Every finding on record at South Shore Health & Rehabilitation Center

Based on observation and interview, the facility failed to maintain comfortable and safe temperature levels for 1 of 4 Units (500 Unit), where 22 residents resided.Finding includes:During the initial tour of the 500 Unit on 5/18/26 at 9:25 a.m., the hallway and resident rooms were very warm and humid. Resident G indicated it was warm.During an interview with the Maintenance Director on 5/18/26 at 9:55 a.m., he was on the phone with Corporate Maintenance and indicated the Heating/Cooling Company had been notified on 5/15/26 and were scheduled to come to the facility on 5/19/26 to change from the boiler to the chiller. He indicated the outside temperatures were cool at night, so the change over had not been completed.During an interview on 5/18/26 at 10:02 a.m., Resident F informed the Maintenance Director it was hot in his room. The Maintenance Director indicated he would go and obtain a thermometer to monitor the room temperatures.A wall thermometer outside of room [ROOM NUMBER] indicated the hallway temperature was 82.During observations on 5/29/26 at 10:41 a.m. through 10:50 a.m., the Maintenance Director obtain the temperatures in the following rooms:The temperature in room [ROOM NUMBER] was 82.2. Residents H and J indicated their room was warm.The temperature in room [ROOM NUMBER] was 82.2.The temperature in room [ROOM NUMBER] was 81.6. Resident K indicated it was quite warm in the room.The temperature in room [ROOM NUMBER] was 81.5.The temperature in room [ROOM NUMBER] was 81.6.The temperature in room [ROOM NUMBER] was 81.2.The temperature in room [ROOM NUMBER] was 81.6.During an interview on 5/18/26 at 12:26 p.m., Resident G indicated it had been warm in her room for the past three days.A facility maintenance policy for a safe and homelike environment, dated 4/9/23 and received from the Director of Nursing as current, indicated temperatures should be in relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. The facility would maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit.IAC (Indiana Administrative Code) 16.1-3.1-19(h)

Based on record review and interview, the facility failed to assess a resident with a change of condition before transfer and did not accurately document vital signs for 1 of 3 residents reviewed for change of condition. (Resident C)Finding includes:The record for Resident C was reviewed on 2/17/26 at 11:40 a.m. Diagnoses included, but were not limited to, kidney failure, heart failure, epilepsy, COPD, and diabetes.The 1/30/26 Medicare 5-day Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making and was dependent with all Activities of Daily Living (ADLs) and transfers.A Situation, Background, Assessment, Recommendation (SBAR) was completed on 1/16/26, the documented reported the resident was being transferred out for a low hemoglobin. There were no vital signs or assessments listed in the SBAR except for the previous weight on 1/14/26.A Nurse's Note, dated 1/16/26 at 12:03 p.m., indicated an order was received to send the resident to the hospital for evaluation related to abnormal hemoglobin level of 6.5.A Nurse's Note, dated 1/16/26 at 8:53 p.m., indicated the resident was sent out on the previous shift for low hemoglobin and they were awaiting an update.Vital signs were documented at 8:17 a.m. and at 3:17 p.m. on 1/16/26.The record lacked documentation indicating when the resident was transferred out.A Nurse's Note, dated 1/17/26 at 10:41 a.m., indicated the resident was admitted to the hospital for a hemoglobin of 6.2 and received a blood transfusion.During an interview on 2/17/26 at 12:31 p.m., the Director of Nursing (DON) indicated the resident was removed from the census at 12:17 p.m. on 1/16/26. Vitals were again documented at 11:00 a.m., after post dialysis. These vitals were obtained before the order was received to send the resident out for evaluation. The vitals that were recorded as checked at 3:17 p.m. had been documented hours after the resident had left the facility. There was no nursing documentation completed to determine what time Resident C had left the facility, they could only go by the census. The DON agreed the SBAR should have been completed entirely with an assessment and vitals at the time of transfer.This citation relates to Intake 2738628.3.1-37(a)

Based on observation, record review and interview, the facility failed to maintain a sanitary kitchen related to a low temperature chemical dishwasher not sanitizing properly. This had the potential to affect all 70 residents who received meals prepared in the kitchen. (Main Kitchen)Finding includes:On 9/15/25 at 9:00 a.m. the initial kitchen tour was completed with the Dietary Manager (DM). The DM indicated they used a chemical dishwasher, but it was not working properly at the time, and the company was coming out to service it on Friday. He obtained a test strip and dipped it into the dishwasher water. It did not register any parts per million of sanitizing solution. Dietary Aide 1 indicated she had put bleach in a bucket of water in the sink to sanitize the dishes. The DM indicated that was not the correct way to sanitize dishes. During an interview on 9/16/25 at 10:29 a.m., the DM indicated he had educated the kitchen staff to use sanitizing solution in the sink to sanitize the dishes until the dishwasher was fixed. The current policy, Warewashing, indicated, All dishware, serviceware and utensils will be cleaned and sanitized after each use. 1. The Dining Service staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure pureed food was prepared correctly. This had the potential to affect all 8 residents who received pureed food from the kitchen. (Main Kitchen)Finding includes: On 9/18/25 at 11:30 a.m., the [NAME] was observed preparing pureed food for lunch. He indicated there were eight residents who received pureed food, and he was preparing ten servings so there would be extra. He scooped out 4 large serving spoons of turkey pot pie and placed it in the blender and started to puree. He had a 4-quart pitcher of hot water to which he added a scoop of chicken stock and mixed in. He then poured approximately a quart of the chicken broth into the blender. He indicated he added about a cup of broth. He then added 10 scoops of food thickener, another one half to one quart of chicken broth, then another 5 scoops of thickener. The recipe for pureed turkey pot was on the counter next to the blender. The recipe indicated to make 10 servings as follows:10 servings each 3 oz protein 1 1/4 cup chicken brothDuring an interview with the [NAME] at that time, he indicated he added extra broth to extend the recipe in case they wanted seconds.During an interview on 9/18/25 at 11:50 a.m., the Dietary Manager indicated he would re-educate the [NAME] on how to make pureed food. 3.1-21(a)(3)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to marred walls and doors, dirty and discolored floor tiles, missing baseboards, stained ceiling tiles, and missing hooks from privacy curtains for 2 of 4 units throughout the facility. (Units 4 and 5) Findings include: During the environmental tour with the Director of Nursing and the Corporate Nurse Consultant on 9/22/25 at 1:35 p.m., the following was observed: 1. Unit 4a. The entry door to room [ROOM NUMBER] had chipped paint and was marred at the base. The cove base located next to bed A was missing along the side of the wall. The privacy curtains for both beds A and B had hooks missing. Two residents resided in the room. 2. Unit 5 a. The walls located next to the bed and the foot of the bed in room [ROOM NUMBER] were scratched and marred. One resident resided in the room. b. The wall next to bed B in room [ROOM NUMBER] was scratched and marred. The ceiling tile located above the heat register was discolored and bulging, and the tile floor throughout the room was scuffed and marred. Two residents resided in the room. c. The wall next to the head of bed B in room [ROOM NUMBER] was scratched and marred. The floor tile in the bathroom had an accumulation of dirt along the baseboard. Two residents resided in the room and four residents shared the bathroom. During an interview at that time, the Director of Nursing indicated she would relay the above concerns to the Maintenance Director. 3.1-19(f)

