Every finding on record at Riverview Care Center

Based on record reviews and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in actual harm for Resident #1 on 04/08/2026 when Resident #1 was transferred from a wheelchair to a bed without utilization of a mechanical lift. Resident #1's care plan indicated she was totally dependent in transferring with the use of a mechanical lift and two person assist. S4CNA reported Resident #1, sitting in her wheelchair, wrapped her arms around CNA's waist area, S4CNA put her arms under Resident #1's arms, lifted Resident #1 and transferred Resident #1 to her bed. S4CNA and S3LPN reported during the transfer, Resident #1's arms popped and Resident #1 complained of pain. Resident #1 was transferred to a local hospital related to bilateral arm pain. Review of Resident #1's hospital record revealed in part, Resident #1 was admitted with acute left clavicle fracture and acute right humerus fracture. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings:Review of Resident #1's facility medical record revealed an admit date of 05/01/2025 with diagnoses including, but not limited to, end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis.Further review of Resident #1's facility medical record revealed Resident #1 was transferred to local hospital on [DATE] and had not returned to the facility. Review of Resident #1's annual MDS assessment with ARD of 04/08/2026 revealed in part, Resident #1 had a BIMS score of 15 indicating intact cognition. Further review of Resident #1's MDS dated [DATE] revealed Resident #1 was totally dependent with chair/bed transfers. Review of Resident #1's quarterly MDS assessment with ARD of 01/14/2026 revealed in part, Resident #1 had a BIMS score of 15 indicating intact cognition and was totally dependent with chair/bed transfers. Review of Resident #1's care plan initiated 05/01/2025 revealed in part, Resident #1 was totally dependent in transferring with the use of a mechanical lift and two person assist. Review of Resident #1's progress notes dated 04/08/2026, revealed in part, Resident #1 was receiving staff assist with changing of clothes, an audible pop was heard by staff from Resident #1's right and left shoulder, and Resident #1 complained of pain. Further review of Resident #1's progress notes dated 04/08/2026 revealed in part, Resident #1's doctor was notified, x-ray of right and left shoulder were ordered, and resident was transferred to local emergency room at Resident #1's family request. Review of Resident #1's bilateral upper extremity x-rays performed in the facility on 04/08/2026 revealed in part, acute fracture of the left midclavicle and acute fracture of right humerus. Review of Resident #1's hospital record revealed in part, an admission date of 04/08/2026 with diagnoses including, but not limited to, acute mildly displaced left distal clavicular fracture and acute mildly displaced fracture of the right proximal humeral diaphysis. Review of Resident #1's hospital record revealed Resident #1 reported the injury occurred while facility staff were assisting her with changing clothes while Resident #1 was in the mechanical lift. Further review of Resident #1's hospital record revealed Resident #1 was admitted for the need of new nursing home placement and pain management. Review of the facility's Incident Report with discovered date of 04/09/2026 for Resident #1 revealed, in part, S3LPN and S4CNA did not utilize a mechanical lift during Resident #1's transfer from a wheelchair to Resident #1's bed which resulted in fractures to both of Resident #1's upper extremities. During an interview on 04/21/2026 at 12:15 p.m., S2DON reported the facility had not received x-ray results at the time Resident #1's family requested Resident #1 be sent to a local emergency room. S2DON reported the facility received Resident #1's x-ray results indicating Resident #1 had a fracture to both upper extremities after Resident #1 was transferred to a local hospital for further evaluation. During a telephone interview on 04/22/2026 at 3:58 p.m., S3LPN reported S4CNA was in Resident #1's room assisting Resident #1. S3LPN reported Resident #1 needed assistance with transferring from the wheelchair to the bed. S3LPN reported the mechanical lift was rolled into Resident #1's room and S4CNA reported Resident #1 did not want to use the lift. S3LPN reported S4CNA proceeded to reach under Resident #1's arms and transferred Resident #1 from the wheelchair to the bed without the use of the lift. S3LPN reported during the transfer a pop was heard and resident complained of pain in her arms. S3LPN confirmed it was reported at first the incident occurred during a change of Resident #1's clothing. During a telephone interview on 04/23/2026 at 2:45 p.m., S4CNA reported being aware Resident #1 required the use of a mechanical lift for transfers. S4CNA reported on 04/08/2026 Resident #1 had returned from dialysis and was needing assistance with transfer from wheelchair to bed. S4CNA reported Resident #1 wrapped her arms around CNA's waist area, CNA put her arms under Resident #1's arms, lifted Resident #1 and transferred Resident #1 to Resident #1's bed. S4CNA reported during the transfer, Resident #1's arms popped and Resident #1 complained of pain. S4CNA confirmed it was reported at first the injury occurred while staff were assisting Resident #1 with a change of clothing. During an interview on 04/22/2026 at 2:13 p.m., S1Administrator confirmed Resident #1's incident occurred on 04/08/2026. S1Administrator reported no abuse or neglect was suspected at time of incident because Resident #1, S3LPN, and S4CNA had all reported the incident occurred while staff were assisting Resident #1 with a change of clothing. S1Administrator reported the facility received an email from Resident #1's daughter on the afternoon of 04/09/2026 which eluded to abuse and prompted the facility to launch an investigation. S1Administrator reported during the facility's investigation, S1Administrator watched facility camera footage and observed S3LPN bring a mechanical lift into Resident #1's room and 45 seconds later, S3LPN was observed bringing the mechanical lift out of Resident #1's room. S1Administrator reported he presented the question to S3LPN and S4CNA if 45 seconds was enough time to transfer a resident using a mechanical lift and both S3LPN and S4CNA reported it was not enough time. S1Administrator reported S3LPN and S4CNA both admitted to not using the lift during Resident #1's transfer from wheelchair to bed. S1Administrator reported both S3LPN & S4CNA reported the incident with Resident #1 did not occur during change of clothing but instead occurred during transfer from wheelchair to bed without use of mechanical lift as Resident #1 was care planned for. S1Administrator reported S3LPN and S4CNA were both terminated on 04/10/2026 as a result of the facility's investigation into the incident with Resident #1. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice beginning on 04/09/2026 with a completion of 04/17/2026: 1. Residents with a BIMS score of 7 or greater were interviewed by facility staff and questioned whether their transfer plan of care was being followed. Residents care planned for use of lift were asked if a lift was used. Completed 04/10/2026.2. On 04/10/2026 a quality assurance meeting was held. It was determined Resident #1 had received an acute fracture proximal humerus with mild malalignment and acute fracture of left midclavicular during a transfer other than what Resident #1 was assessed/care planned for (mechanical lift). It was further determined any resident that is assessed/care planned for mechanical lift could be affected.3. Process/Systems Involved: Lift policy, incident reporting, and documentation. In-service on lift policy conducted by DON/designee beginning 04/09/2026, have all direct care staff read and sign lifting acknowledgment form. DON/designee will do random direct observations of transfer to ensure transferred according to assessed/care planned mechanical lift beginning 04/11/2026. 4. Education/Training plan must begin immediately on 04/09/2026 and capture staff prior to starting next shift: In-service on Lifting policy, lift acknowledgment form, mechanical lift policy, documentation policy, incident reporting and investigation policy, and prevention of neglect in-services done/to be done with direct care staff. 5. Monitoring of Implemented Actions: Starting 04/11/2026, random sample of direct observation to ensure proper mechanical lift is being used at a minimum of 3 times per week for 3 months or until complete compliance is achieved. DON/designee will review CNA documentation of lift/transfer at a minimum of 3 times per week to ensure what was observed is documented properly for 3 months or until complete compliance is achieved. DON/designee will review nurse documentation of random sample of incidents to ensure documentation is supported after investigation at a minimum of 3 times per week for 3 months or until complete compliance is achieved. Review of facility's action plan revealed the following documentation: 1. Starting 04/09/2026 and completed 04/10/2026, residents with a BIMS score of 7 or greater were interviewed by DON/designee and asked if there had been any problems with staff not following their lift status or if staff had transferred them without following their assigned transfer/lift plan of care. Residents interviewed reported transfer plan of care had been followed. 2. DON/designee performed in-service covering documentation/documentation policy and all documentation in a resident's record must be truthful and factual occurred on: 04/09/2026, 04/10/2026, 04/11/2026, 04/14/2026, and 04/15/2026 ensuring all nursing staff received in-service.3. In-service covering neglect prevention and response occurred on: 04/10/2026, 04/11/2026, 04/13/2026, 04/14/2026, and 04/15/2026 ensuring all nursing staff received in-service.4. In-service covering facility lift policy, mechanical lift policy and staff in attendance signed lifting policy acknowledgement form on: 04/09/2026, 04/10/2026, 04/11/2026, and 04/14/2026 ensuring all nursing staff received in-service.5. In-service covering facility incident investigation & reporting, definitions of abuse & neglect, and immediate notification to administrator with any reports or discovery of abuse, neglect, etc occurred on: 04/09/2026, 04/10/2026, 04/14/2026 ensuring all nursing staff received in-service and Neglect Competency quiz administered afterwards.6. In-service covering facility's Resident Rights policy occurred on: 04/10/2026, 04/13/2026 ensuring all nursing staff received in-service.7. Direct observations of mechanical lift usage by DON/designee occurred on:a. On 04/11/2026 DON/designee observed 5 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed.b. On 04/12/2026 DON/designee observed 5 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed.c. On 04/13/2026 DON/designee observed 5 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed.d. On 04/14/2026 DON/designee observed 5 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed.e. On 04/17/2026 DON/designee observed 5 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed.f. On 04/20/2026 DON/designee observed 4 Residents be transferred and observation revealed all transfers were performed following residents' POC task and documentation supported transfer performed. Review of facility's documentation revealed facility's monitoring was ongoing. Further review of facility's documentation revealed facility had reported S3LPN to State Board of Licensed Practical Nurse Examiners on 04/10/2026 and S4CNA to the Louisiana Certified Nurse Aide Registry on 04/13/2026.

Based on record review and interviews, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or a related condition to the appropriate state agency for a Level II PASARR evaluation for 1 (#10) of 1 resident reviewed for PASARR. Findings: Review of Resident #10's medical record revealed a readmission date of 11/15/2023 with a diagnosis of dementia without behavioral disturbance. Further review of Resident #10's diagnoses revealed in part, a diagnosis of Bipolar Disorder with a diagnosis date of 02/04/2025. Review of Resident #10's Level I PASARR screen and determination record dated 03/27/2023 revealed Resident #10 was not suspected to have or had ever been diagnosed with a mental illness. Further review of Resident #10's medical record failed to reveal documented evidence a Level II PASARR was completed after Resident #10 was diagnosed with Bipolar Disorder. During an interview on 12/09/2025 at 12:30 p.m., S3DON confirmed the facility did not have a Level II PASARR for Resident #10. During an interview on 12/09/2025 at 1:52 p.m., S6admission Coordinator confirmed the facility did not have a Level II PASARR for Resident #10.

Based on record review and interviews, the facility failed to develop an individualized comprehensive care plan for 1 (#59) out of 41 total sampled residents reviewed. The facility failed to develop a problem and approach for Resident #59's limited range of motion, restorative care and application of splint/brace.Findings:Review of Resident #59's medical record revealed an admit date of 05/28/2025 with the following diagnoses, in part: injury of radial nerve at wrist and hand level of right and lesion of radial nerve right upper limb. Review of Resident #59's comprehensive care plan failed to reveal problems and approaches for limited range of motion, restorative care and application of splint/brace. Review of Resident #59's hospital records revealed, in part: general medicine progress note with a date of service of 11/23/2025. Further review revealed evaluated by physician and recommend arm splinting to avoid contracture. During an interview on 12/09/2025 at 12:35 p.m. S10 Restorative Aide reported she placed Resident #59's right hand splint/brace on every day for 1 hour as instructed by therapy. During an interview on 12/10/25 at 10:00 a.m. S9 Rehab Director reported Resident #59 was receiving therapy for positioning and passive range of motion. S9 Rehab Director further reported once Resident #59 returned from the hospital, was re-evaluated, a splint was ordered and the restorative aide was instructed on splint application to right hand/wrist. During an interview on 12/10/2025 at 10:05 a.m. S11 Care Plan Nurse acknowledged Resident #59 was not care planned for limited range of motion, restorative care and application of splint/brace.

Based on observation, record review and interviews the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to ensure all staff entering the kitchen wore a hair restraint that covered all hair including hair nets and beard covers. Findings:Review of facility policy Employee Work Practices revised 05/18 revealed in part:Food service employees shall follow sanitary practices to prevent the spread of food borne illness.2. Proper work attire:ii. Wears a clean hat or other hair restraint (e.g. hair net, hat, surgical cap and /or beard restraint) in the food production area. The restraint must cover all hair and prevent the hair from contacting exposed food. Observation on 12/08/2025 at 8:00 a.m. revealed S16 Dietary staff in the kitchen area without a beard or mustache cover in place. Observation on 12/08/2025 at 11:30 a.m. revealed S15 Dietary staff in the kitchen area without a mustache cover in place. During an interview on 12/08/2025 at 11:35 a.m. S14 Dietary Manager confirmed kitchen staff should have facial hair covered and did not. Observation on 12/08/2025 at 11:50 a.m. revealed S1 Administrator walk into kitchen area without a hair or beard cover in place. During an interview on 12/08/2025 at 11:50 a.m. S1 Administrator confirmed a hair and beard cover should be worn when entering the kitchen. Observation on 12/09/2025 at 8:00 a.m. revealed S12 Dietary staff in the kitchen without a beard cover. During an interview on 12/09/2025 at 8:05 a.m. S13 [NAME] confirmed all kitchen staff should have a hair/beard cover on and did not.

Based on record review and interviews the facility failed to develop a post-discharge plan of care for 1 (#116) of 4 resident reviewed for closed records.Review of the facility's Discharge, Transfer and Planning Policy (Latest revision date 08/25, Latest Review Date 09/25) revealed in part: Discharge PlanningDischarge planning shall be initiated by the Social Service Director/Designee with anticipated discharges and on all skilled level care admissions documented in the resident's clinical record. Anticipated means the discharge was not due to an emergency (hospitalization for acute condition) or death.The community shall develop and implement an effective discharge planning process. The discharge plan shall focus on the residents' discharge goals and the preparation of residents to be active partners for post discharge care. The discharge plan shall include an effective transition to post-discharge care, and the reduction of factors leading to preventable readmissions. The interdisciplinary team shall- Ensure the discharge needs of each resident are identified and result in the development of a discharge plan. Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. Communities must update a resident's comprehensive care plan and discharge plan appropriately in response to information received from referrals to local contact agencies or other appropriate entities.Review of the closed record for resident #116 revealed an admission date of 10/22/2025 with a discharge date of 11/03/2025. Diagnoses upon admission included displaced fracture of medial condyle of left tibia, other lack of coordination, generalized muscle weakness, unspecified osteoarthritis, depression and anxiety.Review of the facility nurse progress notes dated 11/03/2025 at 10:53 a.m. revealed resident #116 left AMA with family.Further review of resident #116's closed record revealed a nurse's progress note dated 10/28/2025 resident #116 went out of the facility to an orthopedic appointment and returned with new orders to start PT with Home Health PT when stable. RTC in 4 weeks. X-ray of the left knee 3 views.Review of resident #116's records failed to reveal documented evidence resident #116 had been assisted with an effective discharge plan that included assistance with making an appointment for Home Health and a return appointment for the orthopedic clinic in 4 weeks with an X-ray of the left knee.During an interview on 12/09/2025 at 4:25 p.m. S3 DON reported resident #116 voiced she did not like being at the facility from the time she was admitted . S3 DON reported there was no documentation made to reveal the dislike resident #116 expressed by being admitted to the facility and her plans to leave.Review of resident #116's Comprehensive Plan of Care failed to reveal a focus on discharge are any interventions.During an interview on 12/10/2025 at 2:15 p.m. S6 admission Coordinator reported resident #116's nurse came and reported resident #116 was packing preparing to leave the facility. S6 admission Coordinator reported she spoke with Resident #116 and persuaded resident to remain at the facility a few more days. S6 admission Coordinator reported a discharge was not completed for Resident #116. S6 admission Coordinator reported the Social Worker that would have completed the discharge process, making the appointments for resident #116 to have Home Health PT and everything was no longer employed at this facility.During an interview on 12/10/2025 at 2:30 p.m. S3 DON reported there is no documented evidence resident #116 was assisted by their previous Social Service Worker with the discharge planning process that included the new orders from the orthopedic clinic dated 10/28/2025.

Based on record review and interview the facility failed to ensure the plan of care had been revised for 1(#7) resident out of a total of 41 residents reviewed for plan of care. The facility failed to revise a resident's plan of care for code status change.Findings:Review of Resident #7's physician orders revealed in part an order dated 10/30/2025 DNR (Do Not Resuscitate) Do Not call 911. Call Hospice with any questions or concerns. Review of Resident #7's comprehensive care plan revealed Resident #7's code status as Full Code initiated 06/26/2025.During an interview on 12/09/2025 at 2:00 p.m. S1 Corporate Nurse reviewed Resident #7's physician orders and comprehensive care plan and confirmed Resident #7's code status had not been updated from Full code to DNR status and should have been.

Based on observation, interviews, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#59) of 1 resident investigated for pressure ulcers. The facility failed to follow the recommendations of the consulting Wound Care Nurse Practitioner. Findings:Review of Resident #59's medical records revealed an admit date of 05/28/2025, and diagnoses including: lack of coordination, unspecified severe protein-calorie malnutrition, vascular dementia, stage 4 pressure ulcer of sacral region, and enterocolitis due to clostridium difficile.Review of Resident #59's active physician's orders revealed orders including:12/04/2025 - Isolation for Clostridium Difficile12/02/2025 - Clean pressure injury of the sacrum with wound cleaner and apply Urgoclean Ag along with dry dressing daily one time a day for wound care.Review of Resident #59's Wound Care NP progress note dated 12/01/2025 revealed treatment recommendations including: clean Resident #59's Stage 4 sacrococcyx pressure ulcer with wound cleanser, apply Urgoclean Ag and dry dressing, change daily and as needed if dislodged, saturated, or soiled.During an interview on 12/08/2025 at 10:00 a.m., Resident #59's RP reported resident #59's wound had gotten worse and was a big hole. Resident #59's RP further reported the staff weren't changing the wound dressing when it was soiled with feces, and thought that was why the wound wasn't getting any better.Observation on 12/09/2025 at 7:40 a.m. revealed S4 LPN/Wound Care Nurse performed wound care on Resident #59's sacrococcyx pressure ulcer assisted by S4 CNA. On removal of Resident #59's incontinence brief, the resident's sacrococcyx pressure ulcer was observed to have no dressing covering the wound.During an interview on 12/09/2025 at 7:40 a.m., S4 LPN/Wound Care Nurse confirmed Resident #59's wound should have been covered with a dressing and was not. S4 LPN/Wound Care Nurse further confirmed there was no loose dressing in Resident #59's incontinence brief. S4 LPN/Wound Care Nurse reported staff should notify the Wound Care Nurse whenever Resident #59's dressing became soiled or dislodged, and had not. S4 LPN/Wound Care Nurse further reported the staff nurses were responsible for applying a clean dressing to Resident #59's pressure ulcer when it became soiled or dislodged when the Wound Care Nurse was not available. During an interview on 12/09/2025 at 7:45 a.m., S5 CNA reported the CNA's day shift started at 6:00 a.m., and incontinence care with a brief change for Resident #59 had not yet been completed . S5 CNA further reported the dressing to Resident #59's pressure ulcer must have come off before the beginning of the shift and should have been reported to the nurse.

