9/22 at 10:03 AM with AD #2. She stated she completed the monthly activity calendar and there were no scheduled activities on the weekends since COVID. She stated Saturdays was a day off for families to visit with the residents but if a residents wanted an activity to do, there was a cart the aides could pass around if a resident requested to do an activity. When questioned about the picture of a church on Sundays, she stated Sunday was a day of rest so no activities were scheduled. AD #2 stated they scheduled their church service on Mondays. An interview was completed on 9/9/22 at 11:05 AM with the Administrator. She stated she was made aware today that there were no scheduled activities for the residents on weekends and offered no explanation as to why she was not aware. She stated it was her expectation that there be some sort of activities for the residents on the weekends. 2. Resident #22 was admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22 undated activities care plan read she was a very social person, enjoyed worship services, gospel singing, Bible study and Bingo. Her quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact. Review of Resident #22's Social assessment dated [DATE] indicated she participated in the assessment and she was cognitively intact. She enjoyed worship services, gospel music and occasionally played Bingo. An interview was completed on 9/9/22 at 9:05 AM with Activity Director (AD) #1. She stated she was the AD for the 200 hall and AD #2 was responsible for 400 and 500 halls. AD #1 stated AD #2 had been doing activities for a long time and she assisting with her training. She stated she worked Monday through Friday and AD #2 came in Monday through Friday at 11:00 AM. AD #1 stated AD #2 was responsible for the activity calendar each month and that to her knowledge, there were no scheduled activities on the weekends. When asked about Saturdays family and friends visits, it was a day for families to visit. When asked what the picture of a church meant on Sundays, she stated she thought it meant that there were church services on Sundays but she never inquired. An interview was completed on 9/9/22 at 10:03 AM with AD #2. She stated she completed the monthly activity calendar and there were no scheduled activities on the weekends since COVID. She stated Saturdays was a day off for families to visit with the residents but if a residents wanted an activity to do, there was a cart the aides could pass around if a resident requested to do an activity. When questioned about the picture of a church on Sundays, she stated Sunday was a day of rest so no activities were scheduled. AD #2 stated they scheduled their church service on Mondays. An interview was completed on 9/9/22 at 11:38 Am with Resident #22. She stated there were no activities on the weekends but she wished there was something she could attend other than just visiting other residents. An interview was completed on 9/9/22 at 11:05 AM with the Administrator. She stated she was made aware today that there were no scheduled activities for the residents on weekends and offered no explanation as to why she was not aware. She stated it was her expectation that there be some sort of activities for the residents on the weekends. 3. Resident #4 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact. An interview was completed on 9/9/22 at 9:05 AM, with Activity Director (AD) #1, who worked Monday through Friday. She stated she was the AD for the 200 hall, some of the 300 hall residents and AD #2 was responsible for the 400 and 500 halls. AD #1 stated AD #2 had been doing activities for a long time and had been providing training to her. She explained AD #2 was responsible for the creating the activity calendar each month and that, to her knowledge, there were no scheduled activities on the weekends. When asked about the event scheduled for Saturdays (family and friends visits), it was a day for families to visit. When asked what the picture of a church meant for the scheduled event on Sundays, she stated she thought it meant that there were church services on Sundays, but she had never ever inquired. An interview was completed on 9/9/22 at 10:03 AM with AD #2, who stated she worked Monday thru Friday, coming in at 11:00 AM. She explained she created the monthly activity calendar and there were no scheduled activities on the weekends since the COVID-19 pandemic. She stated Saturdays were a day off for families to visit with the residents but if a resident wanted an activity to do, there was a cart that the aides could pass around for them to choose from. When questioned about the picture of a church on the calendar for Sundays, she stated Sunday was a day of rest, so no activities were scheduled. AD #2 stated they church services were scheduled on Mondays. Resident #4 was interviewed on 9/9/22 at 10:50 AM. She explained she participated in activities through out the week but there were no activities scheduled for the weekends. She added, It would be nice so I could get out of the room on the weekends. An interview was completed on 9/9/22 at 11:05 AM, with the Administrator. She stated she was not aware that there were no activities being provided for the residents on the weekends, but it was her expectation that there be some sort of activities scheduled.

Based on record review, observations, resident and staff interviews, the facility failed to ensure alternating pressure reducing mattresses were set according to the residents' weight for 2 of 3 residents reviewed for pressure injuries (Resident #62, and Resident #14). The findings included: 1. Resident #62 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired, required extensive assistance for activities of daily living and was incontinent of bowel and bladder. The resident was coded with one stage 2 pressure injury during the assessment period. Resident #62's comprehensive care plan was last updated 8/17/2022 and included a focus for pressure injuries. Interventions for prevention of worsening of existing pressure injuries and prevention of new pressure injuries included use of alternating pressure reducing mattress. The resident's medical record indicated she was 98.4 lbs on 9/1/2022. Resident #39's Treatment Administration Record (TAR) for August 2022 indicated the resident was to have a pressure reducing air mattress and the TAR was signed off by the assigned nurse twice daily. On 9/07/2022 at 11:50 PM an interview was conducted with Nurse #4. She stated the facility did not have a wound treatment nurse; the nurses assigned to the resident performed wound care. She stated she was assigned to Resident #62 and was familiar with her history of pressure injuries. She further stated the resident's skin was intact and they were applying a barrier ointment to the newly healed area on her sacrum. On 9/7/2022 at 12:00 PM the resident's pressure reducing mattress was observed to be set on 200 pounds (lbs). The control panel indicated the setting should be set to the occupant's weight. A second interview was conducted with Nurse #4 on 9/07/2022 at 3:43 PM. Nurse #4 observed the resident's pressure reducing mattress set at 200lbs. She stated she did not know why the mattress was set for 200 lbs, the resident was less than 100lbs. She further stated the nurses were responsible for making sure the pressure reducing mattresses are set and functioning properly. She did not know how the setting got changed. She had checked the mattress for functioning but had not checked the settings. An interview was conducted with the DON on 9/9/2022 at 1:00 PM. She stated alternating pressure reducing mattresses should be set to the resident's weight and the nurses assigned to the residents are responsible for checking the mattress for accurate settings and proper functioning. 2. Resident #14 was admit on 12/31/21 with a pressure ulcer and readmitted on [DATE] with a left [CONDITION(S)] and a pressure ulcer to her sacrum. Review of Resident #14's pressure ulcer care plan initiated 6/24/22 included the intervention of an pressure relieving air mattress to her bed. Review of Resident #14's significant change Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact, coded for one stage 3 pressure ulcer and a pressure relieving device on the bed. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read the staff were to check the function and therapeutic range of the air mattress on each shift. Review of Resident #14's Treatment Administration Records for 07/12/22 through 09/08/22 indicated the nurses checked the function of her APM twice daily. A review of Resident #14's electronic medical record indicated a weight of 113.6 pounds on 9/3/22. An observation was completed on 9/6/22 at 11:47 AM. Resident #14 was lying in bed. She confirmed she had a pressure ulcer to her sacral. She stated she did not like the mattress the facility provided. The APM pump was attached to the footboard of her bed. The APM was set for a weight of 400 pounds. Another observation was completed on 9/7/22 at 2:32 PM. Resident #14 was again lying in bed with the weight setting to her APM at 400 pounds. An interview was completed on 9/7/22 at 3:32 PM with Nurse #1. She stated the nurses were to check for inflation and the pump settings on every 12 hour shift and documented it on the TAR. An observation was completed on 9/7/22 at 3:35 PM with Nurse #1. She noted the APM weight setting was set for 400 pounds. Nurse #1 stated she checked it daily for inflation but she should also be checking the weight setting. She adjusted the weight setting on the APM to the proper setting for Resident #14's actual weight. An interview was completed on 9/8/22 at 11:10 AM with Nursing Assistant (NA) #2. She stated the aides were not allowed to adjust any settings on the APM because it was the responsibility of the nurse. An interview was completed on 9/9/22 at 12:45 PM with the Director of Nursing (DON). She stated Resident #14's APM weight setting should be set as near to her actual weight as possible and checked on every shift to ensure accuracy.

Based on observations, record reviews, interviews with staff, Pharmacy Consultant, Nurse Practitioner (NP) and Psychiatric Mental Health Nurse Practitioner (PMHNP), the facility failed to attempt a gradual dose reduction (GDR) for a resident who received two antipsychotic medications for 1 of 5 reviewed for unnecessary medications (Resident #71). The findings included: Resident #71 was admitted on [DATE] with diagnoses that included [CONDITION(S)] with [CONDITION(S)] [CONDITION(S)], dementia, depression, and anxiety. Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, required extensive assistance with activities of daily living, and received antidepressants 7 out of 7 days, antipsychotics 7 out of 7 days, antianxiety medications 7 out of 7 days and opioids 2 out of 7 days during the assessment period. The resident's comprehensive care plan dated 9/6/2022 included a focus for risk of adverse reactions from [CONDITION(S)] medications. Resident #71's medical record had one abnormal involuntary movement scale screening (AIMS) dated 6/13/2022. The resident's calculated AIMS score was 14. The AIMS form included interpretation of AIMS score and read as follows: score of 0-7 there is a low risk of movement disorder, 8 is a borderline risk of movement disorder, and a score of 9 or greater should be referred to neurology for neurological exam. The resident's active orders included: [MEDICATION(S)] (antianxiety medication), 1 milligram (mg) orally 3 times a day with a start date of 8/12/2022 and no end date. [MEDICATION(S)] (antidepressant medication)20 mg at bedtime with a start date of 8/12/2022 and no end date. [MEDICATION(S)] (antidepressant medication), 50 mg orally daily with a start date of 8/12/2022 and no end date. [MEDICATION(S)] (atypical antipsychotic prescribed for [CONDITION(S)] [CONDITION(S)]), 34 mg daily with a start date of 8/12/2022 and no end date. [MEDICATION(S)] (antipsychotic medication), 25 mg at night with a start date of 8/12/2022 and no end date. Resident #71 was seen by Psychiatric Mental Health Nurse Practitioner (PMHNP) on 6/21/2022. The PMHNP's summary indicated there were no psychotic symptoms noted or reported, the resident denied auditory or visual hallucinations, and the resident was not responding to internal stimuli. The PMHNP's recommendations included gradual dose reduction of [MEDICATION(S)] in next 4-8 weeks after resident adjusted to facility. Patient was at risk for adverse effects from polypharmacy of multiple antipsychotics, multiple antidepressants, and multiple sedating agents. She also recommended referral to neurology. Resident #71's behavior monitoring log, provided by the facility, for July, August, and September revealed there were no behaviors documented by staff. The medical record included monthly medication reviews (MMR) by the consulting pharmacist. A MMR dated 7/29/2022 recommended GDR of [MEDICATION(S)]. A MMR dated 8/30/2022 also recommended a GDR of [MEDICATION(S)]. Resident #71's medical record revealed a second dose of [MEDICATION(S)] (antipsychotic medication), 12.5mg orally in the morning was added by Nurse Practitioner (NP) #1 on 9/5/2022 with no end date. An observation of Resident #71 was conducted on 9/6/2022 at 3:01 PM. She was observed in her room, sitting up in bed with eyes closed. She had continuous movement of her mouth and tongue. Resident did not respond when spoken to. A second observation was conducted 9/07/2022 at 10:50 AM. The resident was observed in her room seated in a recliner. Again, she was observed to have continuous movement of the mouth and tongue. On 9/08/2022 at 1:00 PM an interview was conducted with NP#1. She stated she was familiar with Resident #71. She further stated she was aware the resident was on two antipsychotics, two antidepressants and an antianxiety medication and stated she needed every bit of it and probably more. When asked why, she stated the resident had been off the chain recently. NP#1 described visual and auditory hallucinations by Resident #71. When asked, she stated she did not believe the resident received Psych services after 6/21/2022 and she did not know if the resident had seen neurology yet. When asked about signs of tardive dyskinesia (involuntary movement that can be a side effect of antipsychotic use) she stated the resident came in that way and was sure it had not gotten any worse since her admission. When asked if she was aware the resident had an AIMS of 14, she stated she was not aware the resident's AIMS was 14. On 9/08/2022 at 2:17 PM an interview was conducted with Nurse Aide #6 (NA). She stated she was very familiar with Resident #71 and was assigned to her. She further stated the resident has had auditory and visual hallucinations. However, the kiosk where they document behaviors required you to choose from a list of behaviors and hallucinations was not a behavior listed. She stated she made the nurse aware of the behaviors when they occurred. A telephone interview was conducted with the Pharmacy Consultant on 9/09/2022 at 11:40 AM. The pharmacist stated she reviewed the psych note on 6/21/2022, MARs, and the behavior monitoring, prior to recommending a GDR of [MEDICATION(S)]. The resident had been started on [MEDICATION(S)] which is appropriate for [CONDITION(S)] [CONDITION(S)]. She stated the recommendation was made in July and August and she had not received a response from the MD or NP regarding those recommendations. Additionally, she was not aware the NP had increased the [MEDICATION(S)] to twice daily from once daily. It was added after her last review on 8/30/2022. On 9/09/22 at12:33 PM an interview was conducted with the Administrator. She stated the facility had recent challenges filling the position of Medical Director (MD) after their last MD retired the end of April 2022. On 8/16/2022 the Administrator became aware the GDRs were not addressed for all residents. She asked that pharmacy recommendations not be printed and given to the NP but the new medical director. The new MD took over resident care responsibilities on 8/30/2022 and was still getting to know the residents and addressing their GDRs. She further stated Resident #71 had a neurology appointment scheduled on 10/30/2022 but the called and were able to get it moved up to September. A telephone interview was conducted with the PMHNP on 9/12/2022 at 8:00 AM. She stated she saw Resident #71 last on 6/21/2022. She had not been asked to see the resident since. She was not made aware of the increase in [MEDICATION(S)] made by NP#1 on 9/3/2022. It was her recommendation on 6/21/2022 they attempt a GDR of the [MEDICATION(S)]. She further stated she was concerned about polypharmacy in the resident due to the number of antipsychotic and [CONDITION(S)] medications she received. An interview was conducted with the Director of Nursing and the Administrator on 9/9/2022 at 1:00 PM. The Administrator and the DON stated it was their expectation the NP, MD, and Consulting Pharmacist communicate and conduct GDRs when appropriate.