Based on record review and interview, the facility failed to ensure the physician was notified timely of residents not receiving medications as ordered for 2 of 6 residents reviewed for unnecessary medications. (Residents C and B)Findings include:1. The closed record for Resident C was reviewed on 9/17/25 at 10:55 a.m. Diagnoses included, but were not limited to, left below the knee amputation (BKA), diabetes, hypertension, pressure ulcers of the hip and buttock, and heart failure.The 7/29/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and was dependent for activities of daily living (ADLs) and transfers.The resident was admitted to the facility on [DATE] following a hospitalization related to the left BKA surgery. At that time, the resident had a unstageable pressure ulcers to the right thigh and buttock as well as a dehisced (reopened surgical incision) wound to the left leg stump. An 8/5/25 Skin/Wound Note indicated the wound to the right thigh was odorous and had purulent (pus) drainage. An 8/8/25 Progress Note indicated the wound doctor assessed the resident's pressure ulcers and ordered Flagyl (an antibiotic) 500 mg intravenously (IV) every 8 hours for 7 days for the wound infection.An 8/9/25 Nurse's Note indicated the Flagyl was not available, and they were awaiting its delivery from the pharmacy.The August 2025 Medication Administration Record (MAR) indicated the resident did not receive any doses of the Flagyl. The record lacked documentation that the physician was notified that the resident did not receive the Flagyl as ordered.During an interview on 9/18/25 at 10:25 a.m., the Infection Preventionist indicated if an antibiotic was not started as ordered, the nurse should have notified the physician and documented it, but she did not see that had been done.During an interview on 9/19/25 at 10:40 a.m., the wound doctor indicated he would expect the IV antibiotic to be started the day it was ordered, and that he was not informed that the resident did not receive the Flagyl until after 8/14/25.During an interview on 9/19/25 at 2:30 p.m., the DON and Corporate Nurse 1 were informed of the findings. Both indicated they did not know why the Flagyl was not administered to the resident. No further information was received. 2. The record for Resident B was reviewed on 9/19/25 at 9:04 a.m. Diagnoses included, but were not limited to, Alzheimer's, diabetes, and COVID-19.The 8/8/25 Annual Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required substantial assistance with Activities of Daily Living (ADLs), and was independent with transfers.The Physician's Order Summary indicated a Covid test and stat chest x-ray were ordered on 8/6/25 at 10:30 a.m. for shortness of breath. On 8/6/25 at 12:40 p.m., the resident tested positive for Covid.A Nurse's Note, dated 8/7/25 at 2:12 p.m., indicated the resident had wheezing and shortness of breath on exertion. New orders were received including Paxlovid (an oral antiviral medication for treating Covid-19 in patients who are at high risk of the disease progressing to a more severe illness) twice a day for 5 days.The August Medication Administration Record (MAR) indicated the resident only received 3 of the 10 scheduled doses of Paxlovid. A Nurse's Note, dated 8/10/25 at 6:43 p.m., indicated the Paxlovid had not yet arrived, and the nurse manager was made aware. The record lacked documentation that the physician was notified that the resident did not receive the Paxlovid as ordered.During an interview on 9/19/25 at 2:30 p.m., the DON and Corporate Nurse 1 indicated the nurse should have notified the physician that the resident did not receive the medication as prescribed and documented the notification in the resident's record.A policy titled, Notification of Changes, received as current from the DON on 8/19/25 at 2:58 p.m. indicated, . The facility must . consult the resident's physician . when there is a change requiring such notification . Circumstances requiring notification include: . a need to alter a treatment.3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure a resident was fully informed of risks and benefits of a psychotropic medication prior to initiating the medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 11)Finding includes:Resident 11's record was reviewed on 9/17/25 at 1:26 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, renal disease, generalized anxiety disorder and major depression. The admission Minimum Data Set assessment, dated 7/28/25, indicated the resident had severe cognitive deficits and was dependent for bed mobility, transfers and toileting. Physician's Orders, dated 7/22/25, indicated to give alprazolam (an antianxiety medication) 0.5 milligrams (mgs) three times daily for anxiety and quetiapine fumarate (an antipsychotic) 25 mgs, two tablets twice daily for psychotic disorder with delusions. A Nursing Progress Note, dated 7/25/25, indicated the psychiatric Nurse Practitioner had ordered sertraline (an antidepressant) 50 mgs daily.A Psychotropic Consent assessment was completed on 8/13/25 for alprazolam, quetiapine and sertraline and signed by the Social Service Director. It was not signed by the resident or his representative. There was no documentation in the resident's record indicating the resident or representative had been informed about the medication's risks and benefits.During an interview on 9/22/25 at 1:59 p.m., the Director of Nursing indicated she was aware the consent had not been signed by the resident representative. There was no additional information provided. 3.1-3(n)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 24)Finding includes: During a random observation on 9/15/25 at 11:36 a.m., an Albuterol inhaler was observed at Resident 24's bedside. During an interview at that time, the resident indicated he used the inhaler as needed (PRN) and at times he did his own nebulizer treatments. During random observations on 9/16/25 at 9:26 a.m. and 9/17/25 at 8:54 a.m., the inhaler was observed on the resident's bedside table. The resident shared the room with two other residents. The record for Resident 24 was reviewed on 9/17/25 at 2:25 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and hypertension. The 8/31/25 Medicare 5-Day Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 6/7/24 and identified as current, indicated the resident chooses to administer his inhaler. Interventions included, but were not limited to, educate the resident on the order for inhaler use, time and dosage, along with proper storage of the medication, lock box in resident's room for storage of the inhaler, and routine self-administration evaluation.Physician's Orders, dated 8/24/25, indicated the resident was to receive the Albuterol Sulfate 108 (90 base) microgram (mcg) inhaler, 2 puffs every 4 hours as needed PRN for COPD and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml) 3 ml inhale orally every 6 hours via nebulizer while awake for COPD. There was no order to self-administer either medication. A Self-Administration of Medication assessment, dated 6/7/24, indicated the resident could administer his Breztri inhaler and the medication had to be kept in the lock box in the resident's room. There was no current Self-Administration of Medication assessment available for review. During an interview on 9/17/25 at 8:58 a.m., LPN 1 indicated the resident administered his inhaler by himself. During an interview on 9/17/25 at 2:00 p.m., the Director of Nursing indicated she was not sure how often the self-administration of medication assessment was to be completed and she would check the facility's policy. The current facility policy titled Self-Administration of Medications and Treatments was provided by the Director of Nursing on 9/18/25 at 8:56 a.m. The policy indicated a physician's order would be obtained specifying the resident's ability to self-administer medications and/or treatments and, if necessary, listing which medications and treatments would be included in the self administration plan, storage of self-administered medications or treatments would comply with state and federal regulations. All bedside medications would be maintained in a secure location in the resident's room. The resident would also be assessed for continued self-administration of medications and/or treatments quarterly and with any significant change of condition. 3.1-11(a)

Based on observation, record review and interview, the facility failed to maintain a resident's dignity related to wearing a hospital gown during the day and leaving a resident exposed for 1 of 1 resident reviewed for dignity. (Resident 64)Finding includes:During a random observation on 9/16/25 at 10:29 a.m., CNA 2 and CNA 3 were observed bathing Resident 64. The resident was left undressed and exposed throughout the bath.During random observations at the following times, the resident was observed wearing a hospital gown: 9/16/25 at 10:30 a.m., 9/17/2025 at 9:01 a.m., 9/18/25 at 9:39 a.m. and 2:34 p.m., and 9/19/25 at 10:50 a.m.The record for Resident 64 was reviewed on 9/18/2025 at 12:52 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, hemiplegia (paralysis on one side of the body) following a stroke, and gastrostomy status.The 7/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, and was dependent for activities of daily living (ADLs) and transfers. The record lacked a care plan for the resident wearing a hospital gown during the day.During an interview on 9/19/25 at 2:30 p.m., the Director of Nursing (DON) and Corporate Nurse 1 indicated the aides should have kept the resident covered during the bath, only uncovering what was being washed. When informed of the resident wearing a hospital gown during the day without a care plan indicating it was her preference, no additional information was received.A policy titled, Dignity, received as current from the DON on 8/19/25 at 2:58 p.m. indicated, .When assisting with care, residents are supported in exercising their rights. For example, residents are: . encouraged to dress in clothing that they prefer .Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care .3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to CNAs stopping and starting tube feedings for 1 of 5 residents reviewed for tube feedings. (Resident 64)Finding includes:During a random observation on 9/16/25 at 10:29 a.m., CNA 2 and CNA 3 were observed bathing Resident 64. The resident had a gastrostomy tube (a feeding tube inserted through the abdomen), connected to a tube feeding pump. The feeding pump was paused while the resident was lying flat. When the feeding pump started beeping, CNA 3 pushed buttons on the pump. When the bath was completed and the head of the bed was elevated, CNA 3 started the tube feeding pump.During an interview at that time, CNA 2 and CNA 3 indicated they had stopped the tube feeding before lying the resident flat, and re-started it after the head of the bed was elevated. CNA 3 demonstrated which buttons they pushed to stop and start the feedings. The record for Resident 64 was reviewed on 9/18/2025 at 12:52 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, hemiplegia (paralysis on one side of the body) following a stroke, and gastrostomy status.The 7/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent for activities of daily living (ADLs) and transfers. A 9/1/25 Physician's Order indicated enteral feeding (tube feeding) of Jevity 1.2 (a tube feeding forumla) at 50ml/hr (milliliters per hour) for 20 hours; on at 5:00 p.m., off at 1:00 p.m.During an interview on 9/19/25 at 2:30 p.m., the Director of Nursing (DON) indicated the CNAs should not stop or start the tube feedings, but should be getting a nurse to do it. The Indiana State Department of Health Nurse Aide Curriculum, created July 1998 and revised November 19, 2015, indicated, . The resident with a feeding infusing should not lie flat. The head of the bed should be elevated at least 30 . Some procedures will need to be changed slightly for the resident with a feeding tube. For example, an occupied bed cannot be flattened to change the linen or to provide incontinence care with the feeding infusing. If the bed must be flattened, seek the nurse's assistance to turn off the pump prior to the procedure and turn the pump back on after the procedure. Your major responsibility concerning the resident with a feeding tube is to make regular observations and promptly report any problem .3.1-35(g)(1)

Based on observation, record review and interview, the facility failed to provide ongoing activities for dependent residents for 3 of 3 residents reviewed for activities. (Residents 14, 35 and 44)Findings include: 1. Resident 14 was observed in her bed on 9/15/25 at 11:45 a.m. and 3:00 p.m., 9/16/25 at 10:36 a.m., 1:55 p.m. and 3:49 p.m., and on 9/17/25 at 9:13 a.m., 1:21 p.m. and 3:24 p.m. There was no radio or television on in the room. On 9/18/25 at 9:26 a.m., the resident was up in her chair yelling out nonsensically, there was no radio or television on in the room. At 9:57 a.m. a staff member was in the resident's room attempting to calm her and had turned the radio on. The resident's record was reviewed on 9/18/25 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, severe protein calorie malnutrition and adult failure to thrive. The Annual Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had severe cognitive impairment and was dependent for bed mobility, toileting and transfers. An Activity Care Plan, dated 12/11/24, indicated, [Resident's name] enjoys television, may require an optimal amount of sensory as well as cognitive stimulation . During an interview on 9/18/25 at 9:50 a.m., the Activity Director indicated an activity aide would visit the resident three times a week for a one-on-one visit that normally lasted about 15 minutes. She indicated the radio or television should be on for the resident and that normally the nursing staff did that. 2. Resident 35 was observed in her bed on 9/15/25 at 11:45 a.m. and 3:00 p.m., 9/16/25 at 10:36 a.m., 1:55 p.m. and 3:49 p.m., and 9/17/25 at 9:13 a.m., 1:21 p.m. and 3:24 p.m. There was no radio or television on in the room. On 9/18/25 at 9:26 a.m. the resident's roommate was yelling loudly next to her, there was no television or radio on in the room. The resident's record was reviewed on 9/18/25 at 9:45 a.m. Diagnoses included, but were not limited to, cerebral palsy, epilepsy and visual loss. The Annual MDS assessment, dated 7/24/25, indicated the resident had severe cognitive impairment and was dependent for bed mobility, toileting and transfers. A Care Plan, dated 7/10/24, indicated the resident cannot express her care needs and requires assistance with daily needs. Interventions were to provide one-on-one activities, talk/read to her and provide music. During an interview on 9/18/25 at 9:50 a.m., the Activity Director indicated an activity aide would visit the resident three times a week for a one-on-one visit that normally lasted about 15 minutes. She indicated the radio, or television should be on for the resident and that normally the nursing staff did that. During an interview on 9/18/25 at 11:11 a.m., the Director of Nursing was made aware of the lack of activities or sensory stimulation for Residents 14 and 35, there was no additional information provided. 3. During the following random observations, Resident 44 was observed lying in bed, awake, without television, music, or staff interaction: 9/15/25 at 11:36 a.m., 9/16/25 at 9:34 and 10:25 a.m., 9/17/25 at 8:56 a.m. and 1:50 p.m., and 9/18/25 at 9:31 a.m. The resident's record was reviewed on 9/17/25 at 3:04 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) following a stroke affecting the left side, seizures, and dementia. The 7/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs) and transfers. The 4/3/25 Quarterly / Annual Activities Participation Review indicated the resident enjoyed self-directed leisure time activities, participated in sensory stimulation activities, and would listen to music. An Activities Care Plan, identified as current, indicated the resident was on a one-to-one sensory stimulation goal for activities through the next review date. A review of the one-to-one visits report form indicated the resident did not receive 3 one-to-one visits for the week of 9/7/25 to 9/13/25. During an interview on 9/18/25 at 2:17 p.m., the Activities Director indicated the resident should get one-on-one visits three times a week and she was looking into getting more televisions and radios for stimulation. 3.1-33(a)

Based on record review and interview, the facility failed to ensure blood pressure medications were administered and/or held per parameters as ordered. The facility also failed to ensure medications were administered as ordered and laboratory tests were obtained for 3 of 7 residents reviewed for unnecessary medications. (Residents F, E, and D)Findings include: 1. The record for Resident F was reviewed on 9/18/25 at 11:42 a.m. Diagnoses included, but were not limited to, end stage renal disease, hypotension (low blood pressure), and hypertension. The 8/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and he was receiving dialysis while a resident of the facility. A Care Plan, reviewed on 8/22/25, indicated the resident had hypotension with episodes of syncope (fainting) related to dialysis. Interventions included, but were not limited to, administer medications per physician's order. A Physician's Order, dated 8/21/25, indicated the resident was to receive Midodrine HCl (a medication used to treat low blood pressure) 5 milligrams three times a day. The medication was to be held for systolic blood pressure (top number) less/greater than 110 or heart rate less than 60. The August 2025 Medication Administration Record (MAR), indicated the resident received the Midodrine on the following dates and times: 8/23/25 at 9:00 a.m. blood pressure 136/92 8/23/25 at 2:00 p.m. blood pressure 117/78 8/27/25 at 2:00 p.m. blood pressure 127/76 8/21/25 at 9:00 p.m. blood pressure 122/68 8/24/25 at 9:00 p.m. blood pressure 132/68 8/25/25 at 9:00 p.m. blood pressure 115/68 8/26/25 at 9:00 p.m. blood pressure 132/68 8/31/25 at 9:00 p.m. blood pressure 141/71 The September 2025 MAR, indicated the resident received the Midodrine on the following dates and times: 9/12/25 at 9:00 a.m. blood pressure 117/68 9/18/25 at 9:00 a.m. blood pressure 92/62 (the medication was held) 9/4/25 at 2:00 p.m. blood pressure 139/93 9/4/25 at 9:00 p.m. blood pressure 131/79 9/6/25 at 9:00 p.m. blood pressure 135/78 9/9/25 at 9:00 p.m. blood pressure 121/72 9/10/25 at 9:00 p.m. blood pressure 148/80 9/14/25 at 9:00 p.m. blood pressure 119/76 9/16/25 at 9:00 p.m. blood pressure 119/70 9/17/25 at 9:00 p.m. blood pressure 115/65 9/18/25 at 9:00 p.m. blood pressure 121/71 During an interview on 9/19/25 at 2:40 p.m., the Director of Nursing indicated the medication order needed to be clarified. 