Based on record review, observations, and interviews, the facility failed to provide an environment that is free from accident hazards with assistive devices to prevent avoidable accidents for 1 (#59) of 2 (#54, #59) residents reviewed for accident hazards. Findings: Review of Resident #59's medical records revealed an admit date of 05/28/2025 with the following diagnoses, in part: cognitive communication deficit, vascular dementia moderate with agitation, restlessness and agitation. Review of Resident #59's MDS assessment dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. Review of Resident #59's comprehensive care plan revealed problems and approaches for altered thought processes related to dementia, current safety devices and special equipment date initiated 05/28/2025 for assist rail. Observation on 12/09/2025 at 8:00 a.m. revealed Resident #59 had bilateral quarter metal side rails attached to the upper half of the bed. The rail on the left side of the bed was in the lowered position and the rail to the right side of the bed was in the raised position. Resident #59 was observed using the rail on the right to assist with positioning herself during wound care. Further observation revealed the right side rail was loose and moved toward and away from the mattress, and moved back and forth toward the head and foot of the bed when pulled on. Observation on 12/10/2025 at 7:50 a.m. revealed Resident #59 sitting up in bed with metal side rail on right side of bed tilted inward towards resident. Further observation revealed bilateral quarter metal side rails loose, movable in a back and forth motion, and not secured. Observation on 12/10/2025 at 10:10 a.m. revealed Resident #59's bilateral quarter metal side rails loose, movable in a back and forth motion, and not secured. Observation on 12/10/2025 at 10:15 a.m. accompanied by S3 DON revealed Resident #59's bilateral quarter metal side rails were loose, movable in a back and forth motion and not secured. S3 DON attempted to tighten the side rails but was unsuccessful. During an interview on 12/10/2025 at 10:15 a.m. S3 DON acknowledged the bilateral quarter metal side rails on Resident #59's bed did not fit the bed properly, were loose and not secured.

Based on record review and interviews the facility failed to provide services that met professional standards for 1 (#1) of 3 (#1, #2 and #3) sample residents reviewed for impaired cognition and at risk of elopement. S3LPN (licensed practical nurse) failed to implement elopement precautions for Resident #1 when the admission elopement screening completed by S3LPN indicated Resident #1 was at high risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 was found to be an elopement risk upon admission to the facility on [DATE] when S3LPN (licensed practical nurse) completed an elopement risk assessment. S3LPN failed to implement elopement precautions for Resident #1 including notifying the physician and responsible party, placement of a wander guard, and updating the care plan to reflect Resident #1 was an elopement risk. Resident #1 exited through the front door of the facility after following visitors out the door. At 8:09 p.m. police found Resident #1 approximately 2 miles from the facility and returned her to the facility. Resident #1 crossed a four lane divided highway to get to where she was located. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Non-Compliance citation.Findings:Review of the facility's Elopement/Wandering - Residents at Risk policy with latest review date 01/2023 revealed in part: Purpose is to identify residents who are incapable of adequately protecting themselves when they leave the premises without necessary supervision to do so. To implement the appropriate protective measures to help guard against a resident wandering/elopement from the facility.Review of Resident #1's records revealed an admit date of 05/28/2025 with diagnoses including but not limited to vascular dementia, spinal stenosis, lumbar region without neurogenic claudication, muscle weakness, depression, unspecified pain, restlessness and agitation. Review of Resident #1's Internal Medicine History and Physical dated 06/03/2025 revealed an (HPI) history of present illness of worsening dementia unable to care for self.Review of Resident #1's admission MDS (Minimum Data Set) assessment reference date 06/09/2025 revealed in part, Resident #1 had a BIMS (Brief Interview Mental Status) score 07 indicating severe cognitive impairment, wandering behavior, antipsychotic and antidepressant medications.Review of resident #1's Admission/readmission Nursing Screening dated 05/28/2025 completed by S3LPN revealed Resident #1 was at risk for elopement. Further review revealed elopement precautions to be implemented included physician notified of risk of elopement, resident representative notified of risk of elopement, care plan in place for at risk for elopement, security bracelet in place.Review of Resident #1's record failed to reveal S3LPN implemented elopement precautions as indicated in the screening. Review of Resident #1's progress noted dated 06/06/2025 at 9:20 p.m. S3LPN documented Resident #1's daughter came to the facility around 6:05 p.m. and writer told her that her mom was in her room waiting for her. Resident #1's daughter came back to nurse's station and stated Resident wasn't in the room or her bathroom. Writer went down hall and had south CNA's check every room and code (W) announcement was made for staff to do head count and then we checked all rooms. Resident #1 was not in building DON, Administrator and other staff members were called immediately. Staff started to search outside in the parking lots in parked vehicles, some employees got in their vehicles and drove around the neighborhood, others checked in the new building and surrounding areas. Police notified at approximately 6:51 p.m. Resident #1 was found by the police at 8:09 p.m. Resident #1 was accompanied by her family daughter, son-in-law, police and administrative staff. During an interview on 06/17/2025 at 2:40 p.m. S5CNA (certified nursing assistant) reported she had last seen Resident #1 around 5:30 p.m. when she escorted her to her room. During an interview on 06/17/2025 at 10:00 a.m. S2DON (director of nursing) reported the Elopement admission screening was completed by S3LPN. S2DON reported she had talked to S3LPN and asked her why she did not inform her Resident #1 was a high risk for elopement. S2DON reported S3LPN reported she did not think Resident #1 was at risk for elopement at the time of admission to the facility. During an interview on 06/17/2025 at 2:15 p.m. S2DON reported the admission Elopement Screenings can be completed by the floor nurses or the MDS Nurse. S2DON reported all nurses had been in-serviced on completing the elopement screenings correctly and steps to take if a resident was found at a high risk for elopement which included to notify the resident's physician, get an order to place a wander guard on the resident, and then notify her. S2DON reported the root cause of Resident #1's elopement was S3LPN not implementing the elopement precautions after it was found Resident #1 was at risk for elopement. During an interview on 06/17/2025 at 3:10 p.m. S3LPN reported she completed the Admission/readmission Elopement Risk Screening for Resident #1. S3LPN reported Resident #1 had no behaviors or acted as if she wanted to leave the facility. S3LPN reported even though Resident #1 answered yes for the elopement risk questions, she still did not think Resident #1 was at risk for elopement and she acknowledged she did not implement any of the measures to prevent Resident #1 from eloping.During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 06/06/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 06/09/2025.1. On 06/06/2025, Resident #1's comprehensive assessment conducted by EMS upon return. Food and hydration provided. Body audit done by ADON (assistant director of nursing) no physical abnormalities, redness or bruises noted. Wander guard device applied. One on one supervision (observation) initiated on 06/06/2026 at 10:30 p.m. every 30 minutes. Medical director informed of the incident. 2. Starting on 06/06/2025 at 8:25 p.m. all employees reviewed and in-serviced on elopement policy and to continue until all employees in-serviced. All staff members will be trained on elopement prevention and response strategies to ensure resident safety. Examples: Recognizing elopement risks and wandering behaviors. Conducting regular checks and assessments. Regular Drills and audits will be conducted to reinforce training and preparedness.3. Will in-service all staff prior to next shift on elopement policy. Comprehensive training will be validated by successful response to the elopement policy quiz presented to each employee. Director and Assistant Director of Nursing, Staff Development nurse providing education/in-services. In-service and education started on 06/06/2025. 4. Elopement risk evaluation completed on each resident on 06/07/2025. Wander guard applied to Resident #1 secondary to 06/06/2025 incident. Wander guard checked for placement every shift and functioning daily for each resident assessed to need a wander guard. Resident behavior for elopement attempts by incident report, observations and communications weekly for 4 weeks or until substantial compliance attained. Facility QA committee will meet weekly for the next 4 weeks to review compliance with the plan of actions.5. All nurses were specifically in-serviced 06/07/2025 on the implementation of the Elopement Risk Screening and steps to take if a resident is found to be a high risk for elopement. 6. Wander guard system and facility doors were checked 06/06/2025 by Maintenance to ensure proper functioning, no repairs was need. 7. S2DON reported she had specifically in-serviced S3LPN 06/07/2025 on completing the admission Elopement Screening correctly and the steps to take if the screening indicates resident is a high risk for elopement. Validation of Past Noncompliance: The facility corrective actions were confirmed through onsite interviews, observations and record reviews. Review of the facility's documentation of drills regarding missing residents, Code (W) Drills, revealed drills were done on 06/06/2025, 06/07/2025, and 06/10/2025. Review of the in-service sign in records on elopement policy, recognizing elopement risks and wandering behaviors, and conducting regular checks and assessments dated 06/06/2025 and 06/07/2025 revealed attendance of all the facility's staff including Housekeeping, LPNs, CNAs, Dietary, Laundry, Drivers, [NAME] Clerk, RN (registered nurse), Baylor Program Nurses, [NAME] help, and Activities. Review of the facility's Elopement Policy Quiz revealed every employee was quizzed on elopement after the in-services. Reviewed the nursing in-service from 06/07/2025 on the implementation of the Elopement Risk Screening and steps to take if a resident was found to be a high risk for elopement was attended by all nurses. Observation on 06/16/2025 at 8:00 a.m. revealed on surveyor's arrival to the facility a sign posted on the front door entrance that stated do not hold the door open for anyone unless they are with you. Further observation revealed the front doors were locked and staff had to wait and use a code to let anyone in or out of the facility. Observation on 06/16/2025 at 2:30 p.m. revealed Resident #1 was in therapy with a wander guard secured on her left ankle. Observation on 06/17/2025 at 9:30 a.m. revealed Resident #1 moving about in her room. She was clean and neatly dressed, the room was clean and not cluttered. The wander guard was secure on her left ankle. During an interview on 06/17/2025 at 12:00 p.m. S7Maintenance reported he checked the wander guard system and facility doors the night after the elopement and no repairs were needed. He further reported he checked the wander guard system weekly to ensure proper functioning. During an interview on 06/17/2025 at 12:10 p.m. S10CNA reported she had the elopement training when she was hired and again since Resident #1 eloped. During an interview on 06/17/2025 at 2:20 p.m. S8CNA reported she had been trained on the facility's elopement policy when she was hired and again recently since Resident #1 eloped. During an interview on 06/17/2025 at 2:30 p.m. S9CNA reported she had the elopement training when she was hired and had the training again since Resident #1 eloped. During an interview on 06/17/2025 at 2:40 p.m. S5CNA reported she had elopement training when she was hired and had it again right after Resident #1 eloped. Observation on 06/17/2025 at 2:40 p.m. revealed an elopement drill done by the facility. S5CNA, S8CNA and S9CNA were on the south hall one at each exit door. An overhead announcement was made for a CODE (W) and to do a head count of all the residents. During an interview on 06/17/2025 at 3:10 p.m. S3LPN reported she had been re-trained on the facility's elopement policy and the admission elopement screening including when to implement the elopement precautions. Review of the facility's records for the five residents with wander guards revealed the elopement assessment had been completed during admission and they had been re-assessed since Resident #1's elopement and they were completed correctly.

Based on record review and interviews the facility administration failed to have an adequate system in place to ensure adequate supervision for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for impaired cognition and at risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 was found to be an elopement risk upon admission to the facility on [DATE] when S3LPN (licensed practical nurse) completed an elopement risk assessment. S3LPN failed to implement elopement precautions for Resident #1 including notifying the physician and responsible party, placement of a wander guard, and updating the care plan to reflect Resident #1 was an elopement risk. Resident #1 exited through the front door of the facility after following visitors out the door. At 8:09 p.m. police found Resident #1 approximately 2 miles from the facility and returned her to the facility. Resident #1 crossed a four lane divided highway to get to where she was located. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance citation.Findings:Review of the facility's Elopement/Wandering - Residents at Risk policy with latest review date 01/2023 revealed in part: Purpose is to identify residents who are incapable of adequately protecting themselves when they leave the premises without necessary supervision to do so. To implement the appropriate protective measures to help guard against a resident wandering/elopement from the facility. Review of Resident #1's records revealed an admit date of 05/28/2025 with diagnoses including but not limited to vascular dementia, muscle weakness, depression, unspecified pain, restlessness and agitation. Review of Resident #1's Internal Medicine History and Physical dated 06/03/2025 revealed an (HPI) history of present illness of worsening dementia unable to care for self.Review of Resident #1's admission MDS (Minimum Data Set) assessment reference date 06/09/2025 revealed in part, Resident #1 had a BIMS (Brief Interview Mental Status) score 07 indicating severe cognitive impairment, wandering behavior, antipsychotic and antidepressant medications.Review of Resident #1's Baseline Care Plan and Summary dated 05/28/2025 revealed in part: A problem of cognitive loss. Interventions was orient as needed to person, place and time. Introduce self. Approach in a calm manner. Explain what you intend to do while providing care. Observe for non-verbal cues.Review of resident #1's Admission/readmission Nursing Screening date 05/28/2025 completed by S3LPN (licensed practical nurse) revealed Resident #1 was at risk for elopement. Further review revealed elopement precautions to be implemented included physician notified of risk of elopement, resident representative notified of risk of elopement, care plan in place for at risk for elopement, security bracelet in place.Review of Resident #1's record failed to reveal S3LPN implemented elopement precautions as indicated in the screening. Review of Resident #1's progress noted dated 06/06/2025 at 9:20 p.m. S3LPN documented Resident #1's daughter came to the facility around 6:05 p.m. and writer told her that her mom was in her room waiting for her. Resident #1's daughter came back to nurse's station and stated Resident wasn't in the room or her bathroom. Writer went down hall and had south CNA's check every room and code (W) announcement was made for staff to do head count and then we checked all rooms. Resident #1 was not in building DON, Administrator and other staff members were called immediately. Staff started to search outside in the parking lots in parked vehicles, some employees got in their vehicles and drove around the neighborhood, others checked in the new building and surrounding areas. Police notified at approximately 6:51 p.m. Resident #1 was found by the police at 8:09 p.m. Resident #1 was accompanied by her family daughter, son-in-law, police and administrative staff. During an interview on 06/17/2025 at 2:40 p.m. S5CNA (certified nursing assistant) reported she had last seen Resident #1 around 5:30 p.m. when she escorted her to her room. During an interview on 06/17/2025 at 10:00 a.m. S2DON (director of nursing) reported the Elopement admission Screening was completed by S3LPN. S2DON reported when she was notified of Resident #1's elopement she immediately went to the facility. S2DON reported when she arrived to the facility's parking lot she called the police and the police reported they were on the phone with Resident #1's daughter. S2DON reported she talked to S3LPN and asked her why she did not inform her Resident #1 was a high risk for elopement. S2DON reported S3LPN responded she did not think Resident #1 was at risk for elopement at the time of admission to the facility. During an interview on 06/17/2025 at 10:15 a.m. Resident #1's daughter reported she arrived at the facility around 6:05 p.m. on 06/06/2025. Resident #1's daughter reported when she arrived to the facility S5 CNA (certified nursing assistant) reported that her mother had been confused all day. Resident #1's daughter reported her mother was not in her room so she asked S3LPN about her mother. Resident #1's daughter reported at that time staff started looking for her mother but could not find her. Resident #1's daughter reported she called her mother phone because she usually had it but it rang in her mother's bathroom. Resident #1's daughter reported she called the police and gave a description of her mom and what she was wearing. Resident #1's daughter reported the police found her mother across the four lane highway, over on the other side of the railroad tracks in a neighborhood. Resident #1's daughter reported Resident #1 was confused on her return to the facility, her heart was racing due to her being in the back of a police car, stating she didn't know what she had done. Resident #1's daughter reported EMS (Emergency Medical Services) assessed Resident #1 and she was ok. Resident #1's daughter reported she had viewed the facility's camera footage from 06/06/2025 and Resident #1 left the facility when a visitor held the door open for her. During an interview on 06/17/2025 at 2:15 p.m. S2DON reported the admission Elopement Screenings can be completed by the floor nurses or the MDS Nurse. S2DON reported all nurses had been in-serviced on completing the elopement screenings correctly and steps to take if a resident was found at a high risk for elopement which included to notify the resident's physician, get an order to place a wander guard on the resident, and then notify her. During an interview on 06/17/2025 at 3:10 p.m. S3LPN reported she completed the Admission/readmission Elopement Risk Screening for Resident #1. S3LPN reported when she completed the Elopement Risk Screening Resident #1 had no behaviors or acted as if she wanted to leave the facility. S3LPN reported even though Resident #1 answered yes for the elopement risk questions she still did not think Resident #1 was at risk for elopement and she acknowledged she did not implement any of the measures to prevent Resident #1 from eloping.During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 06/06/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 06/09/2025.1. On 06/06/2025, Resident #1's comprehensive assessment conducted upon return by EMS. Food and hydration provided. Body audit done by ADON no physical abnormalities, redness or bruises noted. Wander guard device applied. One on one supervision (observation) initiated on 06/06/2026 at 10:30 p.m. every 30 minutes. Medical director informed of the incident. 2. Starting on 06/06/2025 at 8:25 p.m. all employees reviewed and in-serviced on elopement policy and to continue until all employees in-serviced. All staff members will be trained on elopement prevention and response strategies to ensure resident safety. Examples: Recognizing elopement risks and wandering behaviors. Conducting regular checks and assessments. Regular Drills and audits will be conducted to reinforce training and preparedness.3. Will in-service all staff prior to next shift on elopement policy. Comprehensive training will be validated by successful response to the elopement policy quiz presented to each employee. Director and Assistant Director of Nursing, Staff Development nurse providing education/in-services. In-service and education started on 06/06/2025.4. Elopement risk evaluation completed on each resident on 06/07/2025. Wander guard applied to Resident #1 secondary to 06/06/2025 incident. Wander guard checked for placement every shift and functioning daily for each resident assessed to need a wander guard. Resident behavior for elopement attempts by incident report, observations and communications weekly for 4 weeks or until substantial compliance attained. Facility QA committee will meet weekly for the next 4 weeks to review compliance with the plan of actions.5. All nurses specifically in-serviced 06/07/2025 on the implementation of the Elopement Risk Screening and steps to take if a resident is found to be a high risk for elopement. 6. Wander guard system and facility doors checked 06/06/2025 by Maintenance to ensure proper functioning, no repairs was need. 7. S2DON reported she had specifically in-serviced S3LPN 06/07/2025 on completing the admission Elopement Screening correctly and the steps to take if the screening indicates resident is a high risk for elopement. Validation of Past Noncompliance: The facility corrective actions were confirmed through onsite interviews, observations and record reviews. Review of the facility's documentation of drills regarding missing residents, Code (W) Drills, revealed drills were done on 06/06/2025, 06/07/2025, and 06/10/2025. Review of the in-service sign in records on elopement policy, recognizing elopement risks and wandering behaviors, and conducting regular checks and assessments dated 06/06/2025 and 06/07/2025 revealed attendance of all the facility's staff including Housekeeping, LPNs, CNAs, Dietary, Laundry, Drivers, [NAME] Clerk, RN (registered nurse), Baylor Program Nurses, [NAME] help, and Activities. Review of the facility's Elopement Policy Quiz revealed every employee was quizzed on elopement after the in-services. Reviewed the nursing in-service from 06/07/2025 on the implementation of the Elopement Risk Screening and steps to take if a resident was found to be a high risk for elopement was attended by all nurses. Observation on 06/16/2025 at 8:00 a.m. revealed on surveyor's arrival to the facility a sign posted on the front door entrance that stated do not hold the door open for anyone unless they are with you. Further observation revealed the front doors were locked and staff had to wait and use a code to let anyone in or out of the facility. Observation on 06/16/2025 at 2:30 p.m. revealed Resident #1 was in therapy with a wander guard secured on her left ankle. Observation on 06/17/2025 at 9:30 a.m. revealed Resident #1 moving about in her room. She was clean and neatly dressed, the room was clean and not cluttered. The wander guard was secure on her left ankle. During an interview on 06/17/2025 at 12:00 p.m. S7Maintenance reported he checked the wander guard system and facility doors the night after the elopement and no repairs were needed. He further reported he checked the wander guard system weekly to ensure proper functioning. During an interview on 06/17/2025 at 12:10 p.m. S10CNA reported she had the elopement training when she was hired and again since Resident #1 eloped. During an interview on 06/17/2025 at 2:20 p.m. S8CNA reported she had been trained on the facility's elopement policy when she was hired and again recently since Resident #1 eloped. During an interview on 06/17/2025 at 2:30 p.m. S9CNA reported she had the elopement training when she was hired and had the training again since Resident #1 eloped. During an interview on 06/17/2025 at 2:40 p.m. S5CNA reported she had elopement training when she was hired and had it again right after Resident #1 eloped. Observation on 06/17/2025 at 2:40 p.m. revealed an elopement drill done by the facility. S5CNA, S8CNA and S9CNA were on the south hall one at each exit door. An overhead announcement was made for a CODE (W) and to do a head count of all the residents. During an interview on 06/17/2025 at 3:10 p.m. S3LPN reported she had been re-trained on the facility's elopement policy and the admission elopement screening including when to implement the elopement precautions. Review of the facility's records for the five residents with wander guards revealed the elopement assessment had been completed during admission and they had been re-assessed since Resident #1's elopement and they were completed correctly.