Based on record review, observation and staff interviews, the facility failed to report a medication refrigerator temperature as out of range for 1 of 2 medication refrigerators reviewed (200-hall medication refrigerator). Findings included: The facility's Medication Policy and Procedure, last revised 10/2017 was reviewed. In the Medication Storage in the Facility section, under Temperature, item C indicated Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 C (centigrade) (36 F) and 8 C (46 F) with a thermometer to allow temperature monitoring On 9/08/22 at 2:34 PM the 200-hall medication room was observed. The medication refrigerator was opened, and the thermometer was observed with Medication Aide (MA) #1 and read 34 degrees ( ) Fahrenheit (F). The MA stated she did not check the medication refrigerator or temperatures because she did not administer insulin. The contents of the refrigerator included: 3 Insulin [MEDICATION(S)] pens 100 units (U)/1 milliliter (ml), 3 ml size 6 Insulin [MEDICATION(S)] pens 100 U/1 ml, 3 ml size Information for both insulin [MEDICATION(S)] and insulin [MEDICATION(S)] pens was reviewed and indicated to keep new pens in the refrigerator between 36 F to 46 F, do not freeze, do not use if insulin has been frozen. The refrigerator log noted as Sept. 2022 included instructions at the top of the sheet: Temperature in degrees Fahrenheit-notify maintenance and DON (Director of Nursing) if not between 36 and 46 degrees. Temperature documentation included: 9/3/22 noted as 32 F 9/4/22 noted as 34 F 9/5/22 noted as 30 F An interview was conducted with Nurse #1 on 9/08/22 at 3:03 PM. The nurse stated the night shift checked the medication refrigerator temperatures. She explained unopened insulin was kept in the refrigerator and she did not look at the temperatures. An interview was conducted with the Director of Nursing (DON) on 9/08/22 at 3:48 PM. The DON stated when the nurse had observed the medication refrigerator temperature was below the recommended range, she would have expected the nurse to move the medications to another medication refrigerator and notify maintenance. The DON reviewed the maintenance log and stated she did not see any concerns regarding medication refrigerators noted.

Based on record reviews, observations, and interviews the facility failed to don personal protective equipment (PPE) when entering a room on transmission-based precautions (TBP) for 1 of 1 resident (Resident #39) reviewed for transmission-based precautions. The findings included: The facility's Infection Prevention and Control Manual for Long Term Care, last revised 2/2/2022, indicated when a resident is on contact precautions, gloves and isolation gowns should be utilized and healthcare staff should don gloves and isolation gown before contact with the resident or his/her environment. Resident #39 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's medical record contained a progress note by Nurse Practitioner (NP) #1. The NP saw the resident on 9/1/2022 for a rash characterized as vesicular [CONDITION(S)] of the right flank and right breast that was highly suggestive of [CONDITION(S)] [MEDICATION(S)] (Shingles). Resident #39 was placed on antiviral [MEDICATION(S)] and TBP, contact isolation. On 9/6/2022 Resident #39 was observed to be on transmission-based precautions with signage on door indicating contact precautions. The sign indicated anyone entering the room should perform hand hygiene, don gown and gloves prior to entering the room. There was a PPE caddy with supplies outside the resident's door. On 9/07/2022 at 11:54 AM Nurse Assistant (NA) # 1 was observed entering Resident #39's room. The resident was observed sitting in her wheelchair receiving an aerosolized nebulizer treatment. NA#1 entered the room in her scrubs and face mask, without donning PPE. The NA was interviewed after she exited the room and stated the resident was on precautions for shingles. When asked why she did not don PPE, she stated she was only in the room briefly. She further stated she should have worn a gown and gloves when she entered the room since the resident was on contact precautions. An interview was conducted with the Director of Nursing (DON)/Infection Control Preventionist on 9/9/2022 at 1:00 PM. She stated staff should wear PPE in rooms with residents who are on contact precautions.

Based on record reviews, family and staff interviews, the facility failed to provide the resident and/or responsible party (RP) written notification of the reason for a hospital transfer for 2 of 3 residents reviewed for hospitalization (Residents # 32 and #14). The findings included: 1. Resident #32 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #32 had moderately impaired cognition. Resident #32's medical record revealed she was transferred to the hospital on 8/23/22 for mental status changes. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP) for the reason of the transfer. Resident #32 returned to the facility on [DATE]. The Administrator was interviewed on 9/7/22 at 3:35 PM and explained a written reason for hospital transfer was sent with the resident in the hospital discharge packet. The Administrator added there was no other written notification regarding the hospital transfer that was sent to the RP and/or resident, but they were always notified verbally. She stated she would expect the resident and/or RP to be notified in writing for the reason of the hospital transfer per the regulation. During a phone call on 9/8/22 at 3:15 PM, with Resident #32's RP, she indicated she had not received anything in writing regarding the reason for hospital transfer on 8/23/22, although she was notified by phone. 2. Resident #14 was admitted [DATE]. Review of Resident #14's medical record indicated a family member was listed as her responsible party (RP). Review of Resident #14's significant change Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact. Resident #14's medical record revealed she was transferred to the hospital on 6/21/22 due to a fall. There was no documentation that a written notice of transfer was provided to the resident and/or RP for the reason of the transfer. Resident #14 returned to the facility on [DATE]. The Administrator was interviewed on 9/7/22 at 3:35 PM and explained a written reason for hospital transfer was sent with the resident in the hospital discharge packet. The Administrator added there was no other written notification regarding the hospital transfer that was sent to the RP and/or resident, but they were always notified verbally. She stated she would expect the resident and/or RP to be notified in writing for the reason of the hospital transfer per the regulation. During a phone call on 9/8/22 at 1:50 PM with Resident #14's RP, she indicated she had not received anything in writing regarding the reason for hospital transfer on 6/21/22, although she was notified by phone.

Based on record review and staff interview, the facility failed to revise the care plan in the area of falls. This was for 1 (Resident #48) of 4 residents reviewed for falls. The findings included: Resident #48 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and was coded for one fall without injury. Review of Resident #48's comprehensive care plan last revised on 8/10/22 included a care plan for a risk of falls initiated on 5/21/22. Review of Resident #48's medical record revealed she sustained an actual fall on 7/17/22 and another fall on 8/22/22. There were no injuries and interventions implemented were appropriate. On 9/9/22 at 12:00 PM, an interview was completed with MDS Nurse #1. She stated Resident #48's fall care plan should have been revised after the quarterly MDS dated [DATE] to include the fall she sustained on 7/17/22. She also stated the fall that occurred on 8/22/22 should have also been added to the fall care plan to reflect Resident #48's current falls with updated interventions. MDS Nurse #1 stated it was an oversight. On 9/9/22 at 12:45 PM, the Administrator stated Resident #48's fall care plan should be an accurate reflection of her current status along with the new interventions.