2. The record for Resident E was reviewed on 9/17/25 at 9:49 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertensive heart disease, and hypotension (low blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. A Physician's Order, dated 6/7/24 and listed as current on the September 2025 Physician's Order Summary (POS), indicated the resident was to receive Lisinopril (a blood pressure medication) 10 milligrams (mg) one time daily. The medication was to be held if the resident's blood pressure was less than 100/60. The July 2025 Medication Administration Record (MAR) indicated the resident received the Lisinopril on the following dates and time when her blood pressure was less than 100/60: 7/5/25 at 9:00 a.m. blood pressure 110/59 7/7/25 at 9:00 a.m., blood pressure 110/56 7/10/25 at 9:00 a.m. blood pressure 100/56 7/11/25 at 9:00 a.m. blood pressure 100/56 7/14/25 at 9:00 a.m. blood pressure 108/56 The August 2025 MAR indicated the resident received the Lisinopril on the following dates and time when her blood pressure was less than 100/60: 8/11/25 at 9:00 a.m. blood pressure 89/46 The September 2025 MAR indicated the resident received the Lisinopril on the following dates and time when her blood pressure was less than 100/60: 9/10/25 at 9:00 a.m. blood pressure 103/58 9/12/25 at 9:00 a.m. blood pressure 107/54 A Physician's Order, dated 8/5/24 and listed as current on the September 2025 POS, indicated the resident was to receive Midodrine HCl (a medication for low blood pressure) 10 milligrams (mg) every 8 hours as needed (PRN) for hypotension. Give when systolic blood pressure (top number) was less than 90. The July, August, and September 2025 Medication Administration Records (MARs) indicated the resident's blood pressure was monitored once a day rather than every 8 hours. The July 2025 MAR indicated on 7/30/25 at 9:00 a.m., the resident's blood pressure was 79/55. The resident did not receive the PRN Midodrine. The August 2025 MAR indicated on 8/20/25 at 9:00 a.m., the resident's blood pressure was 83/60. The resident did not receive the PRN Midodrine. During an interview on 9/19/25 at 2:40 p.m., the Director of Nursing indicated the resident should have received the Midodrine as ordered and a clarification order for the Lisinopril should have been obtained. 3. Resident D's record was reviewed on 9/18/25 at 3:07 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction, diabetes mellitus, and atrial fibrillation. The Quarterly MDS, dated [DATE], indicated the resident had moderate cognitive impairment and was dependent for toileting and transfers. A complete blood count (CBC) and comprehensive metabolic panel (CMP) lab tests were completed on 4/28/25. There were handwritten orders at the bottom of the lab results that indicated to repeat the labs in one week and to give potassium 40 milliequivalents x 1. There were no orders for the repeat lab or the potassium entered into the electronic record. There was no indication the repeat lab had been completed in one week or the potassium had been given as ordered. During an interview on 9/22/25 at 1:59 p.m., the Director of Nursing indicated the repeat lab had not been done and the potassium had not been given. This citation relates to Intake 2597285. 3.1-37(a)

Based on record review and interview, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase or prevent further decrease in range of motion for 2 of 4 residents reviewed for mobility. (Residents 44 and B)Findings include:1. During a random observation on 9/16/25 at 9:05 a.m., Resident 44 was observed lying in bed. He did not move his left arm or leg. His left knee appeared contracted. There was no visible intervention in place for the immobile limbs. The resident's record was reviewed on 9/17/25 at 3:04 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) following a stroke affecting the left side, seizures, and dementia.The 7/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs) and transfers.A 6/14/23 Physician's Order indicated the resident was to participate in the restorative care program.A Restorative Care Plan, updated 7/31/25, indicated the resident required assistance with bed mobility and had range of motion (ROM) limitations. Interventions included a splint program to prevent further contracture of the left knee, and passive range of motion exercises.A 7/31/25 Restorative Nursing Note (the last restorative note in the record) indicated the resident's goals were not met, and they would continue the restorative program.The record lacked documentation of ROM exercises or a brace program being implemented since 7/31/25.During an interview on 9/22/25, LPN 2 indicated there had not been a restorative program for a couple of months because they could not staff it. During an interview on 9/22/25, at 2:30 p.m., the DON indicated they planned to resume the restorative care program when they could get enough staff hired and trained.2. During a random observation on 9/15/25 at 3:28 p.m., Resident B was observed sitting in his wheelchair. He did not move his right arm, and he had a carrot splint in his right hand. The record for Resident B was reviewed on 9/19/25 at 9:04 a.m. Diagnoses included, but were not limited to, fractures of the left tibia (shinbone) and left clavicle (collarbone), Alzheimer's, and repeated falls. The 8/8/25 Annual Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required substantial assistance with Activities of Daily Living (ADLs).A 3/3/25 Physician's Order indicated the resident was to participate in the restorative care program.A Restorative Care Plan, updated 5/21/25, indicated the resident required active ROM exercises 5 days a week and participation in a walking program.A 5/21/25 Restorative Nursing Note (the last restorative note in the record) indicated the active ROM and walking programs were recommended to continue. The record lacked documentation of active ROM exercises or a walking program implemented since 5/21/25.During an interview on 9/22/25, LPN 2 indicated there had not been a restorative program for a couple of months because they could not staff it. During an interview on 9/22/25, at 2:30 p.m., the DON indicated they planned to resume the restorative care program when they could get enough staff hired and trained.3.1-42(a)(2)

Based on observation, record review and interview, the facility failed to ensure tube feedings were infusing at the correct times and/or the head of the bed was elevated while tube feeding was infusing for 3 of 5 residents reviewed for tube feeding. (Residents 14, 9 and 64)Findings include:1. Resident 14 was observed in bed on 9/16/25 at 10:36 a.m., there was no tube feeding hanging or infusing at that time. On 9/18/25 at 9:26 a.m. and 11:04 a.m., the resident was observed in her chair in her room, there was no tube feeding hanging or infusing. The resident's record was reviewed on 9/18/25 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, severe protein calorie malnutrition and adult failure to thrive. The Annual Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had severe cognitive impairment and was dependent for bed mobility, toileting and transfers. The Physician's Order indicated to give Jevity 1.2 (a type of tube feeding) continuously at 50 milliliters per hour for 18 hours a day. The September 2025 Medication Administration Record indicated the tube feeding was to be turned on at 6:00 p.m. daily and turned off at 1 p.m. During an interview on 9/18/25 at 11:06 a.m., RN 2 indicated the tube feeding should be on until 1 p.m. The previous nurse had taken it off early, she did not know why, and she had not restarted it. During an interview o 9/18/25 at 11:11 a.m., the Director of Nursing was made aware the tube feeding was not infusing as ordered. There was no additional information provided. 2. During a random observation on 9/15/25 at 10:15 a.m., Resident 9 was observed lying in bed. The head of the bed was up less than 30 degrees. A tube feeding was infusing via a pump. At 10:28 a.m., CNA 1 entered the room, put the head of the bed flat, and proceeded to clean the resident and change his disposable brief. The tube feeding continued to infuse. When asked, CNA 1 indicated sometimes she stopped the feeding pump before lying the resident flat and sometimes she did not. The head of the bed was immediately raised and the nurse brought in to assess the resident with no issues noted. The resident's record was reviewed on 9/16/25 at 2:12 PM. Diagnoses included, but were not limited to, dementia, Alzheimer's, and dysphagia (difficulty swallowing). The 8/15/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent in ADLs, and required maximal assistance with transfers. An 8/11/25 Physician's Order indicated to elevate the head of the bed 30 to 45 degrees at all times with tube feeding, every shift. On 9/15/25 at 10:40 a.m., RN 1 indicated the head of the bed should be up 45 degrees while the tube feeding was infusing and should be stopped when the resident was flat for turning or repositioning. During an interview on 9/17/25 at 2:00 p.m., the Director of Nursing (DON) indicated the CNAs should get a nurse to stop the tube feeding when they need to put the head of the bed down. 3. During random observations on 9/18/25 at 9:39 a.m. and 12:00 p.m., there was no tube feeding hanging or infusing for Resident 64. The record for Resident 64 was reviewed on 9/18/2025 at 12:52 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, hemiplegia (paralysis on one side of the body) following a stroke, and gastrostomy status. The 7/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs) and transfers. A 9/1/25 Physician's Orders indicated enteral feeding (tube feeding) of Jevity 1.2 (a tube feeding forumla) at 50ml/hr (milliliters per hour) for 20 hours; on at 5:00 p.m., off at 1:00 p.m. A 3/20/25 Care Plan indicated the resident had a nutritional problem related to requiring enteral nutrition (tube feeding). Interventions included to provide enteral nutrition formula, rate and fluid flushes as ordered. During an interview on 9/18/25 at 12:00 p.m., RN 2 indicated the tube feeding should have been infusing, but the midnight nurse must have taken the feeding down too early. During an interview on 9/18/25 at 2:30 p.m, the Director of Nursing (DON) indicated the tube feeding should have been infusing as per order. 