Based on observations and interview the facility failed to ensure the most recent survey results were posted in a place readily accessible to the residents, family or visitors to review. Findings: Review of Resident #22's Quarterly MDS (Minimum Data Sets) dated 10/02/2024 had a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. An observation on 10/06/2024 at 10:00 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review. During an interview on 10/08/2024 at 12:30 p.m. Resident Council President, Resident #22 reported she did not see the survey results. Resident #22 further reported she did not know where the survey results were posted and was not aware she could read the past survey results. During an interview on 10/08/2024 at 2:15 p.m. S2 Corporate Nurse confirmed the survey results were not posted in a conspicuous place for residents, visitors and family to find. 30669

30669 Based on record reviews, observations, and interviews, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were accurately assessed for the risk of entrapment from bed rails and an informed consent was obtained from resident or resident representative prior to installation for 15 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106) out of 17 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106, #167, #367) residents reviewed for bed rails. Findings: Resident #10 Review of Resident #10's medical record revealed a readmitted date of 03/21/2024 with diagnoses including the following, but not limited to, cerebral ischemia, long term use of insulin, presence of right artificial shoulder joint, long term use of aspirin, type 2 diabetes mellitus, and hemiplegia. Review of Resident #10's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #10's Quarterly MDS (Minimum Data Sets) dated 07/24/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. An observation on 10/06/2024 at 4:00 p.m. revealed Resident #10 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:15 p.m. revealed Resident #10 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 7:55 a.m. revealed Resident #10 in bed eating breakfast with the bed rails x 2 in the raised position at the head of the bed. Resident #18 Review of Resident #18's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to, adult failure to thrive, muscle weakness, lack of coordination, unspecified dementia, and major depressive disorder. Review of Resident #18's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #18's Quarterly MDS dated [DATE] revealed a BIMS of 11 indicating mildly intact cognition. An observation on 10/07/2024 at 8:00 a.m. revealed Resident #18 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:01 a.m. revealed Resident #18 awake and alert in bed with bed rails x 2 in the raised position at the head of the bed. Resident #20 Review of Resident #20's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to, atherosclerotic heart disease, muscle wasting and atrophy, fibromyalgia, type 2 diabetes mellitus, Review of Resident #20's Quarterly MDS dated [DATE] revealed a BIMS of 13 indicating intact cognition. Review of Resident #20's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/08/2024 at 8:30 a.m. revealed Resident #20's was in bed with bed rails x 2 in the raised position at the head of the bed. Resident #24 Review of Resident #24's medical record revealed in part an admitted [DATE] with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Review of Resident #24's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #24's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 8:45 a.m. revealed Resident #24 was sitting in bed with bed rails x 2 in the raised position at head of bed. During an interview on 10/06/2024 at 8:45 a.m. Resident #24 reported he does not use bed rails. An observation on 10/08/2024 at 7:55 a.m. revealed Resident #24 was in bed with bed rails x 2 in the raised position at the head of the bed. Resident #30 Review of Resident #30's medical record revealed the following diagnoses including, but not limited to, malignant neoplasm of liver, not specified as primary or secondary, unspecified convulsions, chronic obstructive pulmonary disease, Parkinsonism, peripheral vascular disease and primary osteoarthritis. Review of Resident #30's Quarterly MDS assessment dated [DATE] revealed a BIMS score was not given. Review of Resident #30's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/07/2024 at 08:30 a.m. revealed Resident #30 was in bed. Resident #30's bed had bilateral bed rails installed that did not fit the bed properly. The bed rails were in the raised positioned with gaps between the side of the bed's mattress and the bed rails. The bed rails were bent inward. During an interview on 10/09/2024 at 08:30 a.m. Resident #30 reported she used her bed rails to try to turn and position herself in the bed. Resident #36 Review of Resident #36's medical record revealed the following diagnoses including, but not limited to, hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage affecting his left dominant side, type 2 diabetes and muscle weakness. Review of Resident #36's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #36's most recent MDS dated [DATE] revealed a BIMS score was not given, but documented Resident #36 was severely cognitively impaired. An observation on 10/07/2024 at 8:30 a.m. revealed one quarter bed rail and one assist bed rail attached to Resident #36's bed. Resident #36 was non-verbal and unable to be interviewed. Resident #51 Review of Resident #51's medical record revealed an admitted [DATE] with the following diagnosis including, but not limited to, acquired absence of right leg below knee. Review of Resident #51's 5 day MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #51's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 9:05 a.m. revealed Resident #51 sitting in a wheelchair at the bedside. Further observation revealed a bed rail to each side of bed in raised position at the head of the bed. During an interview on 10/06/2024 at 9:05 a.m. Resident #51 reported using the bed rails sometimes for bed mobility. An observation on 10/07/2024 at 2:00 p.m. revealed Resident #51 was sitting in a wheelchair at the bedside talking with family. Further observation revealed a bed rail to each side of the bed in the raised position at the head of the bed. Resident #53 Review of Resident #53's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to, Pick's disease and mixed receptive expressive language disorder. Review of Resident #53's 5 day admit MDS dated [DATE] revealed a staff assessment of cognitive skills with a BIMS score of 3 indicating severely impaired cognition. Review of Resident #53's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/24 at 8:10 a.m. revealed Resident #53 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:30 p.m. revealed Resident #53 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:15 a.m. revealed Resident #53 sitting up in a wheelchair at the bedside. Further observation revealed bed rails x 2 in the raised position at the head of the bed. Resident #57 Review of Resident #57's medical record revealed the following diagnoses including, but not limited to, other intervertebral disc degeneration, lumbar region, other lack of coordination, and cognitive communication deficit. Review of Resident #57's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #57's most recent MDS dated [DATE] revealed a BIMS score of 14 which indicating intact cognition. During an observations on 10/09/2024 at 08:30 a.m. revealed bilateral bed rails attached to Resident #57's bed. During an interview on 10/09/2024 at 9:35 a.m. Resident #57 reported she can only move her upper body and she uses the bed rails to help turn and reposition herself in bed. Resident #66 Review of Resident #66's medical record revealed the following diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, Crohn's disease, muscle wasting and atrophy. Review of Resident #66's MDS dated [DATE] revealed a BIMS score 13 indicating intact cognition. Review of Resident #66's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. During an observation on 10/07/2024 at 08:30 a.m. Resident #66 had bilateral bed rails attached to her bed. During an interview on 10/09/2024 at 9:00 a.m. Resident #66 reported she uses the bed rails to help position herself in the bed. Resident #75 Review of Resident #75's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to, cerebral palsy, muscle weakness, moderate intellectual disabilities, spastic quadriplegic cerebral palsy, and cognitive communication disorder. Review of Resident #75's MDS dated [DATE] revealed a BIMS was not done due to the cognitive skills for daily decision making were severely impaired. Review of Resident #75's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 2:22 p.m. revealed Resident #75 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 8:00 a.m. revealed Resident #75 in bed with bed rails x 2 in the raised position at the head of the bed. Resident #96 Review of Resident #96's medical record revealed the following diagnoses including, but not limited to, chronic obstructive pulmonary disease, shortness of breath, major depressive disorder, other lack of coordination and pain in the right ankle. Review of Resident #96's MDS dated [DATE] revealed a BIMS score 12 which indicates moderately impaired cognition. Review of Resident #96's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/07/2024 at 8:45 a.m. revealed bilateral bed rails attached to Resident #96's bed. During an interview 10/09/2024 at 09:00 a.m. Resident #96 reported she used her bed rails to assist her in standing and turning. Resident #96 reported the bed rail on the right side of her bed was loose and it made her feel like she was going to fall. Resident #96 reported this was the first time someone had asked her about the bed rails. Resident 101 Review of Resident #101's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to, surgical aftercare following surgery of the circulatory system, atherosclerosis of native arteries of extremities with gangrene of left leg, and an open wound to the left foot. Review of Resident #101's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #101's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 8:55 a.m. revealed Resident #101 in bed with bed rails x 2 in the raised position at the head of the bed. During an interview on 10/06/2024 at 8:55 a.m., Resident #101 reported she used the bed rails sometimes to help her change positions in bed. An observation on 10/08/2024 at 10:00 a.m. revealed Resident #101 in bed with bed rails x 2 in the raised position at the head of the bed. Resident #104 Review of Resident #104's medical record had a re-admitted [DATE] with the following diagnoses including, but not limited to, orthopedic conditions, hypertension, depression, and psychotic disorder. Review of Resident #104's MDS dated [DATE] revealed a BIMS of 3 indicating severely impaired cognition. Review of Resident #104's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 2:08 p.m. revealed Resident #104 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:34 p.m. revealed Resident #104 was awake in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:12 a.m. revealed Resident #104 awake in bed with bed rails x 2 in the raised position at the head of the bed. Resident #106 Review of Resident #106's medical record revealed the following diagnoses including, but not limited to, encounter for orthopedic after care following surgical amputation, muscle weakness, diabetes type 2 and chronic kidney disease. Review of Resident #106's MDS dated [DATE] revealed a BIMS score of 15 which indicating intact cognition. Review of Resident #106's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. During an observation on 10/07/2024 at 08:30 a.m. revealed Resident #106 had bilateral bed rails attached to his bed. During an interview on 10/08/2024 at 3:14 p.m. S3 DON (Director of Nursing) confirmed Resident #10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106 did not have a consent for the use of bed rails. During an interview on 10/09/2024 at 9:55 a.m. S2 Corporate Nurse confirmed the facility did not have consents signed for the use of bedrails and resident assessments for entrapment had not been completed correctly. 45317

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) having dirty equipment, and food preparation items used to prepare and/or distribute resident meals in the kitchen, 2) Resident meal plates and saucers stored in an upright position, and 3) the flour scoop was left inside the flour storage container. Findings: Observation of the kitchen on 10/06/2024 at 8:00 a.m. with S4 Morning Cook, revealed the following: 1) The large upright mixer was covered with crumbs and white powder. 2) The oven/warmer had dried food spills and streaks running down the front. 3) Resident meal plates and saucers were stored in an upright position. 4) Plate lids on the meal serving line had food crumbs inside the covers/lids and dried food particles on the serving plates. 5) The flour scoop left inside the flour storage container. During an interview on 10/06/2024 at 10:30 a.m. S5 Dietary Manager acknowledged the dirty kitchen equipment, incorrect plate storage, and storage of the flour scoop in the flour container was a problem that had to be corrected.

Based on record review and interview the facility failed to ensure 1 (#87) of 5 (#9, #10, #30, #87, #317) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of an antipsychotic medication prior to the start of the medication. Findings: Review of Resident #87's medical record revealed in part an admitted [DATE] with diagnoses including, but not limited to, dementia with psychotic disturbance and major depressive disorder. Review of Resident #87's Quarterly MDS (Minimum Data Set) dated 09/18/2024 revealed a BIMS (Brief Interview for Mental Status) of 11 indicating moderately impaired cognition. Further review of Resident #87's Quarterly MDS dated [DATE] revealed Resident #87 was taking an antipsychotic medication on a routine basis. Review of Resident #87's physician's orders revealed in part an order dated 09/03/2024 for Aripiprazole 2mg (milligram) by mouth every day. Review of Resident #87's electronic medication administration record for the month of September 2024 revealed Resident #87 received Aripiprazole as ordered. Review of Resident #87's medical record failed to reveal documentation Resident #87 or Resident #87's representative were informed of the risks, benefits, side effects and possible alternative treatment of an antipsychotic medication prior to the start of the medication. During an interview on 10/08/2024 at 11:13 a.m. S3 DON reported the facility did not have any documentation to confirm Resident #87 or Resident #87's representative had been informed of risk, benefits, side effects and possible alternative treatments of an antipyschotic medication.

Based on observation, record review, and interview, the facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience for 1 (#74) of 1 (#74) residents investigated for restraints. The facility failed to ensure: 1) Resident #74 had a written consent for a self-releasing seatbelt, pommel cushion, scoop mattress and side rails and was able to intentionally remove those items in the same manner as they were applied by the staff, 2) a physician's order was in place for the use of restraints. Findings: Review of the facility's Restraint/Device Policy last revised 10/2022 revealed in part: Restraints and Safety Devices: It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the residents medical symptoms. Restraints may not be used for the convenience of the nursing staff or as punishment to the resident. Physical Restraint Definition: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, restricts freedom of movement or normal access to one's body. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This is not determined by a type of device or method, but can only be determined on an individual basis by evaluating the effect it has on the resident. Do Not focus on the type, intent, or the reason behind the use to determine if it should be classified as a restraint, focus on the effect. The Restraint Device Worksheet helps to make the determination of whether the device is a restraint or not. If it is determined not to be a restraint, it is a device. If the device being used could be considered a restraint, the Device/Physical Restraint Consent shall be completed. Residents with new restraints must be reviewed weekly at the High Risk Management meeting until stable and reviewed monthly thereafter. Re-evaluate resident at least quarterly for possible restraint reduction. The facility must attempt to use appropriate alternatives prior to installing a side rail. If used, the facility must assess the resident of risk of entrapment, review the risks and benefits with the resident or resident representative, obtain informed consent prior to installation, ensure bed dimensions are appropriate for the resident's size and weight, and follow manufacturer's directions for installing and maintaining side rails. Restrained residents must be observed at least every 30 minutes. Restraints must be released at least every 2 hours, and the resident exercised, toileted, or repositioned. Review of Resident #74's medical record revealed an admitted [DATE] with diagnoses that include in part, spastic quadriplegic cerebral palsy, moderate intellectual disabilities, aphasia, major depressive disorder, bipolar disorder, mood affective disorder, and anxiety. Review of Resident #74's physician's orders failed to reveal an order for the use of device/restraints: seatbelt, scoop mattress, side rails and/or pommel cushion. Review of Resident #74's medical record failed to reveal a consent for use of Restraint/Device with risk and benefits discussed with Resident #74 or Resident #74's legal representative. Review of Resident #74's comprehensive care plan revealed in part the following risks/problems and interventions: current safety devices and special equipment initiated 08/29/2024: Anti roll back device, low bed with scoop mattress, seat belt with chest straps, side rails x 2, and wheelchair. Multiple observations during this survey 10/06/2024 through 10/09/2024 revealed Resident #74 sitting in her wheelchair with harness seatbelt and pommel cushion in use. Further observations revealed scoop mattress in place to Resident #74's bed with bed rails in use. During an interview on 10/09/2024 at 9:12 a.m. S2 Corporate Nurse reported when the Restraint/Positioning Device Worksheet was originally done the staff were answering the questions wrong and limiting the choices between restraints or devices. The facility did not consider the seatbelt, pommel cushion or side rails to be a restraint, but considered them a device and a device did not require a physician's order. S2 Corporate Nurse further reported the seatbelt was easy to remove, and was for Resident #74's safety and used as a device. S2 Corporate Nurse acknowledged Resident #74 could not remove the seatbelt herself.