Based on observations, resident, staff interviews and record review, the facility failed to discontinue a wander/elopement alarm in the absence of wandering. This was for 2 (Resident #14 and Resident #68) of 2 residents reviewed for personal alarms. The findings included: 1. Resident #14 was admitted on [DATE]. Resident #14's significant change Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact, exhibited wandering behaviors for 1 to 3 days and not coded for wander/elopement alarm. A wander/elopement alarm was ordered for Resident #14 on [DATE]. Review of Resident #14's nursing notes for April, May and [DATE] revealed occasions of wandering, gathering her things and verbalizing she was going to leave and go back to her apartment. There were nursing notes documenting her increased confusion and episodes of delusions thought to be related to her urinary tract infections. There was no documented evidence of an actual elopement. Review of a nursing note dated [DATE] at 10:00 PM, Resident #14 had ambulated to the bathroom and slipped. She did not call for staff assistance prior to her fall. An x-ray revealed a left [CONDITION(S)] and she was sent out to the hospital on [DATE] and readmitted to the facility [DATE]. Review of a Resident #14's readmission Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Elopement Risk assessment dated [DATE] indicated Resident #14 was not an elopement risk. Review of Resident #14's care plan initiated [DATE] did not include a risk area related to wandering behaviors with the use of a wander/elopement alarm. Resident #14's significant change MDS dated [DATE] indicated she was cognitively intact, exhibited no wandering behaviors and was coded for wander/elopement alarm. The MDS was coded for no ambulation in her room or on the unit and coded for extensive staff assistance for locomotion on and off the unit. Review of Resident #14's Treatment Administration Records for [DATE] to [DATE] indicated the nurse's checked the function of her wander/elopement alarm each shift. An observation and interview was completed on [DATE] at 11:47 AM with Resident #14. She was asked pull up her right pant leg to allow visualization of her wander/elopement alarm. She stated the alarm had been in use for a while and stated that she was not able to ambulate anymore and accepted the facility as her home. She stated at one time she was ambulating throughout the facility with her friend. An interview was completed on [DATE] at 4:00 PM with Nurse #1. She stated prior to Resident #14's fall in [DATE], she was able to ambulate throughout the skilled halls. She stated Resident #14 never breeched the locked door leading to the assisted living hall and the front exit but the potential was there. That was the reason she was ordered a wander/elopement alarm back in [DATE]. Nurse #1 further stated since Resident #14 was readmitted on [DATE] after her fall and resulting [CONDITION(S)], she was no longer ambulating and the alarms should probably come off. Review of Resident #14's electronic medical record included an order dated [DATE] discontinuing the wander/elopement alarm. An interview was completed on [DATE] at 11:07 AM with Nursing Assistant (NA) #5. She stated started working at the facility a few months ago and since she started, she had never observed Resident #14 wandering or stating she wanted to leave the facility. An interview was completed on [DATE] at 11:10 AM with NA #2. She stated she had worked at the facility for 7 years. NA #2 stated Resident #14 used to have a male friend and they would walk about the facility before he died earlier this year. She stated since his death, Resident #14 was more confused and was having delusions. She stated the wander/elopement alarm was added for her safety. NA #1 stated since Resident #14 fell and broke her hip, she was no longer a risk for wandering or elopement. A telephone interview was completed on [DATE] at 1:21 PM with Nurse #5. He stated Resident #14 was no longer a wander/elopement risk. He stated her alarm should have been discontinued once it was determined that she was not going to rehabilitate to ambulating again after her readmission in [DATE]. A telephone interview was completed on [DATE] with Nurse #7. She stated Resident #14 at one time was experiencing increased confusion after her friend died but since falling and breaking her hip, she appeared to have really gone downhill quickly and was no longer able to wander or exit seek. She stated she was unsure why Resident #14 still had the alarm. A telephone interview was completed on [DATE] at 1:54 PM with Nurse #8. She stated Resident used to get up and wander about the facility but never had an unsupervised exit. She stated since her readmission in [DATE], she was no wandering and seldom got out of the bed. She stated she did not understand why she still had the alarm. An interview was completed on [DATE] at 12:45 PM with the Administrator. She stated when Resident #14 was readmitted in [DATE], her wander/elopement alarm order was carried over without considering the Elopement Risk Assessment completed on her readmission and she was unable to explain why the alarm was not discontinued at that time. She stated it should have not been reordered on her readmission. 2. Resident #68 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #68's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #68's nursing progress notes from [DATE] to [DATE] revealed the following behaviors that staff described as wandering: stating she needed to go home, walking in the hallway, looking for her purse and/or family members in other rooms, and walking on a different hallway stating she was lost or looking for markers. There were no further behavioral symptoms after [DATE]. An Elopement Risk Assessment form dated [DATE] indicated the resident was at risk of getting to a dangerous place and had an elopement deterrent device was implemented. A review of Resident #68's behavior logs from [DATE] through [DATE] did not show any behaviors logged by the Nurse Aides (NA). Per the legend on the behavior log, pacing, rummaging, and wandering were included for choices to select if present. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #68 was alert and oriented and displayed no behaviors, wandering or rejection of care. She required supervision and setup for walking in the room/corridor and locomotion on the unit. She required supervision and 1 staff member for locomotion off the unit. She was coded with a wander/elopement alarm used daily. An Elopement Risk Assessment form dated [DATE] indicated the resident was not at risk for elopement but an elopement deterrent device remained implemented. A review of Resident #68's behavior logs from [DATE] through [DATE] did not show any behaviors logged by the NAs. The MDS Nurse #2 was interviewed on [DATE] at 3:45 PM and was the staff member that completed the Elopement Risk Assessment from [DATE]. She reviewed and verified she marked all wandering and exit seeking behavior as no because Resident #68 was not exhibiting any of those behaviors but felt the wander alarm should remain on due to the potential for exit seeking and wandering due to her confusion at night and not as many staff are here during the evening and night times. When asked if the wander alarm had been discussed for the potential of removal since there had been no behaviors of wandering or exit seeking since February 2022, the MDS Nurse #2 stated no, because what if she needed it again. An interview occurred with Resident #68 on [DATE] at 11:30 AM. She was sitting on the side of her bed with a wander alarm present to her right ankle. Resident #68 stated she didn't understand why she had the alarm on her ankle because I never leave this room. An interview occurred with Nurse #3 on [DATE] at 10:40 AM, who was familiar with Resident #68. She explained Resident #68 rarely left her room and received all meals in her room. She had not witnessed her wandering in the hallways for some time. On [DATE] at 10:47 AM, NA #2 was interviewed. She was typically assigned to care for Resident #68 during the day shift (7:00 AM to 3:00 PM) and stated she rarely left her room. At times she would stand in her doorway or want to sit at the door way or hallway to watch staff and others. She added Resident #68 was able to ambulate with her walker or a wheelchair, but she had not witnessed her attempting to seek an exit from the facility. A phone interview occurred on [DATE] at 1:30 PM, with Nurse #5 who worked as the weekend supervisor from 7:00 AM to 7:00 PM. He stated he was familiar with Resident #68 and had not witnessed her wandering in the building or exit seeking. Stated she rarely came out of her room. On [DATE] at 2:33 PM, a phone interview was conducted with NA #3 who was familiar with Resident #68 and provided care to her in the evenings (3:00 PM to 11:00 PM). She stated Resident #68 stayed in her room and at the most would come to her doorway to request assistance or talk to staff. NA #3 stated Resident #68 was still alert and oriented but had some confusion at night. NA #4 was interviewed via phone on [DATE] at 2:42 PM, stating she provided care to Resident #68 on the 7:00 PM to 7:00 AM shift. Stated Resident #68 normally only came to her doorway of her room to ask staff for assistance, to look up and down the hallways or to talk with staff as they passed by. NA #4 stated about four months ago Resident #68 walked to the memory care unit doors (on the same hallway that she resided on) looking for family and her purse, but she had not witnessed this behavior since. She denied Resident #68 came out and wandered in the facility or attempted to exit seek. A phone interview was held with Nurse #6 on [DATE] at 9:56 AM. He stated he was familiar with Resident #68 and cared for her on the weekends 7:00 AM to 11:00 PM. Nurse #6 explained 95% of the time she stayed in her room but would come up to the common area at the nurse's station but no longer was looking for things/people or exit seeking. Typically, though, she would come to her doorway or out in the hall looking around but found her way back to her room without any incidents. Nurse #6 stated he didn't consider these behaviors as wandering or exit seeking. The Nurse Practitioner (NP) was interviewed on [DATE] at 12:50 PM, and reviewed the Elopement Risk Assessment form dated [DATE], showing there was no exit seeking behavior present. The NP stated Resident #68 still required the wander alarm because she walked out in the halls, she had seen her in the common area of the unit at times when she worked at night and added, she could go into any of these rooms, and we wouldn't know where she was. The Administrator was interviewed on [DATE] at 10:35 AM and stated when the NA's completed the behavior log there was an icon that popped up asking if the nurse had been made aware before they were able to complete what behaviors were present. She would expect if a resident exhibited behaviors, such as wandering, to be marked on the behavior log as well as in the nursing progress notes. She continued to explain the Elopement Risk Assessment forms, that were completed every three months, should be utilized to assess the need for continuation of a device such as a wander guard. A trial removal should have been discussed with the Interdisciplinary Team (IDT) since Resident #68 no longer displayed any wandering or exit seeking behaviors.

Based on record review and staff interviews, the facility failed to obtain physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. Resident #214 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the EMR revealed a MOST (Medical Orders for Scope of Treatment) form dated 9/21/21 signed by the nurse practitioner and Resident #214 ' s family member that indicated DNR. A history and physical dated 9/24//21 revealed Resident #214 had a MOST form in place dated 9/24/21 that indicated DNR. On 10/5/21 at 11:56 AM, an interview was conducted with Nurse Supervisor #1. She stated code status is displayed in the EMR on the main page. She added if there is nothing there, it indicated the resident was a full code. Nurse Supervisor #1 also stated there was a binder at the nurses ' stations that held MOST forms and DNR forms, but she could not locate either for Resident #214. On 10/5/21 at 12:00 PM, an interview was conducted with the Administrator. She stated the nursing staff would look at the main page of the EMR to locate a resident ' s code status and if there was nothing there, the resident was a full code. On 10/7/21 at 9:30 AM, an interview was conducted with the Staff Development Coordinator (SDC). She stated when a resident is admitted , the Admissions Director provides the family with the MOST form. The nursing supervisors then put the orders into the computer, the documents get scanned into the EMR and then the MOST forms and DNR ' s go to the resident halls for placement into the binders that hold them. She stated Resident #214 had a MOST form that was scanned into the EMR but she did not know why there was not a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #43 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] A MOST form dated 3/18/21 signed by the nurse practitioner and Resident #43 ' s family member was in the EMR. A progress note authored by the Nurse Practitioner indicated Resident #43 had a MOST form in place and was a DNR. On 10/5/21 at 12:15 PM, Nurse #1 was interviewed. She stated code status for residents is located on the main page of the EMR and that is where she would look to look for a resident ' s code status in the event of an emergency. She added if there was nothing on the main page, it indicated the resident was a full code. Nurse #1 added there was also a binder located at each nurse ' s station that held MOST forms and DNR forms. Nurse #1 could not locate a MOST form or DNR form for Resident #43. On 10/7/21 at 9:30 AM, the Staff Development Coordinator was interviewed. She stated Resident #43 was readmitted to the facility and the MOST form must not have been returned from the hospital. She stated the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations and staff interviews the facility failed to serve cold food at the required temperature, maintain clean dishware, allow cookware to air dry and store open foods in sealed, labeled and dated containers. This was evident in 4 of 4 kitchen observations. Findings Included: 1. An observation of the kitchen on 8/19/19 at 10:45 am with the Dietary Manager (DM) revealed the following: a. A case of chicken tenders, hamburger patties and onion rings were open, exposed to the air and not labeled or dated in the walk-in freezer. b. 9 of 13 third size steamtable pans and 8 of 12 half size steamtable pans were stacked together wet on a storage shelf for clean pots and pans. An interview with the DM on 8/19/19 at 11:00 am revealed he expected all open food items to be sealed, labeled and dated. He stated the wet steamtable were stored by the second shift on the previous day. The DM explained the staff were aware the pans needed to be air dried before being stacked on the shelf. He added there were several drying shelves where the staff should have left the steamtable pans to air dry before they put them away. 2. An observation of the 300-hall service kitchen on 8/21/19 at 11:55 am revealed the following: a. Homemaker #1 in the service kitchen took the temperatures of the food on the steam table using a calibrated thermometer. The chicken salad registered 50 degrees F and the staff member placed the chicken salad back into the refrigerator. She began service of the resident ' s meal trays and was observed to make a chicken salad sandwich using the chicken salad she had placed in the refrigerator. The tray was assembled and placed on the cart to be delivered to the resident. The staff member had not re-checked the temperature of the chicken salad prior to serving the chicken salad sandwich. The temperature was then taken of the chicken salad and it was at 49 degrees F. b. 10 of 10 coffee mugs were heavily stained and stored in a cabinet to be used for service to the residents. An interview with Homemaker #1 on 8/21/19 at 12:00 pm revealed she had not re-checked the temperature of the chicken salad before preparing a resident ' s meal tray. She stated the chicken salad was not at the correct temperature and should not have been served. 3. An observation of the 200- hall service kitchen on 8/21/19 at 11:50 am revealed 20 of 20 coffee mugs were heavily stained and being used for service to the residents. 4. An observation of the 400-hall service kitchen on 8/21/19 at 12:00 pm revealed 12 of 12 coffee mugs were heavily stained and located on the tray line for service to the residents. An interview with the DM on 8/21/19 at 12:15 pm revealed the stained coffee mugs had been identified as a concern from the resident council meeting and they had started to de-stain the mugs twice monthly versus once a month. He stated he thought all the mugs had all been de-stained, but they had obviously missed some. The DM explained the homemakers were responsible to bring dishes that needed to be de-stained to the main kitchen where the supplies were located for this process. An interview with the Administrator on 8/22/19 at 2:15 pm revealed it was her expectation that dishes were not stored wet, food was covered and dated, food was served at the correct temperature and the coffee mugs would have no stains.