3.1-44(a)(1)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 2 of 3 residents reviewed for respiratory care. (Residents 12 and 24)Findings include:1. During a random observation on 9/15/25 at 2:34 p.m., Resident 12 was observed in his room in bed. The resident had oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 8 liters. On 9/16/25 at 9:15 a.m., 11:50 a.m., 2:04 p.m., and 3:45 p.m., the resident was observed in his room in bed. Oxygen via nasal cannula was in use and the oxygen concentrator was set at 8 liters. The record for Resident 12 was reviewed on 9/18/25 at 3:32 p.m. Diagnoses included, but were not limited to, pleural effusion (a collection of fluid around the lungs), heart failure, and anxiety. The 5 day Medicare Minimum Data Set (MDS) assessment, dated 9/5/25, indicated the resident was cognitively intact and received oxygen while a resident of the facility. A Care Plan, dated 7/24/25, indicated the resident received oxygen therapy related to congestive heart failure, history of pneumonia, pulmonary embolism (blood clot), pulmonary edema, and respiratory failure. Interventions included, but were not limited to, administer oxygen per physician's order. A Physician's Order, dated 9/12/25, indicated the resident was to receive oxygen at 4 liters continuously every shift.During an interview on 9/18/25 at 8:50 a.m., the Director of Nursing indicated the resident's oxygen concentrator should have been set at the correct flow rate. 2. During a random observation on 9/15/25 at 11:35 a.m., Resident 24 was observed with oxygen by the way of a nasal cannula in use. The resident's oxygen concentrator was set at 3 liters. On 9/16/25 at 8:52 a.m., the resident's oxygen was in use and the oxygen concentrator was set at 2 liters. At 9:27 a.m., the oxygen concentrator was set at 3 liters. On 9/17/25 at 8:54 a.m., the resident's oxygen was in use and the oxygen concentrator was set at 3 liters. The record for Resident 24 was reviewed on 9/17/25 at 2:25 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and hypertension. The 8/31/25 Medicare 5-Day Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was not receiving oxygen while a resident of the facility. A current Care Plan indicated the resident had oxygen therapy as needed related to COPD and a history of pneumonia to help relieve hypoxia (low levels of oxygen in body tissue). Interventions included, but were not limited to, administer oxygen per physician's order. Physician's Orders, dated 8/27/25, indicated the resident was to receive 2 liters of oxygen per nasal cannula as needed (PRN) to keep his oxygen saturation above 92% every shift. The resident's oxygen saturation was to be monitored every shift.The September 2025 Medication Administration Record (MAR) indicated the oxygen was signed out as being in use each shift for the month except for the evening of 9/13/25. During an interview on 9/17/25 at 8:58 a.m., LPN 1 indicated the resident's oxygen concentrator was always set at 3 liters. During an interview on 9/17/25 at 2:00 p.m., the Director of Nursing was informed of the incorrect flow rate. No further information was provided.3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a Pharmacy recommendation was completed as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident D)Finding includes:Resident D's record was reviewed on 9/18/25 at 3:07 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction, diabetes mellitus, and atrial fibrillation. The Quarterly Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had moderate cognitive impairment and was dependent for toileting and transfers. A pharmacy review was completed on 5/11/25. A recommendation was made to the Physician to consider scheduling a complete blood count (CBC), comprehensive metabolic panel (CMP), A1c (test to measure sugar in the blood), Vitamin D level and lipids at the next convenient lab. The Physician agreed and signed the recommendation on 5/15/25. A CBC and CMP were completed on 5/29/25. The A1c, Vitamin D and lipid test had not been completed. During an interview on 9/22/25 at 9:18 a.m., the Director of Nursing indicated she normally reviews the pharmacy recommendations then gives them to the Physician or Nurse Practitioner. She did not know why the pharmacy recommendation had not been completed. The policy, Medication Regimen Review and Address Irregularities, dated 6/12/23, indicated, .e. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities 3.1-25(i)

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors related to medications not administered as ordered for infections for 2 of 6 residents reviewed for unnecessary medications. (Residents C and B)Findings include: 1. The closed record for Resident C was reviewed on [DATE] at 10:55 a.m. Diagnoses included, but were not limited to, left below the knee amputation (BKA), diabetes, hypertension, pressure ulcers of the hip and buttock, and heart failure.The [DATE] Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and was dependent for activities of daily living (ADLs) and transfers.The resident was admitted to the facility on [DATE] following a hospitalization related to the left BKA surgery. At that time, the resident had a unstageable pressure ulcers to the right thigh and buttock as well as a dehisced (reopened surgical incision) wound to the left leg stump. A Physician's Order, dated [DATE], indicated Tigecycline (an intravenous antibiotic) 100 milligrams two times a day, related to infection of the skin and subcutaneous tissue, for 28 days.A Skin/Wound Note, dated [DATE], indicated the wound to the right thigh was odorous and had purulent (pus) drainage. On [DATE], a culture was sent of the right thigh wound.A Progress Note, dated [DATE], indicated the wound doctor assessed the resident's pressure ulcers and ordered Flagyl (an antibiotic) 500 mg intravenously (IV) every 8 hours for 7 days for the wound infection.A Nurse's Note, dated [DATE], indicated the Flagyl was not available, and they were awaiting its delivery from the pharmacy.The [DATE] Medication Administration Record (MAR) indicated the resident did not receive any doses of the Flagyl. A Skin/Wound Nurse's Note, dated [DATE] at 11:54 a.m., indicated the wound doctor was informed of the wound culture results. New orders were received to discontinue the Flagyl and start Levaquin (an antibiotic) for pseudomonas (a bacteria that can be resistant to many antibiotics). An Acute Care Note, dated [DATE] at 1:20 p.m., indicated the resident was found altered mentally and verbally unresponsive and was being sent to the hospital emergency department (ED) for evaluation. An ED physician's note, dated [DATE], indicated, Pt [patient] in septic shock; source of infection is not known.During an interview on [DATE] at 10:25 a.m., the Infection Preventionist indicated the right hip wound was infected, the wound doctor ordered Flagyl and wanted it started right away. It happened over the weekend, and when she came back Monday, she saw the Flagyl had not been started. At that time, she received the culture results and the antibiotic order was changed. She indicated if an antibiotic was not started as ordered, the nurse should have notified the physician and documented it.During an interview on [DATE] at 10:40 a.m., the wound doctor indicated the right hip wound was the only infected wound he observed, and the resident had no other infectious process he was aware of. He would expect the IV antibiotic to be started the day it was ordered, and that he was not informed that the resident did not receive the Flagyl until after she expired in the hospital on [DATE]. He indicated he could not determine if the resident's outcome would have been different if she had received the Flagyl as prescribed. During an interview on [DATE] at 2:30 p.m., the DON and Corporate Nurse 1 were informed of the findings. Both indicated they did not know why the Flagyl was not administered to the resident. No further information was received. 