Based on record review and interview, the facility failed to accurately assess the residents discharge status for 1 (#116) of 1 (#116) resident reviewed for resident assessments out of a total sample of 31 residents. Findings: Review of Resident #116's medical record revealed an admitted [DATE] and discharge date of [DATE] with diagnoses that included in part, aftercare following joint replacement surgery, and presence of right artificial knee joint. Review of Resident #116's nurses' notes revealed in part, on 07/15/2024 at 2:12 p.m. Resident #116 was discharged home today. Left per family vehicle with family. Review of Resident #116's discharge data collection form dated 07/16/2024 revealed in part, resident is being discharged to Home/Community. Type of discharge: unplanned. Additional Information: Resident discharged per self from facility, sister picked up, left with wheelchair that he brought with him on admit. He stated he just wanted to be home. Left with sister in private vehicle. Review of Resident #116's Discharge Minimum Data Set (MDS) dated [DATE] revealed in part, Section A: Identification Information: Discharge-return not anticipated. Planned . discharged to Short-term General hospital (acute hospital). During an interview on 10/07/2024 at 3:55 p.m. S6 MDS Coordinator acknowledged the discharge MDS was incorrect.

Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 2 (#20 and #104) of 3 (#20, #36, #104) residents reviewed for ADLs. The facility failed to ensure Resident #20 and #104 received nail care. Findings: Nail Care Policy: Purpose - To promote cleanliness, safety and a neat appearance and to observe skin condition on fingers and toes. Procedure - 1. Perform hand hygiene. 4. Soak the resident's hand and feet in a basin of warm water for 10-15 minutes before trimming or trim following a bath. 7. Remove any debris from under the nails with the orangewood stick. Resident #20 Review of Resident #20's medical record revealed the following medical diagnoses including, but not limited to, type 2 diabetes mellitus, muscle wasting and atrophy, and fibromyalgia. Review of Resident #20's Quarterly MDS (Minimum Data Sets) dated 09/18/2024 revealed a BIMS (Brief Interview of Mental Status) of 13 indicating intact cognition. Review of Resident #20's care plan dated 12/26/2023 revealed the following, but not limited to, needs assist x 1-2 staff with all ADLs. During an observation on 10/08/2024 at 8:27 a.m. Resident #20 had brown debris under the nail beds. During an interview on 10/08/2024 at 8:29 a.m. Resident #20 reported she just got back from her morning shower. When asked if the staff cleaned under her fingernails, she reported no. During an interview on 10/08/2024 at 4:07 p.m. S7 LPN (Licensed Practical Nurse) confirmed Resident #20's fingernails were dirty with brown debris under the nail beds and needed to be cleaned. Resident #104 Review of Resident #104's MDS dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #104's care plan revealed the following including, but not limited to, needs assistance with ADLs, assist with ADLs as needed. An observation on 10/06/2024 at 2:04 p.m. revealed Resident #104's fingernails were long and yellow with brown debris under the nail beds. An observation on 10/08/2024 at 8:12 a.m. revealed Resident #104's fingernails were long and yellow with brown debris under the nail beds. During an interview on 10/08/2024 at 4:05 p.m. S7 LPN confirmed Resident #104's fingernails were dirty with brown debris under the nail beds and needed to be trimmed and cleaned.

Based on record review, observation and interviews the facility failed to ensure it was clinically appropriate for a resident to self-administer medications for 1 (Resident #1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice had the potential to affect any of the 117 residents residing in the facility according to the 03/04/2024 Resident Census List provided by the facility. Findings: Review of facility Self-Administration of Medication policy dated 11/17/1994 revealed in part: A resident will be allowed to self-administer medications only if: a. the attending physician writes or gives a verbal order that the resident may keep a medication at bedside for the purpose of self-administration. AND b. the resident has been determined by the interdisciplinary care team to be cognitively, physically, and visually able to self-administer medications, therefore clinically appropriate, and is routinely monitored as to whether the resident continues to be capable and/or still taking medications as ordered. Review of resident #1's medical record revealed an admitted [DATE] with diagnoses that include Chronic obstructive pulmonary disease, Pleural effusion, acute on chronic diastolic congestive heart failure, hereditary and idiopathic neuropathy, Chronic respiratory failure, abnormalities of gait and mobility, depression, essential hypertension, type 2 diabetes mellitus with diabetic neuropathy, difficulty in walking, need for assistance with personal care, edema, osteoporosis without current pathological fracture, pain, dependence on supplemental oxygen. Review of resident #1's Physician orders revealed an order dated 02/25/2024 for Ipratropium 0.5 mg (milligram)-Albuterol 3 mg (2.5 mg base)/3 ml (milliliters) nebulization solution: give 3 mg inhalation four times daily: document pulse, record the number of treatment minutes, and document toleration. Review of resident #1's Physician orders failed to reveal an order for resident #1 to self-administer medication or keep medications at the bedside. Review of resident #1's medical record failed to reveal a consent for resident #1 to self-administer medications. Review of resident #1's MDS (Minimum Data Set) dated 02/15/2024 revealed in part: Cognitive: BIMS (brief interview for mental status)=13-cognitively intact. During an interview on 03/05/2024 at 9:00 a.m. resident #1 reported the nurse leaves her breathing treatment medicines in her bedside table and she takes them when she feels like it. During an observation on 03/05/2024 at 9:00 a.m. resident #1 pointed out her inhalation medications in her unlocked bedside table drawer. During an interview on 03/06/2024 at 3:30 p.m. S1 DON (Director of Nursing) confirmed the facility did not have any residents in the facility with orders to keep medications at the bedside and self-administer the medications. S1 DON acknowledged resident #1 should not have medications at the bedside and all medications should have been administered by resident #1's nurse.

Based on record review and interview the facility failed to ensure the comprehensive care plan had been implemented for 1 (#6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure the hospice care plan had been implemented for Resident #6 by failing to ensure hospice had been notified of Resident #6's 02/07/2024 fall. Findings: Review of Resident #6's medical record revealed Resident #6 was originally admitted to the facility on [DATE] and had diagnoses that included, in part, unspecified dementia, senile degeneration of brain, cognitive communication deficit, muscle wasting and atrophy of right and left thigh and right and left lower leg, anemia, history of falling, difficulty in walking, unsteadiness on feet, vascular dementia, and essential hypertension. Review of physician orders revealed a 01/13/2024 order for Do not resuscitate. Admit to _______ Hospice. Do not call 911. Call ________ Hospice with any questions or concerns. D/C (discontinue) skilled therapy, future appointments, and lab work per Dr. (Doctor) ____. Review of 01/24/2024 Significant Change MDS (Minimum Data Set) revealed Resident #6 had severe cognitive impairment, never/rarely made decisions and had short and long term memory problem. Review of Resident #6's Care Plan revealed: Receiving hospice care with interventions that included, in part, comfort measures as needed and notify physician and hospice of any changes in resident. Review of Resident #6's Incident Report dated/timed 02/07/2024 at 11:00 a.m. revealed Resident #6 was in the dining area trying to stand up and walk and had a fall with multiple staff as witnesses and had no apparent injuries Physician and family notified. Further review of the Incident Report failed to reveal hospice had been notified of the 02/07/2024 fall. Review of 02/07/2024 at 11:19 a.m. progress note indicated .was trying to walk without assistance, he stood up from his wheelchair and was seen .falling backwards very slowly.Supervisor was notified, daughter notified MD (Medical Doctor) notified. Further review of the progress note failed to reveal hospice had been notified of the 02/07/2024 fall. During an interview on 03/06/2024 at 10:35 a.m. S4 Hospice RN (Registered Nurse) reported she had not been made aware of Resident #6's 02/07/2024 fall. During an interview on 03/06/2024 at 2:15 p.m. S3 LPN (Licensed Practical Nurse) reported she could not verify hospice had been contacted regarding Resident #6's 02/07/2024 fall. During an interview on 03/06/2024 at 2:30 p.m. S2 ADON (Assistant Director of Nursing) reported after review of Resident #6's medical record no evidence was found that hospice had been notified of Resident #6's 02/07/2024 fall.

Based on observations, record review and interviews the facility failed to ensure 1 (#28) of 5 (#21, #28, #43, #44, #103) residents reviewed for accidents received necessary care to prevent accidents/falls. The deficient practice resulted in actual harm for Resident #28 on 06/12/2023 at 10:30 a.m. when Resident #28 suffered a major injury during a transfer from the bed to the shower chair. S6 CNA (Certified Nursing Assistant) and S7 CNA transferred Resident #28 without using a lift. S6 CNA and S7 CNA lowered Resident #28 to the floor when the shower chair slid out from under Resident #28. S6 CNA noticed Resident #28 was sitting on the floor with her legs folded under her. Resident #28 was transported to the emergency room (ER) on 06/12/2023 at 10:58 p.m. and was diagnosed with a right distal femur fracture. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #28's clinical record revealed an admitted [DATE] with the following diagnosis, in part, cognitive communication deficit and history of falls. Review of the Discharge MDS (Minimum Data Set) dated 06/12/2023 revealed Resident #28 had a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment. Further review of Resident #28's Discharge MDS revealed Resident #28 required total dependence with transfers. Review of Resident #28's Comprehensive Care Plan dated 01/05/2023 revealed Resident #28 required the use of a lift and 2 person assist for transfers. Review of Resident #28's facility Incident Report dated 06/13/2023 revealed Resident #28 was moved without a lift on 06/12/2023. Resident #28 was sent to the hospital once complaints of pain started. Review of Resident #28's hospital record revealed Resident #28 arrived to theER on [DATE] at 11:17 p.m. and was admitted [DATE] at 3:52 a.m. Review of Resident #28's hospital course revealed in part, Resident #28 fell at NH (Nursing Home) and has Right Distal Femur Fracture. Orthopedics evaluated with recommendations for non-operative management in light of her advanced dementia. Patient is to be non-weight bearing for 8 weeks. Further review of Resident #28's hospital record revealed CT (Contrast Tomography) pelvis without contrast performed on 06/12/2023 diagnosed an acute peri-prosthetic supracondylar fracture right distal femur. Review of Nurses Notes on 06/12/2023 at 11:01 p.m. revealed Resident #28 had complaints of severe pain to the back and bilateral legs and 911 was called. The fire department arrived to the facility at 10:45 p.m. Resident #28 left the facility at 10:58 p.m. per stretcher via fire department. Review of a written statement signed by S13 CNA dated 06/13/2023 revealed To whom it may concern, I was asked to come and get a patient off the floor when I walked in to help the patient was on the floor with bm (bowel movement) all over the floor. There (were) 4 coworkers including myself we went lifted the patient to the bed. Review of S6 CNA's employee record revealed a Disciplinary Action/Counseling form signed and dated by S2 DON (Director of Nursing) on 06/13/2023 which read, in part, S6 CNA did not follow Resident #28's care plan while transferring Resident #28 out of the bed. Review of S7 CNA's employee record revealed a Disciplinary Action/Counseling form signed and dated by S2 DON on 06/13/2023 which read, in part, S7 CNA did not follow Resident #28's care plan while transferring Resident #28 out of the bed. During an interview on 09/13/2023 at 8:00 a.m. S5 LPN (Licensed Practical Nurse) reported S6 CNA and S7 CNA transferred Resident #28 without using a lift on 06/12/2023. The next day, 06/13/2023, the evening nurse reported something did not seem right with Resident #28. S6 CNA and S7 CNA did not report the incident until the evening nurse thought something was off. S5 LPN acknowledged Resident #28 should have been transferred with a lift by 2 staff. During an interview on 09/13/2023 at 8:14 a.m. S2 DON (Director of Nursing) reported on 06/12/2023 Resident #28 was transferred without using a lift by S6 CNA and S7 CNA. S2 DON acknowledge Resident #28 was care planned for a lift and a lift should have been used during transfers. During a phone interview on 09/13/2023 at 10:41 a.m. S6 CNA reported on the morning of 06/12/2023 she and S7 CNA transferred Resident #28 without a lift, from the bed to the shower chair beside the bed. The shower chair slid out from under Resident #28 and S6 CNA and S7 CNA lowered Resident #28 to the floor and noticed Resident #28's right leg was underneath her. S6 CNA reported she informed S5 LPN as soon as they got the resident back in bed. On 09/13/2023 at 2:20 p.m. an interview with S7CNA was attempted and was unsuccessful due to she was no longer employed with the facility and could not be reached for interview. During an interview on 09/13/2023 at 11:25 a.m. S4 CNA reported Resident #28 requires a lift during transfers. During an interview on 09/13/2023 at 1:53 p.m. S2 DON reported the incident with Resident #28 happened on 06/12/2023. The evening staff came in on 06/12/2023 and Resident #28 was complaining of pain. Resident #28 was sent to the hospital on 06/12/2023 at 10:58 p.m. and returned on 06/14/2023 at 5:00 p.m. During an interview on 09/13/2023 at 5:00 p.m. S12 PTA (Physical Therapy Assistant), reported Resident #28 requires two person assist with a lift during transfers. S12 PTA further reported there is no way to transfer Resident #28 without a lift. During an interview on 09/13/2023 at 10:20 a.m. S1 Administrator reported S6 CNA and S7 CNA had been disciplined for lack of judgement for transferring Resident #28 without a lift. An observation on 09/13/2023 at 2:15 p.m. revealed S12 CNA and S13 CNA transferred Resident #28 from the Geri-chair to the bed using a lift. Resident #28 requires a 2 person assist and a 2 person assist was used during the transfer. The lift was used appropriately with no issues or concerns. The facility implemented the following actions to correct the deficient practice with a completion date on 07/27/2023: 1. Resident #28 had been transported to a local hospital on 06/12/2023 for an evaluation. 2. S6 CNA and S7 CNA were suspended for 3 days. 3. A list of residents requiring a lift for transfers was placed in a binder at the nurses' station. 4. The staff were in-serviced 06/13/2023 on transfers and lift transfer list. 5. Maintenance checked each lift in the facility and all were in good repair. 6. An audit on 06/13/2023 was performed for all residents requiring a lift. 7. Observations of lift use were done for 6 weeks and completed. 8. The staff continuously monitors for lift use.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents while smoking for 1 (# 9) of 5 (#2, 4, 5, 6, and 9) residents reviewed for smoking in a total sample of 9 residents. An actual harm occurred on 12/13/17 when Resident #9, who had [MEDICAL CONDITION] affecting his dominant right side and a contracture to his right hand, dropped a lit cigarette butt into his incontinent brief. The resident returned to his room where his bed-bound roommate noticed smoke coming from the resident and realized Resident #9's clothing was on fire. The resident's roommate activated the call light and yelled for help. Staff removed Resident #9's clothing that was on fire and extinguished the flame. Resident #9 sustained two fluid-filled blisters/burns to his right thigh. The facility did not in-service staff for 15 days after the resident was burned. Findings: Resident #9 had [DIAGNOSES REDACTED]. The resident had limited use of his legs and ambulated independently per wheelchair. Review of the Minimum Data Set (MDS) dated ,[DATE] and 01/28/18 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of the Assessment for Safe Smoking v2 form dated 11/03/17 revealed Resident #9 was assessed to be a safe smoker. S11MDS Nurse confirmed there was no more current safe smoking assessment than 11/03/17. S11MDS reported that staff talked to the resident and took his cigarettes away after he burned himself on 12/13/17. Review of a careplan problem dated 12/13/17 revealed, in part, the following: Resident #9 had a potential for injury related to at times I am an unsafe smoker, 12/13/17-resident came in from smoking and cigarette was still lit and caught his brief on fire causing [MEDICAL CONDITION] my upper thigh, 01/04/18-right front inferior thigh healed, 02/06/18-burn healed to thigh. Approaches noted Resident #9 needed a smoke apron when smoking, would be reminded to smoke in a designated smoke area, needed to be instructed on safe measures to dispense smoking material, may need my cigarettes and lighter administered to me when I need to smoke, may need supervision when I smoke and treatment as ordered until healed. Review of nurses' notes for Resident #9 dated 12/13/17 revealed, in part, the following: CNA was called to room at 5PM, resident's pants were on fire, staff immediately put fire out, removed pants, and assessed resident. Review of Resident Incident Report dated 12/13/17 at 5:01PM revealed, in part, the following: CNA called to room, resident's pants were on fire, staff members put out fire, assessed resident for injuries and pain assessment, no pain noted, resident has small 1st degree burn to right thigh, resident alert to person and place. Immediate Action Taken: Immediately put out fire on pants, removed pants from resident's body, assessed resident for injuries and pain. Immediate Post-Incident Action: removed cigarettes from resident's person, resident will need supervision. Record review of Incident Investigation narrative signed by S2ADON revealed, in part, the following: 'resident had lit cigarette butt on his lap and diaper got set on fire, redness noted on the groin area, wound care continues to monitor the reddened area, housekeeping staff was able to take the lit diaper out of the room to whirlpool and turn it off'. Review of the Wound Assessment Reports dated 12/14/17 revealed two separate burns- 1st wound identified on 12/13/17 measured 1.5 centimeter (cm) x 1 cm superficial partial thickness burn to the right upper thigh superior site, presents with a clear fluid filled blister which is intact at this time, skin is moist but resident denies pain, orders to monitor site daily and physician's orders [REDACTED]. A second burn with a date wound identified of 12/14/17 measured 1.0 cm x 1.0 cm partial thickness burn with clear fluid-filled blister which is intact at this time. Notification of physician and responsible party was documented. physician's orders [REDACTED]. The burn measuring 1.5 cm x 1.0 cm resolved in 55 days on 02/06/18. The burn measuring 1.0 cm x 1.0 cm resolved in 21 days on 01/04/18. On 03/14/18 at 3:15PM, observation of Resident #9 revealed he was outside in the smoking area in his wheelchair. S14Activity Director gave the resident a cigarette and held the lighter for the resident to light his cigarette. Resident #9 was not wearing a smoking apron as indicated in his plan of care. At 3:20PM, an interview with S14Activity Director revealed she was the director of the new smoking program. S14Activity Director explained that the new smoking program was initiated on Monday, 03/12/18, and residents that were unsafe smokers now had schedule times for smoking. She reported that staff would take residents out that were unsafe smokers every two hours beginning at 6AM and ending at 10PM. On 03/15/18 at 11AM, an interview with S7CNA reported that she assisted on 12/13/17 when Resident #9's clothing caught on fire. She reported that when the resident came inside from smoking, his roommate smelled smoke and yelled out. She reported that she entered the room and saw that Resident #9 had flames coming from -CNA then used her hand to indicate an area around the right side of the waist area. S7CNA stated that there was smoke in the room and that she and the laundry lady got the brief that was on fire off of the resident. She reported that the laundry staff took the flaming undergarment from the room and put it out. She added that someone pulled the fire alarm. S7CNA stated that the resident got burned on his leg. On 03/16/18 at 11:30AM, an interview with S12Laundry worker confirmed that when Resident #9 caught his clothing on fire she went to assist. She reported that as soon as she turned the corner on the hall, she could smell smoke. She stated that she ripped the burning incontinent brief off Resident #9 while the CNA held the resident's hands. Surveyor asked if the incontinent brief was smoking or flaming, S12laundry worker reported that the brief was on fire and flaming. She stated that she ran into the shower room and extinguished the flame by holding it under the shower. On 03/15/18 at 11:13AM, S8Treatment Nurse provided physical transfer assistance from the wheelchair to the bed for Resident #9. An observation of Resident #9's body audit by S8Treatment Nurse revealed two scarred areas to the resident's upper right thigh. S8 confirmed that two scarred areas on the resident's right upper thigh were burn scars. S8 reported that both areas were blistered and she treated them carefully to make sure they didn't become infected as they healed. S8 further confirmed that she and another nurse complete all weekly body audits on the residents. On 03/15/18 at 3:00PM, an interview with S1DON confirmed that there was no in-service after Resident #9's clothing caught fire in the facility on 12/13/17 until 15 days later on 12/28/17 during the regular monthly in-service. S1DON confirmed that the in-service on 12/28/17 was conducted only one time and did not ensure that all staff were informed. She added that before 03/12/18 unsafe smokers were provided their cigarettes when they asked for them at the nurses' station and were allowed to smoke outside without supervision. She indicated that unsafe smoker's lighter and cigarettes were kept at the desk but they were allowed to ask for one and then go out and smoke without staff supervision. S1DON reported that a smoking program was initiated on 03/12/18. S2DON stated the facility's smoking policy had not been updated to reflect the new smoking program. S1DON reported that residents were informed on 03/09/18 of a new smoking program starting on 03/12/18 during the resident council meeting. Review of the minutes of the resident council meeting indicated that 6 of the 28 smokers in the facility attended the meeting. S1DON confirmed that she did not inform the smokers that had not attended the meeting of the new smoking program. When asked how those smokers were informed, S1DON indicated smokers talk to each other. On 03/16/18 at 12:30PM, an interview with S1DON and S6Administrator confirmed that there was no in-service for staff until 15 days after Resident #9 [MEDICAL CONDITION] his clothing/incontinent brief caught fire. S1DON also confirmed that residents assessed to be unsafe smokers were allowed to go outside and smoke unsupervised until 03/12/18 when a new smoking program was initiated. S1DON explained that unsafe smoker's cigarettes were kept at the front desk and whenever a resident would request a cigarette, staff would give the resident a cigarette and allow them to smoke outside unsupervised. S1DON further confirmed that there had been no staff in-service regarding the new smoking which was initiated on 03/12/18.