Based on observations and staff interviews the facility failed to serve food at a palatable temperature. This was evident in 1 of 1 meal observation. Findings Included: An observation of the 300-hall service kitchen steamtable was conducted on 8/21/19 at 11:55 am. Homemaker #1 took the food temperatures using a calibrated thermometer and they were: beef stroganoff 199 degrees F, noodles 168 degrees F and vegetable blend 159 degrees F. A regular diet test tray was prepared and placed on the 300-hall cart with 5 resident meal trays. The cart was delivered to the hall at 12:26 pm and the last resident meal tray was served at 12:32 pm. The Dietary Manager (DM) checked the food temperatures using the same calibrated thermometer and they were: beef stroganoff over the noodles 122 degrees F and vegetable blend 104 degrees F. The food was tasted with the DM and tasted cool to cold. The DM stated the food was not warm enough to be served to the residents and he expected the food to be hotter when served. An interview with the Administrator on 8/22/19 at 2:15 pm revealed it was her expectation that the resident ' s food was served at the correct temperature.

Based on resident interviews, staff interviews and observation the facility failed to maintain walls and ceilings, window screens, electrical outlets and window ledges for 6 of 12 resident rooms reviewed for a safe, clean, comfortable and homelike environment. (Rooms 306, 501, 504, 506, 508 and 510) Findings included: 1. During an observation of room [ROOM NUMBER] on 7-25-18 at 1:10pm the wall behind the bed was noted to have the paint chipped off exposing the plaster as well as a hole next to the wall electrical outlet allowing the electrical outlet to be loose. The resident stated he was unaware that was an issue and did not know how or when it happened. The maintenance man was interviewed on 7-25-18 at 2:53pm who stated the padding on the back of the beds headboard was removed from behind the bed which allowed the headboard to hit against the wall when the bed was moved, but he was unaware of the damage to the wall. An interview with the Administrator occurred on 7-25-18 at 4:20pm who stated she expected the facility to have a clean, orderly and safe environment for the residents. She also stated she expected staff to use their maintenance repair logs to request repairs when they see an issue in the facility that needs to be fixed in the facility by the maintenance staff. A review of the maintenance repair logs from 5-26-18 to 7-25-18 revealed that there were no requests by staff for room [ROOM NUMBER] 2. During an observation of room [ROOM NUMBER] on 7-25-18 at 1:12pm the popcorn ceiling was noted to be chipping exposing the plaster underneath approximately 10 feet long and 3 inches wide, the screen on the inside had dirt and cob webs and the window ledge was noted to have crumbs and dust. The resident was not interviewable. An interview with the maintenance director on 7-25-18 at 2:55pm revealed he was unaware of the issues with the screen or window ledge because there had not been a request entered into the computer system but that he had been aware of the popcorn ceiling chipping. He stated he had been trying to repair the worst ceilings first. An interview with the Administrator occurred on 7-25-18 at 4:20pm who stated she expected the facility to have a clean, orderly and safe environment for the residents. She also stated she expected staff to use their maintenance repair logs to request repairs when they see an issue that needs to be fixed in the facility by the maintenance staff. A review of the maintenance repair logs from 5-26-18 to 7-25-18 revealed that there were no requests by staff for room [ROOM NUMBER]. 3. During an observation of room [ROOM NUMBER] on 7-25-18 at 1:15pm the popcorn ceiling was noted to be peeling off and chipped approximately 3 feet long and 3 feet wide exposing the plaster underneath. Also, the room's inside window screen was dirty and had cob webs. The residents in the room were not interviewable. The maintenance director was interviewed on 7-25-18 at 2:57pm who stated he was aware of the popcorn ceiling being chipped and that he was addressing the issue but had not been unaware of the screen being dirty because he had not been informed by staff through the computer system. An interview with the Administrator occurred on 7-25-18 at 4:20pm who stated she expected the facility to have a clean, orderly and safe environment for the residents. She also stated she expected staff to use their maintenance repair logs to request repairs when they see an issue that needs to be fixed in the facility by the maintenance staff. A review of the maintenance repair logs from 5-26-18 to 7-25-18 revealed that there were no requests by staff for room [ROOM NUMBER]. 4. During an observation of rooms 506, 508 and 510 on 7-25-18 at 1:20pm the popcorn ceiling was noted to be chipping off exposing the plaster underneath. The popcorn ceiling in room [ROOM NUMBER] was chipping off approximately 3 feet long by 3 feet wide by the bathroom door, the ceiling in 508 had approximately a 6-foot-long by 3 inches wide area chipping off and room [ROOM NUMBER]'s ceiling had an area approximately 3 feet long by 3 feet wide chipping off exposing the plaster underneath. The residents in the 3 rooms stated they had not noticed the issues with the ceiling. The maintenance director was interviewed on 7-25-18 at 3:05pm who stated he was aware of the problem with the popcorn ceilings and that he had been working on the worst ceilings first. An interview with the Administrator occurred on 7-25-18 at 4:20pm who stated she expected the facility to have a clean, orderly and safe environment for the residents. A review of the maintenance repair logs from 5-26-18 to 7-25-18 revealed that there were no requests by staff for room [ROOM NUMBER], 508 and 510.

Based on record review, observations, and staff interviews the facility failed to provide the proper food consistency for 6 of 6 pureed meals served to Resident #500, Resident #300, Resident #31, Resident #82, Resident #57, and Resident #74 in the 500-dining room. Findings included: Resident #500, Resident #300, Resident #31, Resident #82, Resident #57, and Resident #74 diet orders were reviewed and revealed they were all on a pureed diet at meals. Observation on 07/23/18 at 12:25 PM, 6 plates of pureed foods (pureed chicken, pureed carrots, and pureed broccoli) were served to Resident #500, Resident #300, Resident #31, Resident #82, Resident #57, and Resident #74 in a thin liquefied form mixing together on each plate. Observation with the Dietary Manager (DM) on 7/25/18 at 12:15 PM revealed 6 plates of pureed foods were served to Resident #500, Resident #300, Resident #31, Resident #82, Resident #57, and Resident #74 in the 500-dining room. The pureed foods (broccoli, mashed potatoes, and pureed spaghetti sauce) were again in a thin liquefied form mixing together on each plate. The DM did not intervene or obtain another tray for these residents. Resident #500, Resident #300, Resident #31, Resident #82, Resident #57, and Resident #74 were unable to answer questions appropriately when asked about their food. Cook #1 was interviewed on 7/25/18 at 1:28 PM who stated no water had been added to puree the foods. Continued interview with Cook #1 stated they (the facility) tried not to use food thickener for the pureed foods and add more of the actual food to make it thicker. Cook #1 stated the pureed foods should not be in a thin form that would allow the foods to mix together and if known, he would have corrected the thin form of the pureed foods. On 7/25/18 at 1:37 PM, the DM stated there had been past issues about the pureed foods consistency and today (referring lunch on 7/25/18) the consistency of the pureed meal was too thin. DM stated the cook in the kitchen should be following the recipe when making the pureed food. The Administrator was interviewed on 7/25/18 at 4:05 PM and stated she would expect the pureed foods to be the proper consistency and appealing.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for residents in the areas of medications (Resident #107), [DIAGNOSES REDACTED].#85), pressure relief devices and care (Resident #30), and Activities of Daily Living (Residents #8 and #71) for 5 of 19 residents reviewed. The findings included: 1a) Resident #107 was admitted to the facility on [DATE] from another nursing facility. His cumulative [DIAGNOSES REDACTED]. A review of the resident's medical record revealed [REDACTED].#107 on 2/28/16 to be given as 25 milligrams (mg) twice daily. A review of Resident #107's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was assessed to have severely impaired cognitive skills for daily decision making. He required extensive assistance from staff for most of his Activities of Daily Living (ADLs). Section N of the MDS assessment did not indicate the resident received an antipsychotic medication. A review of the April 2016 Medication Administration Record [REDACTED]. The facility's MDS nurse was not available for interview. An interview was conducted on 6/16/16 at 9:00 AM with the facility's Administrator. The Administrator reviewed Resident #107' MDS assessment and medication history. The Administrator acknowledged Resident #107's MDS dated [DATE] should have been coded to indicate he received an antipsychotic medication. 1b) Resident #107 was admitted to the facility on [DATE] from another nursing facility. His cumulative [DIAGNOSES REDACTED].#107 on 3/14/15 to be given as 25 milligrams (mg) once daily. A review of Resident #107's annual MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was assessed to have severely impaired cognitive skills for daily decision making. He required extensive assistance from staff for most of his Activities of Daily Living (ADLs). The resident's MDS assessment (Section I) did not indicate the resident had an active [DIAGNOSES REDACTED]. A review of the Resident's Care Area Assessment (CAA) Summary dated 7/27/15 included the following, in part: . (Name of resident) is diagnosed with [REDACTED]. The facility's MDS nurse was not available for interview. An interview was conducted on 6/16/16 at 9:00 AM with the facility's Administrator. Upon inquiry, the Administrator confirmed depression was incorrectly omitted from Resident #107's list of active [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED]. 2) Resident #85 was admitted to the facility on [DATE] from the hospital. Her cumulative [DIAGNOSES REDACTED]. The resident's admission medication orders included 20 milligrams (mg) [MEDICATION NAME] (an antidepressant) to be given as one tablet by mouth daily. A review of Resident #85's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was assessed to have severely impaired cognitive skills for daily decision making. She required extensive assistance from staff for most of her Activities of Daily Living (ADLs). The resident's MDS assessment (Section I) did not indicate the resident had an active [DIAGNOSES REDACTED]. A review of the Resident's Care Area Assessment (CAA) Summary dated 7/17/15 included the following narrative, in part: .Current (diagnoses) are: .Depression. Resident is on [MEDICAL CONDITION] meds for dementia with behavioral disturbance and depression. A review of Resident #8 's quarterly MDS assessment dated [DATE] also revealed Section I did not indicate the resident had an active [DIAGNOSES REDACTED]. The facility's MDS nurse was not available for interview. An interview was conducted on 6/16/16 at 9:00 AM with the facility's Administrator. Upon inquiry, the Administrator confirmed depression was incorrectly omitted from Resident #85 s list of active [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED]. 3. Resident #8 was admitted to the facility on [DATE] and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated resident #8 was cognitively intact. He required total dependence for bed mobility, transfers and toilet use. During the seven day look back period, the MDS was coded as 8 (activity did not occur) for locomotion on and off the unit, dressing, eating, personal hygiene and bathing. A review of the ADL (activities of daily living) verification worksheet (a worksheet that was used to determine accuracy of coding ADL information on the MDS) revealed Resident #8 was independent with locomotion on and off the unit and eating. Extensive assistance was needed for dressing and personal hygiene. He was totally dependent on staff for bathing. The facility' s MDS nurse was not available for interview. An interview was conducted on 6/16/16 at 10:16AM with the facility's Administrator. The Administrator reviewed Resident #8's MDS dated [DATE] and stated the MDS was coded improperly and she did not know how that would have occurred. The Administrator said a modification would be done immediately to reflect accurate coding for locomotion on and off the unit, dressing, eating, personal hygiene and bathing. 4. Resident #71 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #71 was moderately impaired in cognition. She was independent with eating. A review of the ADL (activities of daily living) verification worksheet for 4/2/16 through 4/8/16 revealed Resident #71 required supervision with eating. On 06/15/2016 at 2:32PM, an interview was conducted with MDS Nurse #1. She reviewed Resident #71's MDS and the ADL verification worksheet and stated Resident #71 should have been coded as supervision with eating. She stated she had witnessed Resident #71 feeding herself but should have coded the MDS based on the information on the ADL verification worksheet. 5. Resident # 30 was admitted to the facility 1/25/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 was cognitively intact and was at risk for pressure ulcers. It also indicated she had a Stage 3 pressure ulcer but did not have a pressure reducing device for her bed or chair and was not receiving pressure ulcer care. Review of the Medical Record from 5/15/16 through 5/23/16 revealed that Resident #30 was receiving pressure ulcer care at the time of the MDS Assessment. Observation of Resident #30 on 6/15/16 at 11:15 AM in her room revealed that she had a pressure reducing mattress on her bed and a pressure reducing cushion on her wheelchair. Interview with the Administrator on 6/16/16 at 10:04 AM revealed that neither of the two MDS Coordinators could be available for interview. She stated that she had reviewed Resident #30 ' s MDS with the MDS Coordinators and that the 5/23/16 MDS was coded incorrectly for Pressure reducing devices and pressure ulcer care. The Administrator added that she did not know why it had been missed on the MDS because Resident #30 did have pressure reducing devices on her bed and in her wheelchair at the time of the MDS, as did all residents, and had been receiving pressure ulcer care at that time as well. The Administrator also said that the MDS needed to be correct and that a correction had already been submitted.