2. The record for Resident B was reviewed on [DATE] at 9:04 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, diabetes, and COVID-19.The [DATE] Annual Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required substantial assistance with Activities of Daily Living (ADLs), and was independent with transfers.The current Physician's Order Summary indicated a Covid test and stat chest x-ray were ordered on [DATE] at 10:30 a.m. for shortness of breath. On [DATE] at 12:40 p.m., the resident tested positive for Covid.A Nurse's Note, dated [DATE] at 2:12 p.m., indicated the resident had wheezing and shortness of breath on exertion. New orders were received including Paxlovid (an oral antiviral medication for treating Covid-19 in patients who are at high risk of the disease progressing to a more severe illness) twice a day for 5 days.A Nurse's Note, dated [DATE] at 6:43 p.m., indicated the Paxlovid had not yet arrived and the nurse manager was made aware. The [DATE] Medication Administration Record (MAR) indicated the resident only received 3 of the 10 scheduled doses of Paxlovid. The record lacked documentation as to why the resident did not receive the medication as ordered. During an interview on [DATE] at 2:30 p.m., the DON and Corporate Nurse 1 indicated the medication came as one unit from the pharmacy, and should have been available for the resident to receive as ordered. They did not know why the resident did not receive the medication as it was prescribed. The manufacturer prescriber administration instructions for Paxlovid indicated to alert the patient of the importance of completing the full 5-day treatment course and to continuing isolation in accordance with public health recommendations to maximize viral clearance and minimize transmission of SARS-CoV-2. If the patient misses a dose of Paxlovid within 8 hours of the time it is usually taken, the patient should take it as soon as possible and resume the normal dosing schedule. This citation relates to Intake 2597285.3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for two random resident care observations. (Residents 9 and 64 )Findings include:1. During a random observation on 9/15/25 at 10:28 a.m., CNA 1 was observed providing a partial bath with incontinence care for Resident 9, who had a gastrostomy tube (a feeding tube inserted through the abdomen). CNA 1 did not wear a gown when providing direct care for the resident. The resident's record was reviewed on 9/16/25 at 2:12 p.m. Diagnoses included, but were not limited to, dementia, Alzheimer's, and dysphagia (difficulty swallowing).The 8/15/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs), and required maximal assistance with transfers.A Physician's Order, dated 9/16/25, indicated the resident required enhanced barrier precautions (EBP) and that all staff must don gown and gloves for all high contact resident care activities.A Care Plan, dated 9/17/25, indicated the resident required enhanced barrier precautions (EBP) during high-contact care including bathing, dressing, hygiene, changing linens and changing briefs.During an interview on 9/17/25 at 2:00 p.m., the Director of Nursing (DON) indicated staff should wear a gown and gloves with any direct contact with a resident on EBP. 2. During a random observation on 9/16/25 at 10:29 a.m., CNA 2 and CNA 3 were observed bathing Resident 64, who had a gastrostomy tube. At that time, neither CNA 2 nor CNA 3 were wearing a gown.On 9/17/25 at 9:07 a.m., CNA 1 was observed pulling Resident 64's legs apart and adjusting her disposable brief. At that time, CNA 1 was not wearing a gown or gloves. The record for Resident 64 was reviewed on 9/18/2025 at 12:52 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, hemiplegia (paralysis on one side of the body) following a stroke, and gastrostomy status.The 7/14/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs) and transfers. A Physician's Order, dated 6/4/25, indicated the resident was on enhanced barrier precautions (EBP), and that all staff must don a gown and gloves for all high-contact activities, including bathing, dressing, hygiene, changing linens and changing briefs.A Care Plan, dated 12/3/24, indicated the resident required EBP during high-contact care related to the presence of a feeding tube.During an interview on 9/17/25 at 2:00 p.m., the Director of Nursing (DON) indicated staff should wear a gown and gloves with any direct contact with a resident on EBP. A policy titled, Enhanced Barrier Precautions, received as current from the Director of Nursing on 9/18/25 at 9:07 a.m. indicated, . EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . High-contact resident care activities include . bathing . providing hygiene . changing briefs or assisting with toileting . The policy indicated EBP should be implemented for residents with a wound or indwelling medical device. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure equipment was properly functioning and ensure fall precautions were in place to prevent injury from a fall for 1 of 3 residents reviewed for accidents. (Resident J)Finding includes: On 8/5/25 at 10:22 a.m. and 10:50 a.m., the resident was observed sitting up in bed asleep. There was no bolster on the bed, there were two pads sitting on the floor in front of the residents' bed.Resident J's record was reviewed on 8/5/25 at 3:21 p.m. The diagnoses included, but were not limited to, heart disease, hypertension (high blood pressure), congestive heart failure, psychotic disorder, depression, and anemia (low iron).The Significant Change in Status Minimum Data Set (MDS) assessment, dated 7/11/25, indicated the resident was moderately cognitively impaired. The resident required dependent assistance with all Activities of Daily Living (adls). The resident was dependent with tub and shower transfers.A Care Plan, dated 7/14/25, indicated the resident was at risk for falls related to impaired ability to stand, transfer, and walk. Interventions included, but were not limited to, placing fall mat next to bed, placing a bolster to the right side of the bed and monitor placement every shift and keep call light within reach.A Physician's Order, dated 7/21/25, indicated to send the Resident to the hospital to evaluate and treat for status post fall.A Incident Note, dated 7/21/25 at 10:02 a.m., indicated the resident experienced a fall during a shower. Nursing staff rendered first aid at the time of the fall and neuro checks were initiated. The resident was awake and verbally responsive, able to follow commands and move all extremities without difficulty.A Post Fall Evaluation, dated 7/21/25 at 11:17 a.m. indicated Resident J had a witnessed fall in the shower room and an injury was obtained. Bleeding was noted to the frontal lobe (forehead) and resident was sent to the hospital for evaluation. Contributing factors indicated the shower bed was broken.The Treatment Administration Record (TAR) indicated the bed bolster was signed out in July but was not listed on the TAR for August. There was no monitoring documented from 8/1/25- 8/5/25.During an interview on 8/6/25 at 8:36 a.m., the Director of Nursing indicated she understood the concern about the broken shower bed and resident J's fall. The staff had been in-serviced about broken equipment and requested if they see something, say something. New shower beds and chairs had been ordered.During an interview on 8/6/25 at 9:20 a.m., CNA 1 indicated she had transferred Resident J to the shower bed with CNA 2. She then pushed the resident to the shower room and pushed the shower bed against the shower wall. She then locked the shower bed. She had washed and dried Resident J's front and had turned the resident on her side to wash/dry her back. That was when the shower bed moved off the wall towards CNA 1. The resident had fallen off the bed where the bed had scooted from the wall. CNA 1 indicated the shower bed was broken; it should never have moved. She screamed for help and stayed with the resident.A policy, titled, Accidents and Supervision and received as current from Nurse Consultant 1 on 8/6/25, indicated, .Identification of Hazards and Risks, the process through which the facility becomes aware of potential hazards in the resident environment and the risk of having an avoidable accident.The facility should make reasonable effort to identify the hazards and risk factors for each resident.This citation relates to Complaint 2580575.3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure dignity was maintained related to knocking before entering a resident's room for 1 of 3 residents reviewed for dignity. (Resident E)Finding includes:On 8/4/25 at 5:55 a.m., Resident E was observed during incontinence care with LPN 1. LPN 1 did not knock on the door before entering the resident's room and did not announce herself when she entered. There were 2 residents residing in the room.During an interview at the time, LPN 1 indicated oops, I forgot to knock.Resident E's record was reviewed on 8/4/25 at 3:47 p.m. The diagnoses included, but were not limited to, Parkinson's, dementia, pressure ulcer sacral stage 4, heart disease, dysfunction of bladder, hypertension (high blood pressure), gastrostomy status, and psychotic disorder.The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/25, indicated the resident was cognitively impaired for daily decision making and was dependent with all Activities of Daily Living and transfers.A policy, titled, Dignity and received as current from Nurse Consultant 1 on 8/6/25, indicated, .7. Staff are expected to knock and request permission before entering residents' rooms.This citation relates to complaint 1540563.3.1-3(t)