Based on record review and interview, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice and the resident's preference. The deficient practice involved 1 (#7) of 4 (#1, #6, #7, and #8) residents reviewed for discharges out of a total sample of 9 residents. This failed practice resulted in an actual harm on 02/27/2018 for Resident #7. Resident #7 had a fall in her room on the evening of 02/23/18. On 02/26/2018, the resident, who was in severe pain, informed the physical therapist of the fall that she experienced on 02/23/2018, and that she had been unable to straighten her left leg out all weekend. The physical therapist revealed that the resident said that she had informed the nurse of the fall on 02/23/2018. An X-ray of the resident's left hip performed on 02/26/2018 revealed the resident had a subluxation of the left hip. On the morning of 02/27/2018, the resident requested to be transported to the hospital by ambulance on a stretcher due to hip pain. The facility transported the resident by wheelchair to the hospital. Findings: A review of Resident #7's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #7's MDS (Minimum Data Set) dated 02/25/2018 revealed a BIMS (Brief Interview for Mental Status) score of 14, which means the resident is cognitively intact. It further revealed Resident #7 required extensive assistance with bed mobility and toileting and limited assistance with transferring. A review of Resident #7's (MONTH) (YEAR) physician's orders [REDACTED]. A review of Resident #7's Medication Administration Record [REDACTED]. A review of Resident #7's nurse's notes revealed the following entries: 02/26/18 at 3:48PM: Physical Therapist came to writer and reported that resident stated she is not participating with therapy due to left hip pain. Resident reported she fell in her room Friday night around 10:30PM. She stated she hit her trash can and landed on floor. Call bell was too far away so she got herself back to bed and then called nurse to report incident. Resident stated she hasn't been able to stand or walk on left leg all weekend. Doctor notified. New orders noted: X-ray to left hip (pain). By: S4LPN 02/27/18 at 1:23AM: Resident X-ray results show subluxation of left hip. Doctor notified. Family at bedside. Will go to hospital at 7AM via Riverview Care Center transportation. Family will meet at ER. 02/27/18 at 7:03AM: Resident up. Alert X 2. Resident informed she will be going to hospital emergency room via Riverview Care Center Transport in wheelchair. Requests to be taken via stretcher in ambulance. Resident informed emergency services are used only in emergent situations. Resident complained of pain in hip and is an emergency. Resident then states she needs to use the bedside commode. Resident told CNA (Certified Nursing Assistant) will be called to room. Resident transfers without assistance. Transferred to bedside commode. Then transferred self to wheelchair. Resident puts on sweater and rolls self to nurse's station and to transport vehicle. Resident is not crying or showing signs of distress. Resident family called and notified she is in route to hospital. Family in route to hospital. Further review of Resident #7's nurse's notes revealed no entries were made regarding a fall on 02/23/18 until 02/26/18 when the physical therapist reported the resident's pain to the nurse on 02/26/18. There were no entries regarding the resident's pain level from 02/23/18 until 02/26/18. Further review of Resident #7's record revealed no vital signs were taken for Resident #7 on 02/27/18. A review of Resident #7's left hip x-ray dated 02/26/18 revealed a left hip replacement was noted and the femoral component was subluxed superiorly and laterally. Impression: Subluxation of the left hip prosthesis. An interview was conducted with S3Physical Therapist, on 03/15/18 at 4:00PM. She stated Resident #7 came to therapy on 02/26/18 and refused to do therapy because she was in severe pain, a 10 out of 10 on the pain scale. PT stated she knew something was wrong because Resident #7 is usually very motivated during therapy because she wants to go home. She said Resident #7 told her she fell while getting up to go to the bathroom and fell on the trash can on the night of 02/23/18. S3PT said Resident #7 said she reported it to the nurse when she was able to get back to the bed. S3PT stated Resident #7 could not straighten her leg out and was in obvious pain so she went to the nurse and told her it needed to be checked out. An interview was conducted with S4LPN at 10:45AM on 03/16/18. She confirmed she was taking care of Resident #7 on 02/26/18 when the physical therapist came around and reported that resident was in a lot of pain since her fall. She confirmed she called the doctor and was given an order for [REDACTED]. She confirmed she had given her a pain pill before therapy which was effective. The Medication Administration Record [REDACTED]. She said this resident always had a problem with pain in her hip and pain all over. An interview as conducted with S2ADON on 03/16/18 at 10:20AM. She confirmed she was working the evening of 02/26/18. She stated the x-ray company came between 10:30PM and midnight. She said she received a text from S1DON with the x-ray results before midnight and family was called. A family member came in right away. She said she spoke with him at bedside and he asked that they wait until the morning to send Resident #7 to the hospital because he needed to go home and check on his cats. She said she reported this to Resident #7's doctor who said she could go now or wait until the morning, whichever she preferred. She stated Resident #7 agreed to wait until 7AM to go to the emergency room . When asked if Resident #7 was in a lot of pain, she stated this resident has asked for pain medicine a lot since admit and always asked for pain medicine in between scheduled times. She said she wasn't screaming or yelling. An interview was conducted with S5Transportation on 03/16/18 at 12:10PM who confirmed she transported Resident #7 to the hospital on [DATE]. She stated resident was fine. She said she pushed her onto the lift in her wheelchair, took her off the lift at the hospital, got her checked in and went to the back with the resident until family arrived. She said Resident #7 was fine but said she was lying down and asked her to turn the lights off. She said she kept asking for pain medicine but they could not give her any until the x-rays were done. She said they said Resident #7 would probably require surgery. S5Transportation stated she stayed until the family arrived and told her she could go. She said the nursing facility does not do stretcher transports on their van. She stated they can only use wheelchairs or geri chairs in the van. An interview was conducted with S1DON on 03/15/2018 at 2:10PM. She stated they do not have a policy regarding the transport of residents to the hospital. She stated they decide if the resident can go out by van by using an algorithm: Whether the resident can sit up in the wheelchair, whether their vital signs are stable, whether they can speak to you or not, and whether the resident is coherent. She stated if they can do these things, then the resident is transported by the facility's transportation. S1DON confirmed Resident #7 was sent to the emergency room in the facility's van with a known partially dislocated hip. She said she was not here when Resident #7 was sent out. She said, I would not have sent her that way. She said she has reviewed the notes and talked with staff about this issue but did not document it anywhere.

Based on record review and staff interviews, the facility failed to ensure the plan of care had been followed for 1(#4) of 5 (#'s 1,2,3,4,5) residents reviewed for implementation of the plan of care out of a total sample of 9. The facility failed to have a system in place to ensure staff monitored resident #4's location every 30 minutes, to report changes in the resident's behaviors to administration, and to ensure resident #4 remained inside the facility. The resident was found outside the nursing home on 7/12/11 and later pronounced dead at the emergency room . The Immediate Jeopardy began for resident #4 on 3/24/11 when she eloped from the facility and got to the parking lot before staff could get her back inside the facility. The Immediate Jeopardy ended on 7/12/11 at 6:29 p.m. for resident #4 when local Emergency Medical Service (EMS) transported her to a local emergency room (ER) after the resident was found outside the nursing home with no pulse or respirations. The Immediate Jeopardy continued for residents #1, #2, #3, #5, #6, #7, #8, #9 when it was determined the facility failed to increase supervision and monitoring of the 8 residents with a history of wandering. The facility failed to ensure the wander guard system was functioning and all of the door alarms in the facility were functioning. The Immediate Jeopardy was removed on 7/19/11 at 4:00 p.m. when observations and record reviews revealed the Plan of Removal had been implemented and was functioning. The deficient practice continued at a scope and severity of third level pattern. The facility's Plan of Removal was accepted on 7/18/11 at 5:00 p.m. Findings: Review of the care plan for resident #4 dated 3/29/11 through 6/27/11, revealed staff were to monitor the resident with visual checks at least every thirty minutes. Further review revealed the following: Resident wears a Wander Guard related to wandering aimlessly, getting out of building. Goal: Resident ' s whereabouts will be known at all times. Approaches: ...3. Monitor resident ' s whereabouts every 30 minutes ... 8. Monitor and report any changes in behaviors. Review of the care plan for resident #4 dated 6/21/11 through 9/19/11 revealed resident #4's care plan had been updated for hearing impairment, fall risk, and walking (environment and furniture to avoid injury in room or facility). No new interventions or approaches for preventing elopements had been found in the care plan. During an interview on 7/14/11 at 4:00 p.m. with CNA S12, she stated she had worked on the afternoon of 7/12/11. She stated the last time she saw resident #4 in the facility was 1:00 p.m. sitting in her wheelchair near the central nurses ' station. During an interview on 7/14/11 at 4:15 p.m. with CNA S13 she stated she had not seen resident #4 the afternoon of 7/12/11. During an interview on 7/14/11 at 5:05 p.m. with ward clerk S9, she stated she had not seen resident #4 on 7/12/11 since she had arrived at work at 4:30 p.m. During an interview with DON S2 on 7/15 11 at 2:50 p.m. the DON stated she saw resident #4 after lunch on 7/12/11, around 1:00 p.m. right after an in-service she had given. DON S2 stated staff had not followed the plan of care for monitoring resident #4 every 30 minutes. She stated a room to room search was initiated to find resident #4 was found between 5:30 p.m. and 6:00 lying outside the nursing home on the ground and unresponsive with no pulse or respirations. During an interview on 7/15/11 at 2:55 p.m. DON #S2 was asked why there was no alarm on the laundry door and she stated there was an alarm on the door. DON #S2 was informed no alarm sounded when the laundry door was opened. DON #S2 went to the nurses' station and the alarm was turned off at the box where the ward clerk monitored the alarms. DON #S2 instructed Ward Clerk #S8 to turn the alarm on and when she did it continuously beeped. Ward Clerk #S8 stated the door does not close securely so the alarm beeps constantly and that is why it is turned off. DON #S2 agreed the alarm was not functioning properly on the laundry door when it was turned off or turned on. The DON agreed, at that time, that a resident could have gone out that door with no alarm sounding. During an interview on 7/18/11 at 2:10 p.m. LPN S20 stated #4's care plan had not been followed because every 30 minute rounds had not been done for resident #4. The facility's Plan of Removal is documented as follows: 1. Each resident wearing a Wander-guard ankle bracelet will be monitored and checked each 30 minutes. A monitoring log has been implemented beginning July 16, 2011. The log will be individualized for each 24 hour periods. The day Charge Nurse will begin the monitoring cycle by providing the resident ' s sheet to the appropriate CNA. The CNA will visualize the resident, log the visualization and return the form to the Charge Nurse at the end of each shift. The Charge Nurse on the subsequent shifts will follow this procedure to provide the forms to the appropriate CNA. At the end of the 24 hour cycle, the Charge Nurse will turn the Monitoring form in to the Director of Nurses. This form will be made part of the resident ' s permanent record. 2. The facility will maintain a log at the Ward Clerk station to monitor alarm activations. The log will identify the door alarmed, the time, reason for alarm, and the responder. This will insure that the alarm is responded to in a timely manner and will insure that an employee is physically checking the door to insure that no resident has exited the door. This will be re-evaluated after the new door locking system is installed. 3. Facility has initiated a daily Sensor check to insure the sensor will initiate the alarm sounding. The Social Service Designee will be responsible for checking each sensor on a daily schedule. The Social Service Director will test each sensor not being used by a resident, by passing the sensor near the door sensors. The results will be documented on a monthly calendar showing the result of each numbered sensor being checked. This is in accordance with the manufacturer ' s recommendation. 4. The sensor on each resident will be checked daily by the CNA responsible for the resident. The documentation will be kept on the 30 minute Census Check. Each shift will verify that the sensor is in place at the beginning of the shift and document such on the daily Census Check Sheet. The 6:30 a.m. to 2:30 p.m. CNA will check the sensor to insure it is working properly by manually carrying the resident to an alarmed door and testing to insure the alarm is activated. Transmitters will be placed on the ankle of the resident unless the resident meets the manufacturer ' s requirements for placing on a wheelchair. This will be re-evaluated after the new system is installed. 5. The Maintenance person will also make weekly checks of all alarmed doors to insure that the alarm systems are functioning properly. These checks will be maintained on a weekly log.