Based on record review and staff interviews, the facility failed to develop a care plan to address the use of [MEDICAL CONDITION] medications for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #107). The findings included: Resident #107 was admitted to the facility on [DATE] from another nursing facility. His cumulative [DIAGNOSES REDACTED]. A review of the resident ' s medical record revealed [MEDICATION NAME] (an antidepressant medication) was initiated for Resident #107 on 3/14/15. A review of the resident ' s annual MDS (Minimum Data Set) assessment dated [DATE] revealed he was assessed as having severely impaired cognitive skills for daily decision making. The resident required extensive assistance from staff for most of his Activities of Daily Living (ADLs). Section N of the MDS assessment indicated Resident #107 received an antidepressant medication on 7 of 7 days during the look back period. A review of the resident ' s Care Area Assessment (CAA) dated 7/27/15 in Section V of the MDS revealed [MEDICAL CONDITION] Medication Use was a triggered care area and would be addressed in his care plan. The CAA Summary for [MEDICAL CONDITION] Medication Use included the following narrative, in part: dementia (without) behaviors, depression, anxiety . (Resident #107) is (diagnosed ) with depression and is prescribed ([MEDICATION NAME]) daily. He is at risk for adverse side effects from this medication. I will proceed to (care plan) to identify those side effects so that staff may monitor for and report on for rapid intervention and interaction with Resident to help minimize the risk of behaviors . A review of Resident #107 ' s care plan initiated 9/4/14 and revised on 4/6/16 revealed the topic of [MEDICAL CONDITION] Medication Use was not addressed. Further review of the resident ' s medical record indicated [MEDICATION NAME] (an antidepressant medication) was initiated on 1/28/16 for Resident #107. The resident was also started on quetiapine, an antipsychotic medication, on 2/24/16. The use of either the antidepressant medication or the antipsychotic medication was not addressed in his care plan. An interview was conducted with MDS Nurse #1 on 6/15/16 at 4:22 PM. Upon inquiry, MDS Nurse #1 reported she would expect a resident receiving an antidepressant and/or antipsychotic to be care planned for the use of a [MEDICAL CONDITION] medication. Upon request, the MDS nurse reviewed Resident #107 ' s care plan and acknowledged it did not appear to include the care area of [MEDICAL CONDITION] medication use. An interview was conducted on 6/16/16 at 9:00 AM with the facility ' s Administrator. Upon review of Resident #107 ' s care plan and medication history, the Administrator reported she would have expected the resident ' s care plan to have included a focus area on the use of [MEDICAL CONDITION] medications.

Based on observation, record review and staff interview, the facility failed to secure the indwelling catheter tubing to prevent excessive tension or accidental displacement for 4 of 4 sampled residents with an indwelling or suprapubic urinary catheter (Resident #13, #39, #65 and #8). The findings included: A facility policy titled Catheter care, urinary dated and last revised 3/1/15 stated, in part, #15. Check to see that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). 1. Resident #13 was admitted to the facility on [DATE] and last admitted [DATE]. Cumulative [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident #13 was cognitively intact. The MDS indicated Resident #13 had an indwelling urinary catheter. A care plan dated 2/10/15 and last reviewed on 4/22/16 stated Resident #13 had an indwelling urinary catheter secondary to [MEDICAL CONDITION] bladder requiring nursing maintenance. Interventions included, in part, to use care when repositioning and transferring resident related to injury, obstruction, pain or accident removal of cath. On 6/14/16 at 10:16AM, an interview was conducted with Resident #13. When asked if the indwelling catheter tubing was secured to her thigh, she stated No and pulled back the covers. The urinary catheter tubing was not secured to her thigh. Also, the urinary catheter tubing was not secured with a clamp to the bed linens. On 6/15/16 at 10:15AM, urinary catheter care was observed. NA#1 performed catheter care and did not secure the urinary catheter tubing to Resident #13' s body. On 6/15/16 at 10:18AM, NA#1 stated she did not put securement devices or secure the catheter to Resident #13's body when Resident #13 was in bed. She stated there were securement devices available on the facility and she had seen them being used on residents at times. On 6/15/16 at 10:30AM, an interview was conducted with the Administrator who stated securement devices were available at the facility and she expected staff to secure the urinary tubing with a securement device to the resident's thigh. 2. Resident #39 admitted to the facility 1/7/12 and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #39 was cognitively intact. The MDS indicated Resident #39 had an indwelling urinary catheter. A care plan dated 6/7/15 and last reviewed 6/13/16 stated Resident #39 had a suprapubic catheter related to [MEDICAL CONDITION] bladder. Interventions included, in part, to anchor the suprapubic catheter to prevent excessive tension. An observation was conducted on 6/15/16 at 10:30 AM. The suprapubic catheter urinary tubing was not secured to Resident #39's body. On 6/15/16 at 10:30AM, an interview was conducted with the Administrator who stated securement devices were available at the facility and she expected staff to secure the urinary tubing with a securement device to the resident's thigh. 3. Resident #65 was admitted to facility 11/3/15. Cumulative [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident #65 was moderately impaired in cognition. The MDS indicated Resident #65 had an indwelling urinary catheter. A care plan dated 11/19/15 and last reviewed on 5/2/16 stated Resident #65 was at risk for infection related to the use of an indwelling urinary catheter. Interventions included, in part, anchor catheter to prevent excessive tension (added on 6/15/16). An observation on 6/15/16 at 9:15AM revealed Resident #65's urinary catheter tubing was not secured to her body. On 6/15/16 at 10:18AM, NA#1 stated she did not put securement devices or secure the catheter to Resident #65's body when Resident #65 was in bed. She stated there were securement devices available on the facility and she had seen them being used on residents at times. On 6/15/16 at 10:30AM, an interview was conducted with the Administrator who stated securement devices were available at the facility and she expected staff to secure the urinary tubing with a securement device to the resident ' s thigh. 4. Resident #8 was admitted to the facility 2/13/15 and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident #8 was cognitively intact. The MDS indicated Resident #8 had an indwelling urinary catheter. A care plan dated 2/26/16 stated Resident #8 had a [DIAGNOSES REDACTED]. He had a suprapubic catheter requiring nursing maintenance. Interventions included, in part, to use care when repositioning and transferring resident related to injury, obstruction, pain or accident removal of catheter. An observation on 6/15/15 at 10:35AM revealed Resident #8 did not have the urinary catheter tubing secured to his body. Resident #8 stated, at that time, that he did not want a securement device applied to the urinary catheter tubing. On 6/15/16 at 10:45AM, an interview was conducted with the Administrator who stated Resident #8 had not told them he did not want a securement for his tubing and, in fact, had allowed staff to apply a securement device to his thigh in the past. She stated he did not have a care plan that stated he did not want the securement device. The Administrator stated she expected staff to secure the urinary tubing with a securement device to the resident's thigh.

Based on record review and staff interviews, the facility ' s Quality Assessment and Performance Improvement committee (QAPI) failed to implement, monitor and revise as needed the action plan developed for the recertification survey dated 7/9/15 in order to achieve and sustain compliance. The facility had a repeat deficiency on Minimum Data Set (MDS) assessment on the recertification survey 7/9/15 and the recertification survey 6/16/16. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain and effective Quality Assurance Program. The findings included: This tag is cross referred to F278: assessment accuracy. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for residents in the areas of medications (Resident #107), [DIAGNOSES REDACTED].#85), pressure relief devices (Resident #30), and Activities of Daily Living (Residents #8 and #71) for 5 of 19 residents reviewed. An interview was conducted with the Administrator on 06/16/2016 at 10:23AM. She stated the deficiency last year for accuracy of the MDS was regarding miscoding of Hospice. The Administrator stated the facility did a plan of correction and her focus was for accuracy of Hospice on the MDS.