Based on record review and interview, the facility failed to ensure a resident who received a left foot/toe injury had thorough and accurate assessments of the area and failed to treat the area as ordered by the Physician, which resulted in the resident being admitted into the hospital with diagnoses of left great toe infection, cellulitis of the left foot, and a MRI of the foot that indicated a result of suspicious for osteomyelitis of the left great toe for 1 of 2 residents reviewed for injuries. (Resident C) Finding includes: Resident C's record was reviewed on 9/27/23 at 10:42 a.m. The diagnoses included, but were not limited to, fracture of the left femur and stroke. A Quarterly Minimum Data Set assessment, dated 7/19/23, indicated an intact cognitive status and required supervision for transfers and locomotion. A Care Plan, dated 8/10/23, indicated an open area was present on the left great toe. The interventions included, caution would be used for all transfers, treatments would be completed as ordered by the Physician, and signs and symptoms of infection or abnormalities would be monitored and the Physician was to be notified. A Nurse's Progress Note, dated 8/1/23 at 11 a.m., indicated the resident reported on 7/31/23 another resident accidentally ran over his right great toe with a wheelchair. The toe was assessed as swollen, discolored, and painful to touch. The Physician was notified and an order for an x-ray of the right foot was received. The Physician's Order, was dated 8/2/23 for an x-ray of the right foot and toes. A Physician's Order, dated 8/3/23, indicated the right foot was to be monitored and skin prep with a dry dressing was to be applied every shift. A x-ray of two views of the right foot was obtained on 8/3/23. The results indicated soft tissue swelling of the anterior foot. The order for the right foot to be monitored and the treatment for the skin prep and dry dressing was missing and lacked initials that indicated the treatment had been completed as ordered on the Medication and Treatment Administration Records (MAR/TAR), dated 8/2023. The Nurses' Progress Notes, dated 8/3/23 at 10:11 p.m., 8/4/23 at 3:13 p.m., 8/5/23 at 2:45 a.m. indicated the skin prep and dry dressing treatment continued to the right toes. There were no assessments of the injury from 8/1/23 to 8/5/23 and no documentation the treatment had been applied every shift as ordered. A Nurse's Progress Note, dated 8/5/23 at 10:54 p.m., indicated the right toe still looked swollen and there were no complaints from the resident. A Skin Assessment Form, dated 8/5/23, indicated the skin was intact, the right great toe was swollen, the treatments to all affected areas continued, and there were no new open areas. A Nurse's Progress Note, dated 8/6/23 at 1:41 a.m., indicated a new order for a dry dressing with skin prep to the right toes every shift and to monitor the area was obtained. A Nurse's Progress Note, dated 8/6/23 at 2:19 p.m., indicated skin prep and a dressing was applied to the right great toe, the foot remained swollen, bruised, and was reddened at the nail bed. There were no further assessments of the foot nor documentation the treatment had been completed until 8/10/23. A Wound Nurse Progress Note, dated 8/10/23 at 11:37 a.m., indicated a ruptured blister to the left great toe. The area measured at 2.4 centimeters (cm) by 2.8 cm x 0.1 cm depth. There was moderate sero-purulent (serum and pus) drainage with a faint odor. The Physician was notified and an order for a culture and sensitivity of the left great toe was received. During an interview with the Wound Nurse on 9/27/23 at 11:41 a.m., she indicated the injury was on the left foot and had taken a picture of the left foot. She was informed by the Nurse there was a blister and when she assessed the area it was an opened blister. There were no other assessments after the assessment on 8/1/23 and then on 8/5/23 it was assessed to still be swollen. The documented assessments had indicated it was the right foot that was assessed not the left. She indicated she should have been notified when the blister was first found. The Physician's Order for the treatment of the skin prep and the dry dressing had not been transcribed correctly, so it had not been placed on the 8/2023 MAR/TAR. There was no documentation the treatment had been completed. The Left Great Toe Assessment picture was of the left foot and toe and indicated there was suspected infection of the area. A Physician's Order was received on 8/10/23 to cleanse the left great toe with normal saline, pat dry, and then calcium alginate (wound treatment) was to be applied and covered with a dry dressing three times a week. A Nurse's Progress Note, dated 8/10/23 at 12:45 p.m., indicated the Wound Nurse completed a culture and sensitivity of the right great toe. A Nurse's Progress Note, dated 8/12/23 at 9:46 a.m. indicated the resident had called EMS (Emergency Medical Services) due to pain in his foot. An ambulance arrived at the facility and transferred the resident to the hospital. A Nurse's Progress Note, dated 8/12/23 at 9:05 p.m., indicated he was admitted to the hospital for treatment to the foot. The TAR, dated 8/2023, indicated the treatment to the left great toe was completed on 8/11/23 and 8/14/23 (resident was admitted into the Hospital on 8/12/23) The emergency room Physician Progress Note, dated 8/12/23 at 10:26 a.m., indicated left foot great toe pain. The resident indicated his toe had been run over by a wheelchair at the long term care facility. He indicated there had been drainage and an odor was present. A wound culture had been completed on 8/10/23. The left great toe was assessed and it was malodorous (bad smelling) and had redness of the toe and foot. An x-ray of the left foot indicated first digit soft tissue swelling, negative for a fracture. The wound culture from 8/10/23 had indicated MRSA (methicillin resistant staphylococcus aureus) of the left great toe. The resident would be admitted into the facility for treatment. The diagnoses included, but were not limited to, infection of the toe and cellulitis of the foot. A MRI of the left foot, dated 8/13/23, indicated, .suspicious for developing acute osteomyelitis A Hospital Wound Nurse assessment, dated 8/13/23, indicated the left hallux was pink and looked like a blister was present that sloughed off. The picture taken was of the left foot. During an interview on 9/27/23 at 3:58 p.m., LPN 1 indicated she had documented the wrong foot on the assessment and it was the left toe he had injured. During an interview on 9/28/23 at 9:17 a.m., RN 2 indicated the injury was on the left foot not the right. The toenail was blue and painful. She indicated the thought the x-ray was taken of the left foot. The initial X-ray was done on the incorrect foot and treatment to the injured left foot was not completed for 10 days due to the error in identification. This Federal tag relates to Complaint IN00415780. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure wound care treatments were completed as ordered by the Physician and weekly preventative skin checks were completed by licensed nursing staff for 2 of 3 residents reviewed for pressure ulcers. (Residents C & D) Findings include: 1. During an observation on 1/16/18 at 8:40 a.m., Resident D was observed in bed. An air mattress was in place on the bed. The Infection Control RN assisted the resident to his side. A dressing was in place to the left upper inner buttock area. The dressing was soiled with dark tan and green colored drainage. The date of 1/12 was written on the dressing. A T was noted below the date. The Infection Control Nurse identified the date as 1/12 and the T was the Wound Nurses's signature. On 1/16/18 at 10:08 a.m., the Wound Nurse was observed completing wound care treatments. A second dressing was noted below the left rib cage area on the abdomen. This dressing was dated 1/12 also. The wound to the left upper abdominal area was open with a red center. The wound measured approximately 3 cm (centimeters) x 2 cm. The Wound Nurse identified both dressings as being last changed by herself on 1/12/18. The dressings were to be changed every Monday, Wednesday, and Friday. The dressing should have been changed yesterday. The record was Resident D was reviewed on 1/16/18 at 11:23 a.m. [DIAGNOSES REDACTED]. The 1/2018 Physician order [REDACTED]. The treatment was last signed out as completed 1/12/18 on the current Treatment Administration Record. Current orders were also written for Weekly Skin Checks to be completed on Shower Days. No Weekly Skin checks were signed out as completed for (MONTH) (YEAR). There was no documentation of skin checks being completed. A Wound care note, dated 1/10/2018, indicated the current treatment for [REDACTED]. The 10/23/17 MDS (Minimum Data Set) Significant Change assessment indicated the resident required extensive assistance of two staff members for bed mobility and was totally dependent on two staff for transfers. A Care Plan, initiated on 1/12/18 indicated the resident was at risk for pressure ulcer development or impaired skin integrity related to incontinence, a history of pressure ulcers, stroke, and diabetes mellitus. The Director of Nursing provided 11/2017 and 12/2017 Bath and Skin Report Sheets for Resident D. There were sections on the forms for the CNA to mark any skin areas observed and Nursing to sign also. No entries were made for any days in 11/2017 or 12/2017. During an interview on 1/16/18 at 11:10 a.m., the Director of Nursing indicated Bath and Skin Report sheets were to be completed with each bath or shower. The 11/2017 and 12/2017 sheets and skin assessments had not been completed. 