Based on observations, record reviews, and interviews the facility failed to ensure adequate supervision was provided for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents who were cognitively impaired and were determined to be wanderers that resulted in the resident's death (#4). The facility failed to ensure adequate supervision was provided for 8 of 8 (#1, #2, #3, #5, #6, #7, #8, #9) cognitively impaired residents currently residing in the facility out of a total of 9 sampled residents reviewed for wandering. The facility failed to: 1. Ensure all doors in the facility had a functioning alarm system when opened. 2. Increase supervision of a resident that had eloped from the facility on [DATE], [DATE], twice on [DATE] (#4). 3. Ensure the wander guard bracelets were tested daily to ensure the doors alarmed. 4. Ensure someone checked to make sure the wander guard were on the residents and working properly according to the Plan of Care. 5. Ensure residents wearing the wander guards were monitored for their whereabouts every 30 minutes according to the Plan of Care. 6. Assess resident #4 after each elopement and document interventions attempted to prevent future elopements. 7. Implement changes to a resident's Plan of Care to address elopement after a resident eloped from the facility (#4). 8. Ensure staff reported resident #4's elopements to the Director of Nursing (DON) and completed an Incident Report for the Elopements. 9. Ensure the wander guard bracelets were applied per Manufacturer's recommendations. 10. Ensure the facility's Elopement Policy and Wandering Unsafe Residents Policy was followed. The Immediate Jeopardy began for resident #4 on [DATE] when she eloped from the facility and got to the parking lot before staff could get her back inside the facility. The Immediate Jeopardy ended on [DATE] at 6:29 p.m. for resident #4 when local Medical Service (EMS) transported her to a local emergency room (ER) after resident #4 was found unattended outside the nursing home with no pulse or respirations. Resident was pronouncsed dead at the emergency room . The Immediate Jeopardy continued for residents #1, #2, #3, #5, #6, #7, #8, #9 when it was determined the facility failed to increase supervision and monitoring of the 8 residents with a history of wandering. The facility failed to ensure the wander guard system was functioning and all of the door alarms in the facility were functioning. The facility's Administrator #S1, DON #S2, and ADON #S3 were informed of the Immediate Jeopardy on [DATE] at 4:50 p.m.. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. The Immediate Jeopardy was removed on [DATE] at 4:00 p.m. when observations and record reviews revealed the Plan of Removal had been implemented and was functioning. The deficient practice continued at a scope and severity of third level pattern. Findings: Observation on [DATE] at 11:15 a.m. revealed a west side door, off of the North Hall closest to the main nurse's station (laundry door), was pulled to, but the push bar to open the door was in a fixed position so the door would not lock. The door opened without activating the push bar and it did not alarm. Review of the facility's Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form (Incident/Accident Report) for resident #4 dated [DATE] at 5:45 p.m. revealed the following documentation: Resident found by CNAs and reported to this nurse. Found lying on right side in fetal position located on the outside by fence on North Hall (West end of hall). Resident was non-responsive with blood noted from nose. Further review of the incident/accident report revealed the first response team performed CPR at 5:50 p.m. and resident #4 was sent to a local hospital by ambulance at 6:00 p.m. Review of the incident/accident report revealed resident #4's physician and responsible party were notified at 6:00 p.m. of the incident. Review of the incident/accident report revealed resident #4's condition before the incident was normal. Attached to the incident/accident report dated [DATE] was an Incident Report Nurses Note completed by LPN #S5 dated [DATE] at 5:45 p.m. that revealed in the Narrative Nurses Notes section the following documentation: 4:30P Resident dinner tray brought from dining room. Resident was not found in room nor dining room. Reported to this nurse that resident was not in room. This nurse notified CNAs to begin a room to room search for resident. 5:15P Reported to this nurse room to room search was completed and resident not found. This nurse informed all CNAs available to check exits and outside. 5:45P Stat called over head. This nurse met CNAs. Resident found on the outside at the west end of north hall laying on her right side in the fetal position about 1 ft. from the fence. Resident was non-responsive with blood noted from nose. 911 called and notified of emergency. 5:50P First response team arrived and began CPR. At 6:00P Resident transported to (name of local hospital) ER. 6:00P MD (name) notified and (name) RP notified. Review of the Elopement Risk Assessment for resident #4 dated [DATE] revealed resident #4 was an elopement risk and interventions put into place were: personal safety alarm devices, exit and stairwell alarms, frequent monitoring, recreational activities, music, personalization of room and staff are aware of resident's wander risk. Summary documentation on the [DATE] Elopement Risk Assessment revealed the following: Wandering guard bracelet intact to monitor whereabouts. Door alarms on. Resident monitored every 30 minutes. Resident redirected. Encouraged to attend activities. Staff aware of resident's wandering. Further review of the [DATE] Elopement Risk Assessment form revealed questions ,[DATE] and questions ,[DATE] were all answered yes (indicating resident #4 was at increased risk for elopement), but no explanation was documented as requested on the form. Review of resident #4's medical record failed to reveal Elopement Risk Assessment forms for resident #4's upon admission, for her elopement on [DATE], or her elopements on [DATE] and [DATE]. Review of the plan of care revealed a problem onset date of [DATE] for risk for wandering with a goal that resident will not wander out of facility every shift. Approaches included: Assist in orientation to room with verbal cues, encourage group activities and attempt to keep occupied, assist in orientation to facility with verbal cues, monitor resident location with visual checks at least every thirty minutes, and put familiar items in residents room to assist them in identifying room. During an interview on [DATE] at 2:10 p.m. LPN #S20 stated before this incident with resident #4 that they were not monitoring and documenting every 30 minutes on resident #4. During a telephone interview on [DATE] at 12:50 p.m. LPN #S5 stated resident #4 was noted to be missing around 4:30 p.m. and the facility was searched inside and out and resident #4 was found outside the west door of the North Hall around 5:45 p.m. He stated resident #4 was found lying on her right side and he noted extremely dark blood coming from her nose. LPN #S5 stated he checked resident #4 and she had no pulse or respirations. LPN #S5 stated he instructed someone to call 911 and asked a CNA (did not remember who) to go get the resuscitation equipment, but 911 arrived before he could get the equipment and start CPR. LPN #S5 stated his shift started at 2:30 p.m. and he made rounds, but resident #4 was not in her room. LPN #S5 stated resident #4 was a wanderer and he just thought she was walking in the facility. LPN #S5 stated only one alarm went off on his shift and that was another resident at the front door at 4:30 p.m. LPN #S5 was asked how often resident #4 was to be monitored and he stated I don't know exactly, but frequently. When asked should the resident be monitored every 30 minutes, he stated she should have been and he knew that now. LPN #S5 stated sheets were passed out on [DATE] regarding every 30 minute monitoring. LPN #S5 stated he was not sure if the monitoring was always supposed to be every 30 minutes or if it changed after the incident with resident #4. Review of the facility's Policy for Elopements revealed the following: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. 2. If an employee observes a resident leaving the premises, he/she should attempt to prevent departure in a courteous manner, get help from other staff, and have another staff member go notify the Charge Nurse or DON that the resident has left premises. 3. When individual returns to facility DON or Charge Nurse shall: examine resident for injuries, notify attending physician, notify resident's legal representative, complete and file Report of Incident/Accident, and document the event in the resident's medical record. 4. If employee discovers resident is missing from the facility he/she shall: determine if resident is on pass, search building and premises, if not found notify Administrator, DON, legal representative, MD, and law enforcement officials, provide search teams, and initiate extensive search of the surrounding area. 5. When resident returns to facility examine for injuries, notify MD and report findings/condition of resident, notify legal representative, notify search team resident has been located, complete and file incident report, and document relevant information in the resident's medical record. Review of the facility's Policy for Wandering, Unsafe Resident revealed: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. Staff will assess at-risk individuals for potentially corrective risk factors related to unsafe wandering. 3. Resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. 7. Staff will notify Administrator or DON immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. Review of the medical record for resident #4 revealed a Nurse ' s Notes dated [DATE] (resident #4's admission note) at 3:30 p.m. revealed the following entry: She is a fall risk and will wander off if not monitored closely. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 on admission. Review of the medical record for resident #4 revealed an Incident Report Nurses Note dated [DATE] at 4:20 p.m. with the following entry: Resident had left facility and was walking down (name of street). Resident was picked up at the bank and brought back to the facility. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 after her elopement from the facility on [DATE]. Review of an Interdisciplinary Note documented the following entry: [DATE]- Staffing Note: Resident #4 had a wander guard in place and remained intact to monitor whereabouts due to several episodes of wandering outside (see N/N [DATE] and [DATE]). Had to be redirected. Wanders up & down hallways. Review of the Nurse's Notes dated [DATE] revealed an entry at 9:30 p.m.- Resident went to bed at 7 PM; after getting out the front door and into the parking lot. Review of a Nurse's Note dated [DATE] revealed an entry at 11:00 a.m.- Resident exit the building attempting to leave facility. Writer and 2 other nurses tried to re-direct her back in building and resident cursed at writer. Resident started to walk faster out to the road (name of street). Writer knew it would not be safe and called resident's daughter who could not re-direct her either. The Floor Tech was able to re-direct resident back in building. Resident appears to be very anxious and agitated. Review of the [DATE] Nurse's Note revealed an entry at 12:30 p.m. resident back out of facility. Dietary worker was able to re-direct her fairly easily. RN put together another wanderguard, but the resident refused to keep it on. Review of the Social Progress Notes & Evaluation dated [DATE] revealed an entry: Resident wanders, sleeps in different rooms and left the building [DATE] unattended shortly after lunch. Resident was caught by staff in the parking lot of the building next door. Resident somehow removed her wander guard, but a new one was placed on resident's ankle by nurse. Review of the [DATE] Nurse's Note revealed an entry at 11:00 a.m.- Resident left out of facility stated she was going home. No wander guard on at this time. Not easily re-directed. Staff x4 to assist getting her back in facility. New wander guard intact to left ankle with no problems. Would not sit still, constantly walking around facility. Review of the [DATE] Nurse's Note revealed an entry at 2:00 p.m.- Ambulating around facility. Has attempted twice to leave building. CNA #S14 walked around with resident outside. Review of the [DATE] Nurse's Note revealed an entry at 5:30 p.m.- Resident left out of facility and made it to the sidewalk. Her wander guard set the alarm off. Staff members got to her before she made it to the parking lot. Assisted resident back into facility. Review of the [DATE] Physician order [REDACTED].*Monitor whereabouts of resident*. During an interview on [DATE] at 3:40 p.m. Administrative Assistant #S21 reviewed the incident/accident report book and was unable to find any incident reports for resident #4 during the month of [DATE] and stated the DON may have them in her office. During an interview on [DATE] at 3:45 p.m. DON #S2 stated she did not have any incident reports in her office. During an interview on [DATE] at 2:50 p.m. DON #S2 stated she was not aware resident #4 eloped on [DATE], [DATE], or [DATE] because no one told her and she did not have an incident report. During an interview on [DATE] at 3:00 p.m. Medicaid Coordinator #S4 stated every 30 minute rounds were implemented on resident #4 about 2 years ago when she first got the wander guard. She stated no one notified her of resident #4's elopements in [DATE] or she would have updated the care plan, but she did not have an incident report. Medicaid Coordinator #S4 stated the updated care plan dated [DATE] for the wander guard just happened to coincide with the regular care plan update in March. Medicaid Coordinator #S4 stated the every 30 minute checks should be documented on the MAR. Review of the [DATE] Medication Administration Record (MAR) revealed under Order Text- [DATE] Wander guard for Residents Safety *Monitor Whereabouts of Resident* and it was initialed for each shift. During an interview on [DATE] at 2:30 p.m. DON #S2 reviewed resident #4's medical record and was unable find the Elopement Risk Assessments for [DATE], [DATE], [DATE], or [DATE]. DON #S2 stated resident #4's elopement risk assessments should have been completed and agreed they had not been done. During an interview on [DATE] at 3:35 p.m. Medicaid Coordinator #S4 reviewed the Interdisciplinary Note dated [DATE] that documented resident #4 eloped on [DATE] and [DATE] and stated that was her writing and signature. She stated she guessed she did not address it on the care plan because she did not have the initial incident report. She stated she should have addressed the wandering/elopement for resident #4 from the information she had from the nurses' notes, but she did not and usually liked to have the incident report. Review of the Significant Change MDS dated [DATE] for resident #4 revealed the following: Section C: Cognitive Patterns- Resident #4 was coded as having short term memory problems and that her cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). Resident #4 was also coded as having Psychomotor retardation that is continuously present and does not fluctuate. Review of Section E: Behaviors- Revealed resident #4 was coded as a 1 (behavior occurred ,[DATE] days) for physical and verbal behavioral symptoms directed toward others. Further review revealed resident #4 exhibited an overall presence of behavioral symptoms that put the resident at significant risk for physical illness or injury and interfered with the resident's care. Review also revealed the behaviors significantly intruded on the privacy or activity of other residents and significantly disrupted care or living environment. Review of Section E0900-Wandering-Presence & Frequency revealed resident #4 wandered ,[DATE] days and that the wandering placed the resident at significant risk of getting to a potentially dangerous place. Review of Section G: Functional Status revealed resident #4 was coded a ,[DATE] (Independent/No setup or physical help from staff) for Bed mobility, walk in room, walk in corridor, locomotion on unit, and locomotion off unit. Resident #4 was coded (Independent/Setup only) for eating. Coded as ,[DATE] (Supervision/one person assist) for transfers. Coded ,[DATE] (Extensive assist/one person assist) for dressing, toilet use, and personal hygiene. Coded ,[DATE] (Dependant/one person assist) for bathing. Further review revealed resident balance during transition and walking was not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer. Resident #4 was coded as having a wheelchair under mobility devices. Review of the MDS under section N: Medications- revealed resident #4 received Antipsychotic medications. Review of the plan of care for resident #4 dated [DATE] and continued on [DATE], revealed the resident was care planned for a Wander guard with a goal of- Resident's whereabouts will be known at all times. Approaches included: Make sure wander guard is on resident and working properly, administer medications as ordered per MD, monitor resident's whereabouts every 30 minutes, answer wander guard alarm in a timely manner, reorient/redirect, notify family/md prn, monitor and report any changes in cognitive status, and monitor and report any changes in behavior. Review of the current plan of care dated [DATE] revealed resident #4 was care planned for Alzheimer's and dementia with the goal to know family and staff. Approaches included: Reality orientation while giving care, involve in enjoyable activities which orient to reality, encourage family to visit and bring photos and momentos, pleasant interaction which reassures resident when confused, explain all procedures and reason for performing them, and verbal reminders which assist resident in orientation. During an interview on [DATE] at 4:00 p.m. CNA #S12 stated on [DATE] she stayed over to work on the North hall in Module 2 to help out and that she had worked the South hall showers that morning. CNA #S12 stated she was going to break at 1:00 p.m. and resident #4 was seated in a wheelchair by the nurse ' s station. CNA #S12 stated that was the last time she saw resident #4. CNA #S12 stated resident #4 was not in the dining room at 5:00 p.m. so she went to let CNA #S14 know resident #4 was not in the dining room. She stated the room to room search was called after that. CNA #S12 stated the room to room search was completed about 5:15 p.m. and 4 CNAs went out the Central hall door and split up left and right to search outside. CNA #S12 stated herself, CNA #S13, and CNA #S14 found resident #4 lying on her right side with the right leg straight, the left leg was bent, and her right arm was stretched out with her head lying on her right arm. CNA #S12 stated she saw resident #4 had blood around her nose and mouth and she noticed a puddle of blood on the ground where she was lying. CNA #S12 stated resident #4 was not breathing and CNA #S14 checked for a pulse on her neck. CNA #S12 stated she used her cell phone and called the ward clerk #S9 and informed her to notify LPN #S5 to get out there now. CNA #S12 stated LPN #S5 arrived out the door almost immediately. CNA #S12 stated LPN #S5 checked for pulse and chest rise. She stated LPN #S5 asked for a towel to wipe off resident #4 ' s face. CNA #S12 stated the blood was dark and had dried some and she assumed resident #4 had been there for awhile. CNA #S12 stated resident #4's skin was ashen in color. CNA #S12 stated they found resident #4 between 5:,[DATE]:45 p.m., EMS was called and when they arrived EMS began CPR and transported resident #4 to the ER. During an interview on [DATE] at 4:15 p.m. CNA #S13 stated on [DATE] she became aware resident #4 was missing between 5:00 p.m. and 5:30 p.m. She stated the room to room search was completed and she went out the laundry door when they went to look outside. CNA #S13 stated she went around the North Hall side and met up with CNA #S12 and CNA #S14. CNA #S13 stated she saw resident #4 lying on the ground on her right side with her right arm out and both legs drawn up and she had some dark brown mucus looking stuff coming out of her nose with blood in it. CNA #S13 stated the blood was dark and had some redness to it. CNA #S13 stated there was an odor that smelled like the resident's foot, which smelled like a bed sore odor. CNA #S13 stated CNA #S12 called on her phone and she beat on the door to get help. CNA #S13 stated the LPN #S5 was there almost immediately and when he arrived LPN #S5 checked to see if resident #4 was breathing by putting his hand on her neck. CNA #S13 stated someone called 911 and when 911 arrived they hooked her up to a lot of equipment. During an interview on [DATE] at 4:40 p.m. CNA #S16 stated she has been back to work here at the facility about 2 weeks. CNA #S16 stated on [DATE] she fed her residents at the desk between 4:00 p.m. and 4:30 p.m. and went down the hall to feed her other residents about 4:45 p.m. and finished feeding about 5:10 p.m. CNA #S16 stated she brought her residents back to their rooms from the dining room and made rounds about 5:30 p.m. CNA #S16 stated she finished her round about 5:55 p.m. and a room to room search was called. She stated she went out the Central hall door and looked outside and came in South hall door and was told they found resident #4. She stated she went back to where resident #4 was and LPN #S5 asked her to go get a towel and LPN #S5 wiped her face off. She stated after giving LPN #S5 the towel she went back inside as 911 was arriving and it was about 6:15 p.m. CNA #S16 stated she did not see resident #4 from the time she clocked in at 2:39 p.m. until resident #4 was found. During an interview on [DATE] at 4:50 p.m. CNA #S17 stated she worked the South hall on [DATE] and about 5:45 p.m. CNA #S14 asked had she seen resident #4 and she said no and did a room to room search. CNA #S17 stated it was around 6:00 p.m. when resident #4 was found outside and she arrived outside. CNA #S17 stated LPN #S5 was at resident #4's side and resident #4 was lying on her right side and both legs were drawn up and arms were folded over. CNA #S17 stated she saw blood coming from resident #4's nose and mouth and it looked like it was mixed with mucus. CNA #S17 stated the blood on the ground was dark brown and about the size of a saucer. CNA #S17 stated she came back inside and told the ward clerk to call 911. CNA #S17 stated it was after 6:00 p.m. when she told the ward clerk to call 911 and it took 911 about 10 minutes to arrive. CNA #S17 stated she opened the side gate for the ambulance to get through and came back in the building. CNA #S17 stated she clocked in at 2:21 p.m. and she did not see resident #4 the entire time she was there until they found her outside. During an interview on [DATE] at 5:00 p.m. CNA #S15 stated she was working on the Central hall on [DATE]. CNA #S15 stated sometime between 5:00 p.m. and 6:00 p.m. a room to room search was done and resident #4 was not found. CNA #S15 stated her and CNA #S16 went out the Central hall door and went south to look for resident #4 and when they came back in the building they were told resident #4 was found. CNA #S15 stated when she went outside the nurses and CNAs were around resident #4. CNA #S15 stated she came back in the building and did not go back outside. During an interview on [DATE] at 5:05 p.m. Ward Clerk #S9 stated on [DATE] CNA #S14 asked her to announce a room to room search and that was around 5:45 p.m. or 5:50 p.m. and she announced a room to room search for a resident. She stated the CNA #S14, CNA #S12, CNA #S16, CNA #S15 and some others stated they were going to do an outside search and about 2 minutes later she was told to call 911 and it was after 6:00 p.m. Ward Clerk #S9 stated it was maybe ,[DATE] minutes when 911 arrived. Ward Clerk #S9 stated she was not aware of what time 911 left with resident #4. Ward Clerk #S9 stated she arrived to work about 4:10 p.m. and did not see resident #4. A tour was made of the facility on [DATE] at 9:45 a.m. to check the door alarms. This surveyor tested all the doors in the facility while the other surveyor remained at the nurses ' station to determine if the alarms activated when the doors were opened. The alarm did not activate when the laundry door was opened. During an interview on [DATE] at 10:10 p.m. Maintenance Supervisor #S10 stated only 3 doors in the facility are key coded for the wander guard alarm and that was the front door, the Northeast door (Ambulance door), and the Southeast door. He stated the alarm will activate if the person wearing the wander guard gets too close and warn staff of the resident trying to leave. When tested , the alarm sounded at approximately 4 feet away from the Southeast door and ,[DATE] feet from the Northeast door. When attempting the front door the alarm did not activate. Maintenance Supervisor #S10 placed the wander guard bracelet directly in front of the sensor and it did not activate. Maintenance Supervisor #S10 opened the front door and once the door was opened the wander guard alarm sounded. During an interview on [DATE] at 10:15 a.m. Ward Clerk #S8 was asked to explain her role at the desk when the wander guard system went off. She stated if a resident with a wander guard goes to the front door, the ambulance door (North Hall East Door), or the South Hall East Door she would hear the alarm that was above her head. Ward Clerk #S8 stated all the other doors are just regular alarms that go off when the door is opened. Ward Clerk #S8 stated she was able to turn off the alarm by pushing a button. She stated the alarm would not start alarming again unless the door was not completely shut. Ward Clerk #S8 stated the button can reset all the regular alarms. She stated there were only 3 doors with wander guard alarms although there are 4 buttons on the box. Ward Clerk #S8 stated 1 of the 4 buttons has never alarmed. Ward Clerk #S8 stated she could not reset the wander guard alarm. Ward Clerk #S8 stated she saw resident #4 on the North Hall around 3:00 p.m. on [DATE] in her wheelchair going away from the Ward Clerk desk. Ward Clerk #S8 stated resident #4 looked weak like she could fall out of her wheelchair. She stated resident #4 had been that way for a couple of weeks. Ward Clerk #S8 stated it was possible that resident #4 went out the laundry door. Ward Clerk #S8 stated she went on break around 2:35 p.m. or 2:40 p.m. and there were several CNAs around the desk. She stated no alarm went off from 3:00 p.m. to 4:30 p.m. Ward Clerk #S8 stated resident #4 got out into the parking lot earlier this year, but she was a fast walker then. She stated resident #4 could have gone out the door and been gone pretty quick. During an interview on [DATE] at 10:30 a.m. Detective #S18 stated she had recovered resident #4's wander guard bracelet from the hospital as evidence. Detective #S18 stated on [DATE] she entered the facility with resident #4's wander guard bracelet in an evidence envelope and when she walked in the front door the alarm did not sound. Detective #S18 stated she was told the alarm probably did not activate because the wander guard bracelet was in an envelope. Detective #S18 stated she removed the wander guard bracelet from the envelope and walked in and out of the facility's front door 5 times. Detective #S18 stated the alarm did not sound when she left the facility's front door using the left and right doors. Detective #S18 further stated when she re-entered the building the alarm did not sound when she entered the right door on 3 occasions, but it did sound the 2 times she entered through the left door. During an interview on [DATE] at 2:30 p.m. LPN #S11 stated on [DATE] resident #4 left through the front door and stated she was going home and was not easily re-directed and walked almost all the way to the street. LPN #S11 stated another resident informed her that resident #4 had left the building and the wander guard alarm did not go off. LPN #S11 stated resident #4 had removed her wander guard bracelet and it appeared to be a straight cut. She stated the incident occurred around lunch. LPN #S11 stated once resident #4 was back in the facility she calmed down, but tried again to leave later that afternoon. LPN #S11 stated CNA #S14 took resident #4 outside and walked around with her to keep her calm. LPN #S11 stated there was no monitoring of resident #4 except for the wander guard. LPN #S11 stated they were checking on resident #4 every 2 hours. LPN #S11 stated she could not remember the date, but she remembered an in-service sometime this year on elopements. During an interview on [DATE] at 2:50 p.m. DON #S2 stated she saw resident #4 twice the morning of [DATE] and once that afternoon at the ward clerk desk around 1:00 p.m. that day. DON #S2 stated if a resident made it out the door it was considered an elopement. DON #S2 stated Social Services are responsible for putting on the wander guards and nursing is responsible for monitoring them. She stated they do not monitor the wander guard batteries because they should last 3 years. DON #S2 stated they monitor the residents with wander guards every 30 minutes, but there was no documentation of the 30 minute rounds. During an interview on [DATE] at 2:55 p.m. DON #S2 was asked why there was no alarm on the laundry door and she stated there was an alarm on the door. DON #S2 was informed no alarm sounded when the laundry door was opened. DON #S2 went to the nurses' station and the alarm was turned off at the box where the ward clerk monitored the alarms. DON #S2 instructed Ward Clerk #S8 to turn the alarm on and when she did it continuously beeped. Ward Clerk #S8 stated the door does not close securely so the alarm beeps constantly and that is why it is turned off. DON #S2 agreed the alarm was not functioning properly on the laundry door when it was turned off or turned on. The DON agreed, at that time, that a resident could have gone out that door with no alarm sounding. The Administrator #S1, DON #S2, and ADON #S3 were notified on [DATE] at 4:50 p.m. of the Immediate Jeopardy situation regarding the death of resident #4 and the potential for other residents to elope due to the ineffective wander guard system. During an interview on [DATE] at 10:05 a.m. Social Service Director (SSD) #S6 stated the wander guard bracelets do not come with manufacturer's recommendation for use, but you can request them if needed. SSD #S6 provided the most recent invoice for the wander guard purchase dated [DATE] for 6 three year adult transmitters and one Instruction Sheet for Transmitter Straps. When asked, SSD #S6 stated she was not able to locate the instruction sheet, but she had given the Administrator the information on Friday ([DATE]). During an interview on [DATE] at 10:10 a.m. the Administrator #S1 stated he did get information on the wander guard on [DATE] from SSD #S6, but he left it at home and would have to go get it. During an i