Based on observations, record reviews, and staff interviews, the facility failed to provide the resident with a right foot rest on her broda chair to prevent the resident's foot from slipping during transportation in the broda chair and getting under the chair which resulted in the fracture of the femur to 1 of 3 residents reviewed for accidents. (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively severely impaired; required extensive assistance of two staff with transfers; required total assistance of one staff with locomotion on and off of the unit; and, had no limitation with the range of motion of her extremities. Review of the Occupational Therapy (OT) Evaluation dated 3/29/16 indicated Resident #1 was referred for therapy due to a new onset of decrease in range of motion, decreased postural alignment and, reduced static and dynamic balance placing the resident at risk for muscle atrophy, contracture(s), decreased participation with functional tasks, decreased skin integrity, and pneumonia. The resident's family requested that the resident have a broda chair (specialized wheelchair) for greater support to her back and to assess for decreased leaning over side of chair-right. The OT Note dated 3/30/16 revealed Resident #1 was up in a broda chair with good positioning; no lateral leaning or forward sliding. The left foot pedal was in place; however, the right foot pedal was bent and unable to latch. The staff were educated on the use of the broda chair for daily use. The objective was to have the right foot pedal adjusted for appropriate fit to allow proper foot positioning while the resident was up in the broda chair. Review of the Occurrence Report dated 3/31/16 revealed that on 3/30/16, one of the foot pedals of Resident #1's wheelchair was removed by Therapy because it was not latching properly to her chair. Therapy put in a work order with the Maintenance Department to repair the chair. Before Maintenance could repair the chair, the resident was being rolled down the hallway with both feet on the one good foot rest. The resident's right foot fell off of the foot rest and went under the wheelchair as it was being rolled. The resident complained of knee pain. The nursing assistant stated when she realized what happened she stopped propelling the chair and the resident started saying my knee hurts really bad. My knee is broke. The nurse assessed the knee and it did not appear swollen at that time. Pain medication was administered and the nurse practitioner was notified and he assessed the resident. An x-ray was ordered which indicated an acute distal femoral fracture. Orders were received and the resident was sent to the hospital via the emergency medical services for further evaluation. The review of the summary from the Hospital's Emergency Department dated 3/30/16, revealed Resident #1 was diagnosed with [REDACTED]. The resident was given 25mcg (microgram) injection of fentanyl (pain medication), home care instructions and a follow-up appointment with Orthopedics for 3/31/16. The Orthopedic's Note dated 3/31/16 indicated Resident #1 had a non-operative fracture that required pain control in a dementia patient and should be closely observed and modified by the facility's staff. The Note revealed the family of Resident #1 chose conservative management, with strict non-weight bearing and the resident was to stay in the right leg immobilizer. In a report of the investigation of the incident by the RN/NHA (registered nurse/nursing home administrator) dated 4/1/16, a Root Cause Analysis was completed revealing that Resident #1 should have had both foot rests on the chair despite her ability to hold both legs on the same foot pedal. The Occupational Therapy Note dated 4/4/16 indicated Resident #1's use of the broda chair was discontinued due to the change in her status due to her fractured femur. Facility staff were educated on positioning the resident in a geri-chair using a mechanical lift for transfers requiring the assistance of two staff with one staff supporting the resident's right leg. On 4/20/16 at 1:30pm, Resident #1 was observed in a geri-chair being propelled by a nursing assistant in the hallway. The resident was alert, sitting upright with feet elevated. The resident's legs were covered with a blanket and the resident displayed no signs of pain. During an interview on 4/20/16 at 2:19pm, SN#1 (Staff Nurse #1) revealed that she had worked with Resident#1 for three months and that the resident was alert, verbal but very confused. SN#1 stated that the resident always required two leg rests due to the resident was unable to hold her legs up. She also revealed that the resident never attempted to propel herself in the wheelchair. SN#1 stated that on 3/30/16, prior to the incident, NA#1 (Nursing Assistant #1) informed her the leg rest on the resident's wheelchair was not functioning, and she (NA#1) had also informed the Therapy Department about it (Therapy responsible for assigning wheelchairs and leg rests), but after asking two to three times, Therapy had not returned it or given her a new one for the resident. SN#1 revealed that she was informed by Therapy staff that the leg rest was given to the Maintenance department for repair. SN#1 revealed that between 12:00pm-1:00pm, NA#1 requested that she (SN#1) assess the resident's leg due to the resident's leg fell off of the leg rest of her wheelchair. NA#1 informed her (SN#1) that while she was propelling the resident up the hall to the dining room in the wheelchair, the resident's right leg fell off of the leg rest and went under the wheelchair. NA#1 informed SN#1 that she had placed both of the resident's legs on one leg rest in a crossed position. SN#1 stated she observed NA#1 standing behind the resident's wheelchair and another nursing assistant holding the resident's right leg in an extended position. The resident refused to allow SN#1 to touch her knee. SN#1 instructed the two nursing assistants to transport the resident back to her room (NA#1 pushing the wheelchair while the other nursing assistant holding the resident's extended right leg). SN#1 stated that she notified her immediate supervisor and the NP (Nurse Practitioner) who was on-site that day. The NP attempted range of motion on the resident's right leg, the resident was crying and yelling. The NP noted that the leg wasn't swollen and was unsure if the pain the resident was experiencing was part of her chronic pain (old hip fracture) or if there was a new injury. When NP asked SN#1 opinion, SN#1 revealed that she informed him that the resident's crying and yelling was not part of her usual signs of chronic pain. The NP made decision at that time to have an x-ray completed of resident's leg on-site. Until the x-ray was done, the resident's pain was managed with tramadol (pain medication). SN#1 revealed the results of the x-ray as a fracture of the distal end of the femur. The Physician was notified and an order was received to have the resident transported to the hospital via emergency medical services for evaluation. SN#1 stated that the hospital stabilized the resident's leg with an immobilizer and the resident returned to the facility with a follow-up appointment with the Orthopedics Specialist. SN#1 revealed NA#1 should not have propelled the resident in a wheelchair with both feet on one leg rest. SN#1 also revealed that NA#1 informed her that therapy staff instructed her to cross the resident's legs and put both feet on one leg rest. SN#1 stated that when she spoke with therapy staff, she was informed that they (therapy) told NA#1 to be careful. During an interview on 4/20/16 at 3:47pm, NA#1 revealed she had worked with Resident #1 since her admission and that the resident was alert, verbal and able to answer most questions. NA#1 stated that the resident was able to lift her legs; but, resident always had two footrests on her wheelchair. NA#1 revealed the resident very rarely propelled herself in the wheelchair. The day of the accident was the resident's second day in the broda chair. NA#1 indicated that the Therapy department educated her on the proper use of the broda chair when the resident received it; and at that time the footrests worked fine, would latch without a problem. NA#1 stated that prior to the incident on 3/30/16, the resident was able to stand and pivot. NA#1 revealed that on 3/30/16 at 7:30am, she noticed that the right footrest on the resident's broda chair would not latch, so she removed it to avoid skin tears or bruising. NA#1 revealed that she then crossed the resident's right leg so that the resident's right foot rested on top of her left foot which rested on the left footrest and proceeded to propel the resident to the dining room for breakfast. On the way to the dining room, NA#1 informed one of the therapist about the broken right footrest. The resident was returned to her room after breakfast by another nursing assistant, without incident. NA#1 stated that when she arrived to resident's room to transfer her from the wheelchair to her recliner, she noticed that the broken footrest had been removed and assumed therapy had it. NA#1 indicated that at approximately 10:00am, she transferred the resident from her recliner to the wheelchair and positioned the resident's legs the same as she did earlier. While propelling resident to the shower room, NA#1 asked a different therapy staff about the leg rest for the resident's chair; the therapist informed her that the leg rest was being worked on. NA#1 stated that during lunch time, while on her way to kitchen, she noticed the resident was still in her room in her broda chair (the resident should have been in the dining room for restorative dining). NA#1 revealed that she place the resident's right leg in the same position that she had done all morning (crossed onto left leg). As NA#1 propelled the resident in the broda chair across her room and through the doorway, the resident never yelled out. As they proceeded down hallway, NA#1 revealed that she felt a jolt and stopped immediately, bent down in front of the resident and saw that the resident's right leg was bent and her right foot was on the floor instead of the footrest; NA#1 asked resident what was wrong, what hurt, and she indicated that the resident complained of knee pain and that her knee was broke. NA#1 indicated that the resident moved her right leg from beneath wheelchair area and was able to move her ankle. NA#1 revealed she placed the resident's right leg back into the crossed position on the left foot rest. NA#1 stated that the resident did not grimace, yell, or cry or verbalize pain. NA#1 indicated that as she propelled resident towards the dining room, she stopped and informed a staff nurse of the incident and that the resident complained of knee pain. The staff nurse did not observe any swelling and the resident was not crying. After leaving the resident in the dining room, NA#1 stated that she informed the Nurse Supervisor of incident. NA#1 revealed that she was informed by a restorative nursing assistant that the resident was returned to her room due to the resident was in dining room crying that her pain was getting worst. During an interview on 4/21/16 at 12:23pm, the COTA (Occupational Therapist Assistant) revealed Resident#1 was evaluated by therapy for positioning due to her family's request due to trunk weakness and lateral leaning. She indicated that the resident was unable to propel herself in a wheelchair. A broda chair was obtained during evaluation. The COTA stated that the day after receiving the broda chair, she arrived at the resident's room for her usual treatment and was informed by NA#1 the footrest would not lock and that she (NA#1) gave it to the therapist for repair. The COTA revealed that she located the footrest on the occupational therapist's desk. She stated that she checked the footrest and realized it was bent; therefore would not latch. The COTA indicated that she then contacted the Maintenance Supervisor who said he would work on it after lunch. The COTA stated that the broda chair probably should not have been used, until the food rest could have been repaired. She revealed that it was not appropriate for the nursing assistant to place both of the resident's feet on the left footrest due to safety reasons. The COTA concluded that it would have been appropriate for therapy to provide an alternative means of transporting the resident, such as in a geri-chair, until the footrest was repaired. She also stated that had she been made aware that the resident was to eat lunch in the dining room and not in her room, then an alternative means of transportation would have been provided. During an interview on 4/21/16 at 10:50am, the RN/NHA revealed that as the result of the investigation of the incident, the QAPI Committee, of which she was a member, conducted a Root Cause Analysis Summary on 3/31/16 and a plan of correction was initiated on the same day. The RN/NHA presented a plan of correction with a corrective date of 4/11/16, which consisted of: 1) On 3/31/16, Resident #1 was transported and seen by a local Orthopedist. An immobilizer was placed and the resident was determined not to be a candidate for surgery. Pain medication was prescribed. The resident's broda chair was removed from service until repaired and both foot pedals operational. The incident was reviewed by the IDT (Inter Disciplinary Team) to determine root cause and intervention on Kardex-Footrest needs to be in place when transported in a broda/wheelchair. Completion date of 3/31/16. On 4/1/16, Resident #1's Kardex was updated by the DON (Director of Nursing) and NS#1 (Nursing Supervisor) to reflect the resident must be transported in a broda/wheelchair with leg rests and foot pedals. DON requested that the therapist assess the resident for therapy needs and proper chair positioning. Completion date of 4/1/16. 2) On 3/31/16, the second shift nursing staff reviewed all residents in the facility to determine those residents needing leg rests and/or foot pedals on their broda and/or wheelchairs. It was determined that residents who self-propel themselves are safer without leg rests and/or foot pedals and these residents were identified. One resident was identified as needing foot pedals and were installed. One resident's personal chair lacked foot pedals and family was notified. This resident was provided a facility wheelchair until family can equip/repair her personal chair. Completion date of 3/31/16. On 4/1/16, the DON and SN#2 held in-services with all Health Care Staff with instructions: 1. All residents who are transported in wheelchairs and that do not use their legs to self-propel will have leg rests. 2. The nursing department along with therapy will ensure that all leg rests are appropriate and in good repair. 3. No resident requiring leg rests will be transported in a wheelchair without the leg rests. 4. The nursing department will audit residents during transport to ensure compliance daily. 5. Any resident requiring leg/foot rests will have this information placed in their Kardex. Facility Department Managers to monitor for compliance of use of footrest while transporting residents. Reporting to QAPI Committee using the Nursing Facility Observation Audit as directed by QAPI Committee. Facility QAPI will evaluate the effectiveness of intervention measures by a decrease noted in incidents related to non-use of footrest when providing transportation to our residents. Completion date of 4/4/16. 3) a. Facility-wide in-service 4/7/16. DON will present Safety in Motion to all staff. Completion date of 4/7/16. b. All department managers will have their staff in-serviced by 4/11/16, pertaining to Safety in Motion. Completion date of 4/11/16. c. All department managers will monitor staff compliance with the new initiative, Safety in Motion. The data (Nursing Facility Observation Audits) will be reported at the QAPI meeting. 4) These measures will be monitored by the DON with oversight by the Administrator through the Quality Assurance process. The DON will report on the measures implemented to the QAPI Committee which will monitor for effectiveness for minimum of twelve months. The Committee will make further recommendations to adjust the measures as needed. The Administrator is responsible to see that recommendations are acted upon in a timely manner. Facility department managers will monitor for compliance use of footrests while transporting residents using the Nursing Facility Observation Audit. 5) The facility made the decision to formulate the QAPI (Quality Assurance and Performance Improvement) on 3/31/16. Throughout the survey period (4/19/16 through 4/21/16), observations were made of facility staff propelling residents in wheelchairs and broda chairs with the residents' feet correctly positioned on both leg rests. On 4/19/16 at 2:36p, Resident #4 was observed in her room, sitting in a wheelchair with her feet on the left and right foot pedals. On 4/21/16 at 1:32pm, Resident #2 was observed in the dining room in a broda chair with her feet positioned on the right and left foot pedals. Resident #1's Care Plan and Kardex were updated to include the requirement of both leg rests attached to her broda/wheelchair. Review of facility records revealed in-services were conducted from 4/1/16 through 4/7/16 on ensuring leg rests were applied to and used for wheelchairs and broda chairs of residents who were unable to propel themselves. The Nursing Facility Observation Audits were completed daily beginning 3/31/16, ensuring all identified residents requiring leg rests on their wheelchairs and/or broda chairs were monitored by the Director of Nursing, the Assistant Director of Nursing, the Nursing Supervisor, and the Charge Nurse.