Based on observations, record reviews, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently for 1 (#4) of 5 (#'s 1,2,3,4,5) cognitively impaired sampled residents with wander guard bracelets, out of a total of 8 (#'s 1,2,3,5,6,7,8,9) cognitively impaired residents with wander guard bracelets who currently resided in the facility. Administration failed to: 1. Have a system in place to provide increased supervision to ensure residents identified as being wanderers/elopement risk did not exit the facility's building without staff knowledge. 2. Have a system in place to ensure staff reported all elopement events to administration. 3. Have a system in place to ensure the facility's elopement policy and wandering, unsafe resident's policy was implemented for residents identified as at risk for elopement. 4. Ensure the wander guard system was functioning correctly. The Immediate Jeopardy began for resident #4 on [DATE] when she eloped from the facility and got to the parking lot before staff could get her back inside the facility. The Immediate Jeopardy ended on [DATE] at 6:29 p.m. for resident #4 when local Emergency Medical Service (EMS) transported her to a local emergency room (ER) after resident #4 was found outside with no pulse or respirations. The Immediate Jeopardy continued for residents #1, #2, #3, #5, #6, #7, #8, #9 when it was determined the facility failed to increase supervision and monitoring of the 8 residents with a history of wandering. The facility failed to ensure the wander guard system was functioning and all of the door alarms in the facility were functioning. The staff failed to complete incident reports for resident #4's elopements and failed to notify the Administrator and DON of the elopements on [DATE], [DATE], and [DATE]. The facility's Administrator #S1, DON #S2, and ADON #S3 were informed of the Immediate Jeopardy on [DATE] at 4:50 p.m.. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. The Immediate Jeopardy was removed on [DATE] at 4:00 p.m. when observations and record reviews revealed the Plan of Removal had been implemented and was functioning. The deficient practice continued at a scope and severity of third level pattern. Findings: 1. Observation on [DATE] at 11:15 a.m. revealed a west side door, off of the North Hall closest to the main nurse's station (laundry door), was pulled to, but the push bar to open the door was in a fixed position so the door would not lock. The door opened without activating the push bar and it did not alarm. Review of the facility's Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form (Incident/Accident Report) for resident #4 dated [DATE] at 5:45 p.m. revealed the following documentation: Resident found by CNAs and reported to this nurse. Found lying on right side in fetal position located on the outside by fence on North Hall (West end of hall). Resident was non-responsive with blood noted from nose. Further review of the incident/accident report revealed the first response team performed CPR at 5:50 p.m. and resident #4 was sent to a local hospital by ambulance at 6:00 p.m. Review of the incident/accident report revealed resident #4's physician and responsible party were notified at 6:00 p.m. of the incident. Review of the incident/accident report revealed resident #4's condition before the incident was normal. Attached to the incident/accident report dated [DATE] was an Incident Report Nurses Note completed by LPN #S5 dated [DATE] at 5:45 p.m. that revealed in the Narrative Nurses Notes section the following documentation: 4:30P Resident dinner tray brought from dining room. Resident was not found in room nor dining room. Reported to this nurse that resident was not in room. This nurse notified CNAs to begin a room to room search for resident. 5:15P Reported to this nurse room to room search was completed and resident not found. This nurse informed all CNAs available to check exits and outside. 5:45P Stat called over head. This nurse met CNAs. Resident found on the outside at the west end of north hall laying on her right side in the fetal position about 1 ft. from the fence. Resident was non-responsive with blood noted from nose. 911 called and notified of emergency. 5:50P First response team arrived and began CPR. At 6:00P Resident transported to (name of local hospital) ER. 6:00P MD (name) notified and (name) RP notified. Review of the Elopement Risk Assessment for resident #4 dated [DATE] revealed resident #4 was an elopement risk and interventions put into place were: personal safety alarm devices, exit and stairwell alarms, frequent monitoring, recreational activities, music, personalization of room and staff are aware of resident's wander risk. Summary documentation on the [DATE] Elopement Risk Assessment revealed the following: Wandering guard bracelet intact to monitor whereabouts. Door alarms on. Resident monitored every 30 minutes. Resident redirected. Encouraged to attend activities. Staff aware of residents wandering. Further review of the [DATE] Elopement Risk Assessment form revealed questions ,[DATE] and questions ,[DATE] were all answered yes (indicating resident #4 was at increased risk for elopement), but no explanation was documented as requested on the form. Review of resident #4's medical record failed to reveal Elopement Risk Assessment forms for resident #4's upon admission, for her elopement on [DATE], or her elopements on [DATE] and [DATE]. Review of the plan of care revealed a problem onset date of [DATE] for risk for wandering with a goal that resident will not wander out of facility every shift. Approaches included: Assist in orientation to room with verbal cues, encourage group activities and attempt to keep occupied, assist in orientation to facility with verbal cues, monitor resident location with visual checks at least every thirty minutes, and put familiar items in residents room to assist them in identifying room. During an interview on [DATE] at 2:10 p.m. LPN #S20 stated before this incident with resident #4 that they were not monitoring and documenting every 30 minutes on resident #4. During a telephone interview on [DATE] at 12:50 p.m. LPN #S5 stated resident #4 was noted to be missing around 4:30 p.m. and the facility was searched inside and out and resident #4 was found outside the west door of the North Hall around 5:45 p.m. He stated resident #4 was found lying on her right side and he noted extremely dark blood coming from her nose. LPN #S5 stated he checked resident #4 and she had no pulse or respirations. LPN #S5 stated he instructed someone to call 911 and asked a CNA (did not remember who) to go get the resuscitation equipment, but 911 arrived before he could get the equipment and start CPR. LPN #S5 stated his shift started at 2:30 p.m. and he made rounds, but resident #4 was not in her room. LPN #S5 stated resident #4 was a wanderer and he just thought she was walking in the facility. LPN #S5 stated only one alarm went off on his shift and that was another resident at the front door at 4:30 p.m. LPN #S5 was asked how often resident #4 was to be monitored and he stated I don't know exactly, but frequently. When asked should the resident be monitored every 30 minutes, he stated she should have been and he knew that now. LPN #S5 stated sheets were passed out on [DATE] regarding every 30 minute monitoring. LPN #S5 stated he was not sure if the monitoring was always supposed to be every 30 minutes or if it changed after the incident with resident #4. Review of the facility's Policy for Elopements revealed the following: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. 2. If an employee observes a resident leaving the premises, he/she should attempt to prevent departure in a courteous manner, get help from other staff, and have another staff member go notify the Charge Nurse or DON that the resident has left premises. 3. When individual returns to facility DON or Charge Nurse shall: examine resident for injuries, notify attending physician, notify resident's legal representative, complete and file Report of Incident/Accident, and document the event in the resident's medical record. 4. If employee discovers resident is missing from the facility he/she shall: determine if resident is on pass, search building and premises, if not found notify Administrator, DON, legal representative, MD, and law enforcement officials, provide search teams, and initiate extensive search of the surrounding area. 5. When resident returns to facility examine for injuries, notify MD and report findings/condition of resident, notify legal representative, notify search team resident has been located, complete and file incident report, and document relevant information in the resident's medical record. Review of the facility's Policy for Wandering, Unsafe Resident revealed: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. Staff will assess at-risk individuals for potentially corrective risk factors related to unsafe wandering. 3. Resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. 7. Staff will notify Administrator or DON immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. Review of the medical record for resident #4 revealed a Nurse ' s Notes dated [DATE] (resident #4's admission note) at 3:30 p.m. revealed the following entry: She is a fall risk and will wander off if not monitored closely. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 on admission. Review of the medical record for resident #4 revealed an Incident Report Nurses Note dated [DATE] at 4:20 p.m. with the following entry: Resident had left facility and was walking down (name of street). Resident was picked up at the bank and brought back to the facility. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 after her elopement from the facility on [DATE]. Review of an Interdisciplinary Note documented the following entry: [DATE]- Staffing Note: Resident #4 had a wander guard in place and remained intact to monitor whereabouts due to several episodes of wandering outside (see N/N [DATE] and [DATE]). Had to be redirected. Wanders up & down hallways. Review of the Nurse's Notes dated [DATE] revealed an entry at 9:30 p.m.- Resident went to bed at 7 PM; after getting out the front door and into the parking lot. Review of a Nurse's Note dated [DATE] revealed an entry at 11:00 a.m.- Resident exit the building attempting to leave facility. Writer and 2 other nurses tried to re-direct her back in building and resident cursed at writer. Resident started to walk faster out to the road (name of street). Writer knew it would not be safe and called resident's daughter who could not re-direct her either. The Floor Tech was able to re-direct resident back in building. Resident appears to be very anxious and agitated. Review of the [DATE] Nurse's Note revealed an entry at 12:30 p.m. resident back out of facility. Dietary worker was able to re-direct her fairly easily. RN put together another wanderguard, but the resident refused to keep it on. Review of the Social Progress Notes & Evaluation dated [DATE] revealed an entry: Resident wanders, sleeps in different rooms and left the building [DATE] unattended shortly after lunch. Resident was caught by staff in the parking lot of the building next door. Resident somehow removed her wander guard, but a new one was placed on resident's ankle by nurse. Review of the [DATE] Nurse's Note revealed an entry at 11:00 a.m.- Resident left out of facility stated she was going home. No wander guard on at this time. Not easily re-directed. Staff x 4 to assist getting her back in facility. New wander guard intact to left ankle with no problems. Would not sit still, constantly walking around facility. Review of the [DATE] Nurse's Note revealed an entry at 2:00 p.m.- Ambulating around facility. Has attempted twice to leave building. CNA #S14 walked around with resident outside. Review of the [DATE] Nurse's Note revealed an entry at 5:30 p.m.- Resident left out of facility and made it to the sidewalk. Her wander guard set the alarm off. Staff members got to her before she made it to the parking lot. Assisted resident back into facility. Review of the [DATE] Physician order [REDACTED].*Monitor whereabouts of resident*. During an interview on [DATE] at 3:40 p.m. Administrative Assistant #S21 reviewed the incident/accident report book and was unable to find any incident reports for resident #4 during the month of [DATE] and stated the DON may have them in her office. During an interview on [DATE] at 3:45 p.m. DON #S2 stated she did not have any incident reports in her office. During an interview on [DATE] at 2:50 p.m. DON #S2 stated she was not aware resident #4 eloped on [DATE], [DATE], or [DATE] because no one told her and she did not have an incident report. During an interview on [DATE] at 3:00 p.m. Medicaid Coordinator #S4 stated every 30 minute rounds were implemented on resident #4 about 2 years ago when she first got the wander guard. She stated no one notified her of resident #4's elopements in [DATE] or she would have updated the care plan, but she did not have an incident report. Medicaid Coordinator #S4 stated the updated care plan dated [DATE] for the wander guard just happened to coincide with the regular care plan update in March. Medicaid Coordinator #S4 stated the every 30 minute checks should be documented on the MAR. Review of the [DATE] Medication Administration Record (MAR) revealed under Order Text- [DATE] Wander guard for Residents Safety *Monitor Whereabouts of Resident* and it was initialed for each shift. During an interview on [DATE] at 2:30 p.m. DON #S2 reviewed resident #4's medical record and was unable find the Elopement Risk Assessments for [DATE], [DATE], [DATE], or [DATE]. DON #S2 stated resident #4's elopement risk assessments should have been completed and agreed they had not been done. During an interview on [DATE] at 3:35 p.m. Medicaid Coordinator #S4 reviewed the Interdisciplinary Note dated [DATE] that documented resident #4 eloped on [DATE] and [DATE] and stated that was her writing and signature. She stated she guessed she did not address it on the care plan because she did not have the initial incident report. She stated she should have addressed the wandering/elopement for resident #4 from the information she had from the nurses' notes, but she did not and usually liked to have the incident report. Review of the Significant Change MDS dated [DATE] for resident #4 revealed the following: Section C: Cognitive Patterns- Resident #4 was coded as having short term memory problems and that her cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). Resident #4 was also coded as having Psychomotor [MEDICAL CONDITION] that is continuously present and does not fluctuate. Review of Section E: Behaviors- Revealed resident #4 was coded as a 1 (behavior occurred ,[DATE] days) for physical and verbal behavioral symptoms directed toward others. Further review revealed resident #4 exhibited an overall presence of behavioral symptoms that put the resident at significant risk for physical illness or injury and interfered with the resident's care. Review also revealed the behaviors significantly intruded on the privacy or activity of other residents and significantly disrupted care or living environment. Review of Section E0900-Wandering-Presence & Frequency revealed resident #4 wandered ,[DATE] days and that the wandering placed the resident at significant risk of getting to a potentially dangerous place. Review of Section G: Functional Status revealed resident #4 was coded a ,[DATE] (Independent/No setup or physical help from staff) for Bed mobility, walk in room, walk in corridor, locomotion on unit, and locomotion off unit. Resident #4 was coded (Independent/Setup only) for eating. Coded as ,[DATE] (Supervision/one person assist) for transfers. Coded ,[DATE] (Extensive assist/one person assist) for dressing, toilet use, and personal hygiene. Coded ,[DATE] (Dependant/one person assist) for bathing. Further review revealed resident balance during transition and walking was not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer. Resident #4 was coded as having a wheelchair under mobility devices. Review of the MDS under section N: Medications- revealed resident #4 received Antipsychotic medications. Review of the plan of care revealed resident #4 had a care plan for a Wander guard with a goal of- Resident's whereabouts will be known at all times. Approaches included: Make sure wander guard is on resident and working properly, administer medications as ordered per MD, monitor resident's whereabouts every 30 minutes, answer wander guard alarm in a timely manner, reorient/redirect, notify family/md prn, monitor and report any changes in cognitive status, and monitor and report any changes in behavior. Review of the plan of care revealed resident #4 was care planned for Alzheimer's and dementia with the goal to know family and staff. Approaches included: Reality orientation while giving care, involve in enjoyable activities which orient to reality, encourage family to visit and bring photos and mementos, pleasant interaction which reassures resident when confused, explain all procedures and reason for performing them, and verbal reminders which assist resident in orientation. During an interview on [DATE] at 4:00 p.m. CNA #S12 stated on [DATE] she stayed over to work on the North hall in Module 2 to help out and that she had worked the South hall showers that morning. CNA #S12 stated she was going to break at 1:00 p.m. and resident #4 was seated in a wheelchair by the nurse ' s station. CNA #S12 stated that was the last time she saw resident #4. CNA #S12 stated resident #4 was not in the dining room at 5:00 p.m. so she went to let CNA #S14 know resident #4 was not in the dining room. She stated the room to room search was called after that. CNA #S12 stated the room to room search was completed about 5:15 p.m. and 4 CNAs went out the Central hall door and split up left and right to search outside. CNA #S12 stated herself, CNA #S13, and CNA #S14 found resident #4 lying on her right side with the right leg straight, the left leg was bent, and her right arm was stretched out with her head lying on her right arm. CNA #S12 stated she saw resident #4 had blood around her nose and mouth and she noticed a puddle of blood on the ground where she was lying. CNA #S12 stated resident #4 was not breathing and CNA #S14 checked for a pulse on her neck. CNA #S12 stated she used her cell phone and called the ward clerk #S9 and informed her to notify LPN #S5 to get out there now. CNA #S12 stated LPN #S5 arrived out the door almost immediately. CNA #S12 stated LPN #S5 checked for pulse and chest rise. She stated LPN #S5 asked for a towel to wipe off resident #4 ' s face. CNA #S12 stated the blood was dark and had dried some and she assumed resident #4 had been there for awhile. CNA #S12 stated resident #4's skin was ashen in color. CNA #S12 stated they found resident #4 between 5:,[DATE]:45 p.m., EMS was called and when they arrived EMS began CPR and transported resident #4 to the ER. During an interview on [DATE] at 4:15 p.m. CNA #S13 stated on [DATE] she became aware resident #4 was missing between 5:00 p.m. and 5:30 p.m. She stated the room to room search was completed and she went out the laundry door when they went to look outside. CNA #S13 stated she went around the North Hall side and met up with CNA #S12 and CNA #S14. CNA #S13 stated she saw resident #4 lying on the ground on her right side with her right arm out and both legs drawn up and she had some dark brown mucus looking stuff coming out of her nose with blood in it. CNA #S13 stated the blood was dark and had some redness to it. CNA #S13 stated there was an odor that smelled like the resident's foot, which smelled like a bed sore odor. CNA #S13 stated CNA #S12 called on her phone and she beat on the door to get help. CNA #S13 stated the LPN #S5 was there almost immediately and when he arrived LPN #S5 checked to see if resident #4 was breathing by putting his hand on her neck. CNA #S13 stated someone called 911 and when 911 arrived they hooked her up to a lot of equipment. During an interview on [DATE] at 4:40 p.m. CNA #S16 stated she has been back to work here at the facility about 2 weeks. CNA #S16 stated on [DATE] she fed her residents at the desk between 4:00 p.m. and 4:30 p.m. and went down the hall to feed her other residents about 4:45 p.m. and finished feeding about 5:10 p.m. CNA #S16 stated she brought her residents back to their rooms from the dining room and made rounds about 5:30 p.m. CNA #S16 stated she finished her round about 5:55 p.m. and a room to room search was called. She stated she went out the Central hall door and looked outside and came in South hall door and was told they found resident #4. She stated she went back to where resident #4 was and LPN #S5 asked her to go get a towel and LPN #S5 wiped her face off. She stated after giving LPN #S5 the towel she went back inside as 911 was arriving and it was about 6:15 p.m. CNA #S16 stated she did not see resident #4 from the time she clocked in at 2:39 p.m. until resident #4 was found. During an interview on [DATE] at 4:50 p.m. CNA #S17 stated she worked the South hall on [DATE] and about 5:45 p.m. CNA #S14 asked had she seen resident #4 and she said no and did a room to room search. CNA #S17 stated it was around 6:00 p.m. when resident #4 was found outside and she arrived outside. CNA #S17 stated LPN #S5 was at resident #4's side and resident #4 was lying on her right side and both legs were drawn up and arms were folded over. CNA #S17 stated she saw blood coming from resident #4's nose and mouth and it looked like it was mixed with mucus. CNA #S17 stated the blood on the ground was dark brown and about the size of a saucer. CNA #S17 stated she came back inside and told the ward clerk to call 911. CNA #S17 stated it was after 6:00 p.m. when she told the ward clerk to call 911 and it took 911 about 10 minutes to arrive. CNA #S17 stated she opened the side gate for the ambulance to get through and came back in the building. CNA #S17 stated she clocked in at 2:21 p.m. and she did not see resident #4 the entire time she was there until they found her outside. During an interview on [DATE] at 5:00 p.m. CNA #S15 stated she was working on the Central hall on [DATE]. CNA #S15 stated sometime between 5:00 p.m. and 6:00 p.m. a room to room search was done and resident #4 was not found. CNA #S15 stated her and CNA #S16 went out the Central hall door and went south to look for resident #4 and when they came back in the building they were told resident #4 was found. CNA #S15 stated when she went outside the nurses and CNAs were around resident #4. CNA #S15 stated she came back in the building and did not go back outside. During an interview on [DATE] at 5:05 p.m. Ward Clerk #S9 stated on [DATE] CNA #S14 asked her to announce a room to room search and that was around 5:45 p.m. or 5:50 p.m. and she announced a room to room search for a resident. She stated the CNA #S14, CNA #S12, CNA #S16, CNA #S15 and some others stated they were going to do an outside search and about 2 minutes later she was told to call 911 and it was after 6:00 p.m. Ward Clerk #S9 stated it was maybe ,[DATE] minutes when 911 arrived. Ward Clerk #S9 stated she was not aware of what time 911 left with resident #4. Ward Clerk #S9 stated she arrived to work about 4:10 p.m. and did not see resident #4. A tour was made of the facility on [DATE] at 9:45 a.m. to check the door alarms. This surveyor tested all the doors in the facility while the other surveyor remained at the nurses ' station to determine if the alarms activated when the doors were opened. The alarm did not activate when the laundry door was opened. During an interview on [DATE] at 10:10 p.m. Maintenance Supervisor #S10 stated only 3 doors in the facility are key coded for the wander guard alarm and that was the front door, the Northeast door (Ambulance door), and the Southeast door. He stated the alarm will activate if the person wearing the wander guard gets too close and warn staff of the resident trying to leave. When tested , the alarm sounded at approximately 4 feet away from the Southeast door and ,[DATE] feet from the Northeast door. When attempting the front door the alarm did not activate. Maintenance Supervisor #S10 placed the wander guard bracelet directly in front of the sensor and it did not activate. Maintenance Supervisor #S10 opened the front door and once the door was opened the wander guard alarm sounded. During an interview on [DATE] at 10:15 a.m. Ward Clerk #S8 was asked to explain her role at the desk when the wander guard system went off. She stated if a resident with a wander guard goes to the front door, the ambulance door (North Hall East Door), or the South Hall East Door she would hear the alarm that was above her head. Ward Clerk #S8 stated all the other doors are just regular alarms that go off when the door is opened. Ward Clerk #S8 stated she was able to turn off the alarm by pushing a button. She stated the alarm would not start alarming again unless the door was not completely shut. Ward Clerk #S8 stated the button can reset all the regular alarms. She stated there were only 3 doors with wander guard alarms although there are 4 buttons on the box. Ward Clerk #S8 stated 1 of the 4 buttons has never alarmed. Ward Clerk #S8 stated she could not reset the wander guard alarm. Ward Clerk #S8 stated she saw resident #4 on the North Hall around 3:00 p.m. on [DATE] in her wheelchair going away from the Ward Clerk desk. Ward Clerk #S8 stated resident #4 looked weak like she could fall out of her wheelchair. She stated resident #4 had been that way for a couple of weeks. Ward Clerk #S8 stated it was possible that resident #4 went out the laundry door. Ward Clerk #S8 stated she went on break around 2:35 p.m. or 2:40 p.m. and there were several CNAs around the desk. She stated no alarm went off from 3:00 p.m. to 4:30 p.m. Ward Clerk #S8 stated resident #4 got out into the parking lot earlier this year, but she was a fast walker then. She stated resident #4 could have gone out the door and been gone pretty quick. During an interview on [DATE] at 10:30 a.m. Detective #S18 stated she had recovered resident #4's wander guard bracelet from the hospital as evidence. Detective #S18 stated on [DATE] she entered the facility with resident #4's wander guard bracelet in an evidence envelope and when she walked in the front door the alarm did not sound. Detective #S18 stated she was told the alarm probably did not activate because the wander guard bracelet was in an envelope. Detective #S18 stated she removed the wander guard bracelet from the envelope and walked in and out of the facility's front door 5 times. Detective #S18 stated the alarm did not sound when she left the facility's front door using the left and right doors. Detective #S18 further stated when she re-entered the building the alarm did not sound when she entered the right door on 3 occasions, but it did sound the 2 times she entered through the left door. During an interview on [DATE] at 2:30 p.m. LPN #S11 stated on [DATE] resident #4 left through the front door and stated she was going home and was not easily re-directed and walked almost all the way to the street. LPN #S11 stated another resident informed her that resident #4 had left the building and the wander guard alarm did not go off. LPN #S11 stated resident #4 had removed her wander guard bracelet and it appeared to be a straight cut. She stated the incident occurred around lunch. LPN #S11 stated once resident #4 was back in the facility she calmed down, but tried again to leave later that afternoon. LPN #S11 stated CNA #S14 took resident #4 outside and walked around with her to keep her calm. LPN #S11 stated there was no monitoring of resident #4 except for the wander guard. LPN #S11 stated they were checking on resident #4 every 2 hours. LPN #S11 stated she could not remember the date, but she remembered an in-service sometime this year on elopements. During an interview on [DATE] at 2:50 p.m. DON #S2 stated she saw resident #4 twice the morning of [DATE] and once that afternoon at the ward clerk desk around 1:00 p.m. that day. DON #S2 stated if a resident made it out the door it was considered an elopement. DON #S2 stated Social Services are responsible for putting on the wander guards and nursing is responsible for monitoring them. She stated they do not monitor the wander guard batteries because they should last 3 years. DON #S2 stated they monitor the residents with wander guards every 30 minutes, but there was no documentation of the 30 minute rounds. During an interview on [DATE] at 2:55 p.m. DON #S2 was asked why there was no alarm on the laundry door and she stated there was. DON #S2 was informed no alarm sounded when the laundry door was opened. DON #S2 went to the nurses' station and the alarm was turned off at the box where the ward clerk monitors the alarms. DON #S2 instructed Ward Clerk #S8 to turn the alarm on and when she did it continuously beeped. Ward Clerk #S8 stated the door does not close so the alarm beeps constantly and that is why it is turned off. DON #S2 agreed the alarm was not functioning properly on the laundry door when it was turned off or turned on. The Administrator #S1, DON #S2, and ADON #S3 were notified on [DATE] at 4:50 p.m. of the Immediate Jeopardy situation regarding the death of resident #4 and the potential for other residents to elope due to the ineffective wander guard system. Observations on [DATE] from 9:25 a.m. through 9:43 a.m. of the residents with a wander guard bracelet (#'s1,2,3,6,7,8,9) revealed that 7 of the 8 residents had their wander guard bracelets attached to their wheelchairs. None of these residents were observed with their feet elevated while in their wheelchairs. During an interview on [DATE] at 10:05 a.m. Social Service Director (SSD) #S6 stated the wander guard bracelets do not come with manufacturer's recommendation for use, but you can request them if needed. SSD #S6 provided the most recent invoice for the wander guard purchase dated [DATE] for 6 three year adult transmitters and one Instruction Sheet for Transmitter Straps. When asked, SSD #S6 stated she was not able to locate the instruction sheet, but she had given the Administrator the information on Friday ([DATE]). During an interview on [DATE] at 10:10 a.m. the Administrator #S1 stated he did get information on the wander guard on [DATE] from SSD #S6, but he left it at home and would have to go get it. During an interview on [DATE] at 10:45 a.m. the Administrator #S1 stated the cameras located in the facility were not working and had not worked in years. When asked about the wander guard bracelets being placed on the wheelchair, the Administrator #S 1 stated if the resident refused to have it on their body then it would be placed on the wheelchair. When asked, the Administrator #S1 stated he did not know if the 7 residents with wander guard bracelets on their wheelchairs refuse

Based on record reviews and interviews the facility failed to ensure an assessment was completed for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents who were cognitively impaired with a history of wandering out of total sample of 8 residents currently residing in the facility with wander guards in place. The facility failed to: 1. Complete an admission Elopement Risk Assessment on 10/16/09 when resident #4 was admitted to the facility with a known history of wandering/elopement. 2. Complete an Elopement Risk Assessment for resident #4 when she eloped from the facility on 8/31/10. 3. Complete an Elopement Risk Assessment for resident #4 when she eloped from the facility on 3/24/11,twice on 3/26/11. The Immediate Jeopardy began for resident #4 on 3/24/11 when she eloped from the facility and got to the parking lot before staff could get her back inside the facility. The Immediate Jeopardy ended on 7/12/11 at 6:29 p.m. for resident #4 when local Emergency Medical Service (EMS) transported her to a local emergency room (ER) after resident #4 was found outside nursing home with no pulse or respirations. The facility's Administrator #S1, DON #S2, and ADON #S3 were informed of the Immediate Jeopardy on 7/15/11 at 4:50 p.m.. The facility's Plan of Removal was accepted on 7/18/11 at 5:00 p.m. The Immediate Jeopardy was removed on 7/19/11 at 4:00 p.m. when observations and record reviews revealed the Plan of Removal had been implemented and was functioning. The deficient practice continued at a scope and severity of third level pattern. Findings: 1. Review of the medical record for resident #4 revealed a Nurses's Notes dated 10/16/09 (resident #4's admission note) at 3:30 p.m. revealed the following entry: She is a fall risk and will wander off if not monitored closely. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 on admission. 2. Review of the medical record for resident #4 revealed an Incident Report Nurses Note dated 8/31/10 at 4:20 p.m. with the following entry: Resident had left facility and was walking down (name of street). Resident was picked up at the bank and brought back to the facility. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 after her elopement from the facility on 8/31/10. 3. Review of the Nurse's Notes dated 3/24/11 revealed an entry at 9:30 p.m.- Resident went to bed at 7 PM; after getting out the front door and into the parking lot. Review of a Nurse's Note dated 3/26/11 revealed an entry at 11:00 a.m.- Resident exit the building attempting to leave facility. Writer and 2 other nurses tried to re-direct her back in building and resident cursed at writer. Resident started to walk faster out to the road (name of street). Writer knew it would not be safe and called resident's daughter who could not re-direct her either. The Floor Tech was able to re-direct resident back in building. Resident appears to be very anxious and agitated. Review of the 3/26/11 Nurse's Note revealed an entry at 12:30 p.m. resident back out of facility. Dietary worker was able to re-direct her fairly easily. RN put together another wander guard, but the resident refused to keep it on. Review of the medical record for resident #4 did not reveal an elopement risk assessment had been completed for resident #4 after her elopements from the facility on 3/24/11 or 3/26/11. Review of the medical record for resident #4 did not reveal she had been assessed to determine the cause of resident #4's elopements. During an interview on 7/18/11 at 2:30 p.m. DON #S2 reviewed resident #4's medical record and was unable find the Elopement Risk Assessments for 10/16/09, 8/31/10, 3/24/11, or 3/26/11. DON #S2 stated resident #4's elopement risk assessments should have been completed and agreed they had not been done. The facility ' s Plan of Removal is documented as follows: 1. Each resident wearing a Wander-guard ankle bracelet will be monitored and checked each 30 minutes. A monitoring log has been implemented beginning July 16, 2011. The log will be individualized for each 24 hour periods. The day Charge Nurse will begin the monitoring cycle by providing the resident ' s sheet to the appropriate CNA. The CNA will visualize the resident, log the visualization and return the form to the Charge Nurse at the end of each shift. The Charge Nurse on the subsequent shifts will follow this procedure to provide the forms to the appropriate CNA. At the end of the 24 hour cycle, the Charge Nurse will turn the Monitoring form in to the Director of Nurses. This form will be made part of the resident ' s permanent record. 2. The facility will maintain a log at the Ward Clerk station to monitor alarm activations. The log will identify the door alarmed, the time, reason for alarm, and the responder. This will insure that the alarm is responded to in a timely manner and will insure that an employee is physically checking the door to insure that no resident has exited the door. This will be re-evaluated after the new door locking system is installed. 3. Facility has initiated a daily Sensor check to insure the sensor will initiate the alarm sounding. The Social Service Designee will be responsible for checking each sensor on a daily schedule. The Social Service Director will test each sensor not being used by a resident, by passing the sensor near the door sensors. The results will be documented on a monthly calendar showing the result of each numbered sensor being checked. This is in accordance with the manufacturer ' s recommendation. 4. The sensor on each resident will be checked daily by the CNA responsible for the resident. The documentation will be kept on the 30 minute Census Check. Each shift will verify that the sensor is in place at the beginning of the shift and document such on the daily Census Check Sheet. The 6:30 a.m. to 2:30 p.m. CNA will check the sensor to insure it is working properly by manually carrying the resident to an alarmed door and testing to insure the alarm is activated. Transmitters will be placed on the ankle of the resident unless the resident meets the manufacturer ' s requirements for placing on a wheelchair. This will be re-evaluated after the new system is installed. 5. The Maintenance person will also make weekly checks of all alarmed doors to insure that the alarm systems are functioning properly. These checks will be maintained on a weekly log. 6. Nursing staff will complete an Incident/Accident report on all occasions in which a resident attempts elopement. 7. The facility will provide in-service training on the systems put into effect. Staff will be in-serviced on the following: a. Increased monitoring of the Wander guards b. Completion of Incident/Accident reports on all elopements c. Elopement procedures d. Responding to alarms, both keypad and regular door e. CNA documentation of 30 minute Census Checks f. Door monitoring of alarms at the Ward Clerk station Additional actions, which the facility will take to insure compliance, are: 1. The service repair person has been called to check and replace any defective door alarms (completed 7/16/11). 2. The facility will replace all current door alarms with the magnetic locks. These will be placed on all exit doors. This procedure must be approved by the State Fire Marshal's Office. The facility will provide a document stating that the system installed upon approval of the Fire Marshall. 3. The facility is attaining bid proposals to install a camera monitoring system in the facility.