Based on observation, record review, and staff interview, the facility failed to prevent 2 of 3 cognitively impaired residents (#32 and #176) from exiting the facility without the knowledge of staff. Resident #32 fell outside and sustained a fractured humeral neck (a fracture of the upper arm bone, near the top, just under shoulder joint). Resident #176 walked 8/10 of a mile from the facility on a two lane road with no shoulder. The immediate Jeopardy began on 4/25/13 for Resident #32, and 5/7/13 for Resident #176. The immediate Jeopardy was identified on 5/22/13 at 9:40 am and was removed on 5/23/13 at 5:03 pm. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete implementation of system changes and monitoring the corrective action stated in the credible allegation. The findings included: 1. Resident #32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #32 required limited assistance to complete activities of daily living. The MDS further identified the resident as being severely cognitively impaired. Resident #32 did not exhibit wandering during the assessment period. Review of the Elopement Risk assessment dated [DATE], 10/31/12, 1/16/13 and 4/5/13 revealed Resident #32 had a score of 12 identifying the resident was at risk for elopement. A Review of the Fall Risk Assessments dated 8/18/12, 10/31/12, 1/16/13, and 4/5/13 revealed the resident had a score not to exceed 17 indicating the resident was a high risk for falls. A review of Resident #32's Care Plan dated 8/13/12 and quarterly review dated 4/10/13 revealed the resident had a Care Plan for Elopement. The care plan revealed a goal of " Resident will remain within the health care unit x 90 days " . The approaches on the plan of care were listed as, " maintain wanderguard bracelet and check battery weekly, re-direct resident when she tries to leave the building, attempt diversional activities such as a magazine, walking to the courtyard, going to activities, speak to resident in a calm quiet voice, wandergaurd for safety, and encourage participate in diversional activities after supper. " The Care plan identified Resident #32 had an episode of elopement on 4/25/13. Review of Resident #32's care plan further revealed the resident was care planned for falls, and cognitive loss. A review of nursing notes written by nurse #2 dated 4/25/13 revealed the facility was notified that a resident was outside on the ground at 11:30 am. The note further revealed Resident #32 was found on her left side complaining of right shoulder pain and right hip pain. The note further indicated the resident's walker was 4 feet behind her. The nursing note revealed the residents vital signs were taken and wanderguard taken from her right ankle prior to transport to the hospital via stretcher. Nursing note dated 4/25/13 revealed Resident #32 returned to the facility with a [DIAGNOSES REDACTED]. The medical record revealed a physician order [REDACTED]. Resident #32's medical record further revealed an order written [REDACTED]. Review of Hospital Discharge records dated 4/25/13 reveal the resident had a right humeral neck fracture due to a fall. Hospital discharge records dated 4/25/13 indicated the resident was prescribed Lortab 5 milligrams every 6 hours for pain. A review of the facility Unanticipated Occurrence Report and Investigation revealed a visitor had found Resident #32 out to the front left of the building in the grass on the ground on 4/25/13 at 11:30 am. The resident's walker was near side. The report further revealed the resident was calling for help and was lying on her left side. The Occurrence Report revealed that prior to the incident on 4/25/13, Resident #32 was in an activity in which staff had taken the resident to Unity (spiritual singing). The Incident Report revealed the staff member that was responsible for the resident (Home Maker Guide #2) left Resident #32 due to another resident that required medical assistance. When the staff member returned to Resident #32 the activity had concluded and there were no more residents remaining in the activity upon the staff 's return. The Investigation report indicated the facility checked all exits doors, initiated a head count of all residents, and initiated maintenance requests to check all doors. Review of the Home Maker Guide Job description revealed Essential duties and responsibility included; " Maintain a safe, comfortable and functional environment by assessing the household for potential hazards, implementing practices utilizing appropriate techniques regarding sanitation, infection control, fire safety, disaster preparedness and emergency care, attending or assuring the household is presented on all appropriate councils and team of the community, investigation and reporting all incidents and accidents, observing the team for safe work habits and addressing observations, and develops and implements social programs which will provide communication among residents through group activities and recreations. " Interview with nurse # 2 on 5/21/13 at 11:07 am revealed the she was approached by the Director of marketing on 4/25/13 at 11:30 am. Nurse #2 indicated the Director of Marketing revealed a Resident was outside of the facility lying on the grass in the front of the building. Nurse#2 indicated Resident #32 was located outside the front of the building lying on her side. Nurse #2 identified the location Resident #32 was found. The location was beyond main entrance (3) to left of the building. The Resident was just beyond the sidewalk at the beginning of a decline in the grass. The identified area was visible to the main parking lot. Nurse#2 further revealed Resident #32's walker was just behind the resident and the resident was wearing a wanderguard on her ankle. Nurse #2 revealed she provided Resident #32 with a pillow for comfort and stayed with the resident until EMS arrived. Nurse#2 indicated that she was unaware of how long Resident #32 was outside of the facility. Nurse #2 revealed Resident #32 had never made attempts to exit the building. Nurse#2 further revealed Home Maker Guides took the resident to an activity prior to the incident occurring. Nurse #2 stated Home Maker Guides did not communicate to the Nursing staff when they escorted residents to the non-skilled side of the building. Nurse #2 further indicated that Home Maker Guides did not communicate when they return a resident from an activity and there was currently no log that would relay information regarding a resident that had been taken from the skilled area. Interview with Home Maker Guide #2 on 5/21/13 at 1:16 pm revealed Resident #32 was escorted to an activity at " Unity Place " by Home Maker Guide #2. The Home Maker Guide revealed " Unity Place " was area of the facility used for various activities or church events. The Home Maker Guide indicated she escorted Resident #32 to the Unity place with one other resident. The Home Maker Guide #2 further revealed Home Maker Guide #3 had also taken 2 residents to the activity at " Unity Place. " Home Maker Guide #2 indicated the activity was full of residents from the skilled side of the facility and residents from independent living. The Home maker guide revealed there were over 30 residents in the activity. The Home Maker Guide revealed one of the residents had an emergent health concern that required immediate attention. The Home Maker Guide revealed she left Resident #32 in the activity. The Home Maker Guide indicated that she did not inform any staff member that she was leaving Resident #32 unattended while she sought out medical attention for the other escorted resident. The Home Maker Guide stated Resident #32 was only left unattended for 10 minutes. Home Maker Guide #2 revealed that when she returned to Resident #32 the activity had concluded and the there were no residents remaining in " Unity Place. " The Home Maker Guide indicated she was under the impression that another staff member had escorted Resident #32 back to the skilled side of the facility. The Home Maker Guide reveled she does not communicate to nursing staff that she is escorting a resident to an activity on the non-skilled side of the facility. The Home Maker Guide further revealed she was unaware of how long Resident #32 had been outside of the facility. Interview with Home Maker Guide #3 on 5/21/13 at 1:42 pm revealed she did not see Resident #32 in the activity on 4/25/13. The Home Maker guide indicated she had taken a small group of residents to the activity with the assistance of the facility Chaplin. The Home Maker Guide further indicated that there were more residents in the activity from the skilled side of the facility than were escorted by Home Maker Guide #2 and Home Maker Guide #3. The Home Maker Guide revealed at the conclusion of the activity she had to assist with escorting the residents back to the skilled side of the facility. The Home Maker guide indicated a lot of wheelchair residents were in attendance that required assistance back to the skilled side of the facility. At no time did Home Maker Guide #3 see Resident #32 while providing residents assistance back to the skilled side of the facility. Home Maker Guide indicated that she does not communicate to nursing staff when residents are taken to activities on the non-skilled side of the facility. Home Maker Guide further revealed she does not communicate to nursing staff when a resident has been returned to the skilled side of the facility. Interview with the Maintenance Director on 5/21/13 at 3:20 pm revealed the facilities only alarmed doors were located within the skilled area of the facility. The Maintenance Director further indicated the alarms on the doors were routinely monitored on a weekly basis. The Maintenance Director further revealed the 3 main entrance doors into the facility would not alarm if a resident with a wanderguard were to exit. Interview with the Director of Marketing on 5/23/13 at 8:57 am revealed she takes lunch around 11:30 am. The Director of Marketing further revealed that upon exiting the building for lunch she and a visitor observed Resident #32 lying in the grass in front of the building. The Director of Marketing indicated she left the visitor with the Resident #32 while she retrieved Nurse #2. The Director of Marketing stated that she was unaware of which exit Resident #32 exited the building. Interview with NA# 3 on 5/23/13 at 9:12 am revealed she was the Aide assigned to Resident #32 at the time of the incident on 4/25/13. NA# 3 indicated she was unaware the resident did not return from the activity and was told Resident #32 was found injured outside of the facility. NA# 3 further indicated that Home Maker Guides do no communicate when residents are taken from assignment due to an activity or when the resident is returned following an activity. NA #3 indicated that Resident #32 was confused often but never attempted to exit the building. Interview with the Director of Nursing (DON) on 5/2/13 at 10:40 am revealed Resident #32 did sustain an injury following a fall outside of the facility. The DON indicated that the resident did have a wanderguard on at the time of the incident. Resident #32 was located outside the facility in the grass. The DON indicated the resident was in the grass before the facility parking lot. The DON further indicated the Home Maker Guide responsible for Resident #32 had briefly left resident while in activity in the non-skilled side of the building due to the illness of another resident. The DON indicated that when the Home Maker Guide returned to the activity it had concluded and Resident # was not in " Unity Place. " The DON revealed the responsible Home Maker Guide had assumed that another staff or Home Maker Guide had escorted Resident#32 back to the skilled side of the facility. The DON indicated the skilled side of the facility had alarms for residents with wanderguards. The DON indicated that due to the resident being in an activity on the non-skilled/unalarmed area of the facility, no alarm would sound in the instance Resident #32 eloped from the building. Interview with the Administrator on 5/3/13 at 3:30 pm revealed Resident #32 had a fall outside of the facility that resulted in fracture of the resident arm. The Administrator revealed the facility immediately implemented preventative measures following the elopement of Resident #32. The Administrator indicated preventative measures included checking the facility wanderguard alarm system, revising the ratio of Home Maker Guides to resident, and any resident who wears a wanderguard would not be taken out of the secure unit unless one-on-one supervision could be provided. 2. Resident #176 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission assessment dated [DATE] indicated the resident required assistance of 1 person for transfers and ambulation. An "Elopement Risk Assessment" dated 5/2/13 revealed that Resident #176 was assessed as being at low risk for elopement due to the resident having no history of wandering or attempting to leave the building, no expressed desire to leave the premises or display of restlessness or anxiousness, and required assistance with ambulation. Nurse's Notes dated 5/2/13 at 1:30 PM, written by Nurse #1, revealed that a door alarm transmitter band was placed on Resident #176's ankle due to possible wandering. (The transmitter will signal a sensor near an exit door to engage a magnetic door lock to prevent the resident from opening the door, or if the door is ajar, will activate an audible alarm to alert staff that a resident is attempting to leave the building.) During an interview on 5/22/13 at 2:30 PM, Nurse#2 indicated she talked with Resident #176 on admission and believed a door alarm transmitter was appropriate because the resident was confused and very mobile. Nurse#2 did not know if the resident had a history of [REDACTED]. Nurse#2 indicated she instructed Nurse#1 to put a transmitter on the resident. Nurse's Notes dated 5/2/13 at 6 PM revealed the resident was alert with some intermittent confusion, oriented to person only. Physician orders [REDACTED]. Physical Therapy Notes dated 5/6/13 indicated that Resident #176 walked 100 feet with only "contact guard assist" (physical therapist has one or both hands on the resident's body to help with balance if needed) and on 5/7/13 walked 300 feet with contact guard assist. Additional PT notes dated 5/7/13 revealed the physical therapist met with a family member to discuss discharge around the 14th day of the resident's stay due to her high level of mobility. The family member was agreeable. During an interview on 5/22/13 at 2:11 PM, the Physical Therapist Assistant (PTA) indicated Resident #176 was at high risk for falls when first admitted due to balance problems, but made rapid progress to the point of just needing stand by assistance for stabilization when first standing. The PTA added he had never witnessed the resident wandering in the facility or trying to exit. Nurse's Notes from 5/2/13 - 5/6/13 revealed no documentation of exit seeking behavior. Nurse's Notes dated 5/7/13 at 4:20 PM read, "Found that Res. (Resident #176) walked away from facility, was found on (name of road) by a good citizen and kept at his home until (family member) went and picked her up, she returned to facility with (family member)." Review of an "Unanticipated Occurrence Report and Investigation" for Resident #176's elopement of 5/7/13 revealed that a family member called the facility on 5/7/13 to report that the resident had walked away from the facility. A written statement from Nurse#2 revealed a family member (FM#1) called to report that the resident had gotten out of the facility and was at a man's house but she did not know where. FM#1 reported that the resident had remembered FM#2's phone number and the resident called FM#2. FM#2 called FM#1 to report the resident had left the facility and was at a man's house. The statement revealed that RN#2 checked the resident's room, did not find her, and called a "Code Purple" (the code used when a resident is missing, announced over the public address system, to alert staff on other units to participate in the search). During an interview on 5/23/13 at 8:58 AM, FM#2 stated she had received a phone call on 5/7/13 at 3:35 PM from an unknown man who said her relative (Resident #176) was with him. FM#2 then spoke with the resident who reportedly said, "Come and get me and take me home." FM#2 indicated she again spoke with the man who said he would stay with the resident until someone could come and pick her up, and gave directions to their location. FM#2 indicated she called FM#1, then FM#3 who said he would pick up the resident. During an interview on 5/22/13 at 3:10 PM, FM#3 stated he picked up the resident about 8/10 of a mile down the road from the facility, in front of a house. FM#3 recalled several facility staff walking alongside the road as he drove past the facility. Shortly thereafter he saw the resident and a man standing in a yard. FM#3 stated they were on the same side of the road as the facility. FM#3 said it started raining right after he picked up the resident and the resident was dry. FM#3 indicated he was unsure of the time they returned to the facility. A written statement (undated) by Nurse#1 revealed the resident and FM#3 arrived at the facility around 3:50 PM on 5/7/13. According to www.wunderground.com <http://www.wunderground.com>, the area temperature in the afternoon of 5/7/13 was 67-68 degrees Fahrenheit with scattered clouds. Nurse's Notes dated 5/7/13 at 4:20 PM indicated Resident #176 was assessed for injuries with none noted. Blood pressure was 120/70, temperature 98 degrees Fahrenheit, pulse 78 and respirations 20. (Vital signs on the 7-3 shift were 118/56, 97.6, 54 and 18.) The resident was positioned in bed, given a snack and fluids and placed on every 15 minute checks. FM#3 remained with the resident. There was no documentation that Resident #176 made any further attempt to exit the building. A "Post Hazardous Wandering & Elopement Assessment" dated 5/9/13 indicated that 1:1 supervision was started at 7:00 PM on 5/7/13. During an interview on 5/22/13 at 8:55 AM, NA#5 acknowledged she worked the 7-3 shift on 5/7/13 on the hall where Resident #176 resided. NA#5 said the resident walked independently and was usually in the 300 hall dining area when she was not in therapy. NA#5 indicated that she had never observed Resident #176 to wander or attempt to exit the building. On the day the resident eloped, NA#5 recalled last seeing her at 3:10 PM in the dining area, sitting at the counter. During an interview on 5/22/13 at 4:59 PM, NA#6 acknowledged she was assigned to Resident #176 on the 3-11 shift of 5/7/13. NA#6 said she was familiar with the resident and knew the resident walked around the unit independently. She had never seen Resident #176 attempt to exit the building. NA#6 recalled last seeing the resident shortly after 3 PM on 5/7/13. At that time the resident was in the dining area. NA#6 stated she then made her first rounds on her residents which took 20 -30 minutes. When she was done, NA#6 said she noticed Resident #176 was not in the dining room but she was not concerned because she knew the resident to walk around the unit independently and go to and from her room. NA#6 added that she checked her residents visually every hour when they were up, then every 2 hours after they were in bed. During an interview on 5/23/13 at 11:42 AM, Nurse#1 indicated that on 5/7/13, she last saw Resident #176 around 3:15 PM, sitting in the dining area talking with NA#5. Nurse#1 said she had never witnessed Resident #176 attempt to leave the facility. Nurse#1 added that Resident #176 walked very well independently with no notable difficulty. Nurse#1 was not aware that the resident left the building. A written statement dated 5/7/13 by NA#4 revealed, "Around 3:15 or 3:30, I saw a couple of men coming in the 500 hall door and a woman in a yellow jump suit going out. The door did not alarm and she said her daughter was picking her up at the back door. She asked if I could find a number for someone and I explained my phone doesn't work. She didn't say anything and left walking." During an interview on 5/21/13 at 3:06 PM, NA#4 indicated she did not work on the hall where Resident #176 resided and did not know the resident. NA#4 explained that on 5/7/13, shortly after 3:00 PM she saw a woman (Resident #176), dressed in a pantsuit and carrying a purse, walking out the door at the end of the 500 hall. No alarm sounded. NA#4 stated there was a lot of activity on the hall that afternoon due to construction workers going in and out the exit door as a new shelf was being installed at the 500 hall nursing station. NA#4 said she then noticed the resident standing on the loading dock and looking kind of confused. NA#4 said the resident asked to use her cell phone; NA#4 told her she did not have a working cell phone that day. NA#4 indicated the resident then said she was waiting for her daughter to pick her up. NA#4 added that it was unusual for family to pick up residents at that location since the door was always locked and required a code to open it, but it was possible. NA#4 went on to say that following the elopement, she had received additional training and would take measures to verify the identity of a person before assisting them to exit the facility or leave them outside unattended. She would ask the person if they lived at the facility or were visiting, and get their name. She would verify whether or not the name was on the resident roster. She would also visually check for a transmitter band on their wrists and ankles. During an interview on 5/23/13 at 8:30 AM, the Maintenance Director stated at the time Resident #176 eloped, the door on the 500 hall was the only exit door in the skilled section of the facility that was not equipped to lock or alarm if a resident with a transmitter approached the door. Rather, the 500 hall door was always kept locked and a code was required to open it. All employees in the skilled section were given the code. On 5/23/13 at 10:54 AM, observation of the loading dock/ambulance entrance outside the 500 hall door revealed a concrete pad with a ramp going down to a paved surface which led to the main road. The distance from the 500 hall door to the front yard of the home where Resident #176 was found was clocked at 8/10 of a mile per odometer. This distance was then walked at a moderate pace and took 16 minutes. The road had 2 lanes and several curves. The speed limit was posted at 45 miles per hour (mph) with the exception of 1 curved span that was 30 mph. During the walk, 25 cars passed by. The pavement did not extend to provide a shoulder. The terrain adjacent to the pavement was uneven and grassy. One section of the road, approximately 30 feet long, had a span approximately 6 feet wide from the edge of the pavement to a sharp drop-off of an estimated 12-15 feet. The embankment was lined with rocks. The area walked was on the same side of the road as the facility. Nurse's Notes through 5/10/13 revealed no indication of further attempt to exit. 1:1 supervision round-the-clock was maintained. Therapy notes dated 5/10/13 revealed the family announced they were taking the resident home. The therapist advised family to see the charge nurse so proper discharge arrangements could be made. A physician order [REDACTED]. A "Post Discharge Plan of Care" form was completed with instructions for activity, diet, medications and follow-up appointments. During an interview on 5/21/13 at 3:10 PM, the Director of Nursing (DON) stated when the facility was made aware that Resident #176 was missing, immediate action was taken in accordance with the "Missing Residents" policy, including to first check the resident's room, doing a resident head count and calling a "Code Purple" over the public address system to signal other staff to participate in the search. The search was still in process when the resident returned. The resident was assessed and there was no indication of injury. Every 15 minute checks were initiated immediately, then changed to 1:1 supervision. The DON indicated staff members were educated on the importance of ensuring that they were not inadvertently assisting a resident out of the facility by asking the person if they lived at the facility and to state their name. Staff members were expected to compare the stated name with the resident roster. Staff members were also instructed to look for a transmitter band on the wrist or ankle. The DON added that she could not verify that a staff member had held the door open for the resident since there were contracted workers using the 500 hall door that day. She said the facility immediately changed the code to the door, and only the executive director, administrator and she had the new code. The DON explained that if ambulance service was needed, there was a button at the nurse's station that would unlock the door. The Administrator and Director of Nursing were notified of Immediate Jeopardy on 5/22/13 at 9:40 am. The Allegation of Compliance was received on 5/23/13 at 9:19 pm. The Allegation of Compliance was accepted on 5/23/13 at 5:03 pm. 1) Address how corrective action has been or will be accomplished for those residents found to have been affected by the deficient practice. Incident dated 4/25/13 Resident (#32) was located and assessed by Registered Nurse supervisor. Emergency medical services were summoned, arrived and transported resident to hospital. Resident (#32) was diagnosed with [REDACTED]. Resident (#32) returned same day to facility. 4/25/13 A one-to-one in-service was conducted with each Homemaker Guide with instructions, " Effective immediately, no residents with wander bracelet will be taken out of the healthcare secured area to attend activities. The only exception to this policy will be circumstances where arrangements have been made for the resident to have constant one-to-one supervision while they are outside the secure area. " 4/29/13 Incident dated 5/7/13 One-on-one supervision (24-hours) was immediately assigned to this resident. Resident (#176) was reassessed and determined to be a high risk of elopement. Executive Director and Healthcare Administrator met with the resident ' s family immediately after the incident to relate details of the incident, interventions taken, and to solicit their input as to any other action they would like from the facility. 5/7/13 Nursing supervisor and Director of Nursing assessed resident (#176) for injury, none found. Director of Nursing initiated every 15min staff checks at 4:15PM. At 7:00PM, one-on-one nursing assistant/sitter supervision was initiated and continued until resident ' s discharge. The family declined facility ' s offer and recommendation to have resident transferred to a local closed (double-locked) facility stating, " We like it here. " Resident (#176) was discharged home on[DATE] per family request. 5/7/13 2) Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. Incident dated 4/25/13 Residents having the potential to be affected by this deficient practice were identified by receiving an elopement risk assessment upon admission, quarterly and as need indicates (exit seeking behavior). The Administrator in-serviced all Homemaker Guides that residents who wear wander bracelets can no longer leave the HC secure area without one-to-one supervision. Instructions stating, " CNAs - DO NOT take residents with wandering bracelets outside of the healthcare unit. " were placed in the nursing assistants ' daily assignment notebook. 4/29/13 Incident dated 5/7/13 A root cause analysis was conducted to identify the factors leading to the deficiency. The following systemic changes have been implemented to address these factors: 1. Staff member failed to identify individual as a healthcare resident with risk for elopement. Action Taken: An in-service was placed in the nursing in-service notebook at the 500 nursing station to clearly establish the expectation they are to determine the identity of an individual before permitting them to exit the facility. Training included instruction on how to properly identify whether an individual is an at-risk resident or visitor to include visual inspection for wander bracelets and appropriate questions to ask the individual to make the determination. 5/8/13 2. Assure only those who need door codes know the door codes. Action Taken: All door codes were changed within the facility to ensure only those who need the codes know them. 5/8/13 3. Restrict use of the 500 ambulance door to authorized staff only. Action Taken: On 5/8/13, established a unique code for the 500 ambulance door, known only to the Executive Director, Healthcare Administrator, Director of Nursing, Assistant Director of Nursing, nursing shift supervisors and security. 500 door was retrofitted on 5/10/13 to incorporate the Secure Care System wander sensor/locking mechanism by the contractor. 5/10/13 4. Assure proper operation of existing security measures and wandering system operation. Action Taken: All exit doors were tested by the Director of Plant Operations, to assure proper working order. 5/7/13 5. Assess elopement risk for other healthcare residents. Action Taken: Reviewed 100% of healthcare residents to ensure all residents at risk for elopement had proper identifiers and interventions in place. Each resident at risk for elopement was determined to have bracelet in place, photo in notebook, and monitoring on MAR for placement every shift and weekly function test. 5/8/13 6. Increase awareness of visitors to the potential for elopement. Action Taken: New larger signs have been posted at all exit doors, replacing smaller older signs, instructing visitors to not allow residents to follow them as they exit the facility. 5/8/13 3) Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur. (The measures must include all staff that could be involved and all residents that could be involved.) a) The Director of Plant Operations will continue to monitor and check the Secure Care System on a weekly basis to ensure proper operation. 4/25/13 b) An in-service was placed by the Assistant Director of Nursing in the nursing in-service notebook located at the 500 nursing station to clearly establish the expectation they are to determine the identity of an individual before permitting them to exit the facility. Training included instruction on how to properly identify whether an individual is an at-risk resident or visitor to include visual inspection for wander bracelets and appropriate questions to ask the individual to make the determination. Questions include " May I help you? " " Are you a resident or a visitor? " " Who are you visiting? " " What is the room number of the resident? " If any question is inappropriately answered, staff was instructed to get assistance from a nurse and make the individual aware that this is protocol to ensure all residents ' sa