2. During an observation on 1/16/18 at 1:45 p.m., Resident C was provided incontinence care by CNA 1 and CNA 2. A dressing was in place to the mid back area. The dressing was dated 1/16/18. The record for Resident C was reviewed on 1/16/18 at 9:34 a.m. [DIAGNOSES REDACTED]. The 10/17/17 MDS (Minimum Data Set) Quarterly assessment indicated the resident's cognitive skills were severely impaired. Extensive assistance of staff was required for bed mobility and dressing. The resident was dependent on staff for transfers and toileting. One healed pressure ulcer was present on admission. The resident was at risk for the development of pressure ulcers. A Care Plan, initiated on 10/26/17, assessed Resident C as being at risk for the development of pressure ulcers related to bowel and bladder incontinence. A physician's orders [REDACTED]. The 1/2018 Treatment Administration Record indicated the above treatment was not signed out as completed on 1/17/18. The Director of Nursing provided 11/2017 and 12/2017 Bath and Skin Report Sheets for Resident D. There were sections on the forms for the CNA to mark any skin areas observed and Nursing to sign also. No entries were initiated for any days in 11/2017 and 12/2017 During an interview on 1/16/18 at 10:34 a.m., the Wound Nurse indicated she had completed the treatment to the resident's back about 1/2 hour ago. No dressing was in place on the wound when the treatment was rendered. The dressing should have been in place. During an interview on 1/16/18 at 11:10 a.m., the Director of Nursing indicated Bath and Skin Report sheets were to be completed with each bath or shower. The 11/2017 and 12/2017 sheets and skin assessments had not been completed. The facility Administrator provided the Showers/Skin Assessment policy on 1/16/18 at 11:15 a.m. and identified the policy as the one currently being used by the facility. All residents were to have a complete evaluation of the skin on a regular basis. Showers/Baths were to be offered 2 times a week at the minimum. Skin assessments were to be completed during showers or baths. A Licensed Nurse was required to verify skin assessments completed during showers/baths. This Federal tag relates to Complaint IN 852. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was maintained related to ensuring Wanderguard and exit door elopement prevention devices were in working order and exit door alarms were on resulting in cognitively impaired residents exiting the facility unnoticed and found by staff outside the facility for 2 of 3 residents reviewed with Wanderguard devices in place to prevent elopements. (Residents F & C) A total of 9 of the 68 residents currently in the facility had a Physician order [REDACTED]. (Residents K, M & N) The Immediate Jeopardy began on 5/30/17 when a cognitively impaired resident exited the front door of the facility unnoticed and was found by incoming staff on the sidewalk outside the building. Upon return to the facility, the Wanderguard was observed to not be functioning for one side of the doorway. The door involved was fixed and staff alerted to check both sides of the doorway, but no other systemic monitoring or resident evaluations were completed, allowing for another resident to elope from the building unnoticed into a side parking lot and into an employee's parked vehicle on 7/14/17. The Administrator was notified of the Immediate Jeopardy on 7/24/17 at 1:20 p.m. The Immediate Jeopardy was removed on 7/27/17, but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During Orientation Tour on 7/24/17 at 8:30 a.m., Resident F was observed sitting on her bed on the 400 hall. The Wanderguard alarm on the 200 hall exit door was tested by LPN 1. The LPN held a Wanderguard device up to the box on the first set of doors and the alarm sounded. The Maintenance Supervisor opened the second set of doors, which lead directly to the outside, and this alarm did not sound. The record for Resident F was reviewed on 7/24/17 at 9:26 a.m. [DIAGNOSES REDACTED]. A Nursing Note, dated 7/14/17 at 2:00 p.m., indicated the resident was returned to the unit from outside of the 500 hall door. The last entry prior to this was completed on 7/6/17. The Admission MDS (Minimum Data Set) assessment, dated 5/10/17, indicated Resident F's skills for decision making were severely impaired. Wandering occurred daily during the (7) day reference period. Wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). An Elopement Risk Assessment, dated 5/3/17, consisted of (9) questions to be answered with either a yes or a no. Three of questions were not answered. The Risk Level score was listed as (4), which indicated the resident was at a Low Risk level. The questions which were not answered were as follows: -History of elopement? -Inability to identify safety needs? -[DIAGNOSES REDACTED].? The resident's [DIAGNOSES REDACTED]. No Interventions were checked on the assessment and no recommendations were listed. A Care Plan, initiated on 5/10/17, indicated Resident F was an elopement risk, wandered, and had the [DIAGNOSES REDACTED]. A Facility Incident, dated 7/14/17, indicated Resident F was found outside of the facility in the parking lot at 2:00 p.m. She was observed seated in an employee's truck. The truck doors were unlocked and the windows were down. According to the facility cameras, the resident was outside of the facility from 1:26 p.m. until 2:01 p.m. Staff were observed walking in the parking lot but were not aware Resident F was in the truck. A Housekeeping staff member observed the resident in the truck and assisted her back into the building. No injuries were observed. An investigation noted a Wanderguard was in place but did not alarm upon the residents return into the facility. The alarm box on the exit door was also in the off position at the time. Observation of the area on 7/24/17, indicated the 500 hall exit doors led to the facility parking lot. The parking lot was on the intersection of the facility one way street (runs South) and an adjoining busy three lane one way street (running West). The parking lot was not fenced in or secured. During an interview on 7/24/17 at 9:40 a.m., the facility Administrator indicated Resident F resided on the 400 hall and exited out of the door at the end of the main hallway just past the 500 hall. The door is used by ambulance services when they pick up or return residents. The door leads to the outside to an unsecured parking lot. Maintenance is responsible for checking all the exit door alarms and Wanderguard devices weekly. This was in place prior to the Resident F's elopement and the same protocol for weekly door checks remained in place. 2. The closed record for Resident C was reviewed on 7/24/17 at 11:01 a.m. Diagnoses, included, but were not limited to, dementia, anxiety, atypical psychosis, syncope (dizziness), insomnia, and high blood pressure. The Quarterly MDS (Minimum Data Set) assessment, dated 5/22/17, indicated resident C's cognitive patterns were severely impaired, wandering occurred daily, and the resident was able to walk in the corridors with supervision. The most recently Elopement Risk Assessment, completed on 1/28/17, consisted of (9) questions to be answered with a yes or a no answer. Four of the questions were answered yes. The question of [DIAGNOSES REDACTED].? was not marked with a yes and the score was a (4). The resident's [DIAGNOSES REDACTED]. Recommendations included, but were not limited to, left ankle alarm placed on 1/28/17. A Care Plan, initiated on 6/2/16, indicated the resident had impaired cognitive function related to a [DIAGNOSES REDACTED]. A Care Plan, initiated on 2/6/17, indicated the resident had a Wanderguard in place due to attempts to push open doors. Interventions included, but were not limited to, distract resident from wandering by offering pleasant diversions and structured activities, and a Wanderguard alert to be in place. A Care Plan, initiated on 6/3/16, indicated the resident was receiving psychotropic medications. Interventions included, but were not limited to, monitor behavioral symptoms. A Facility Incident, dated 5/30/17 at 6:45 a.m., indicated Resident C resided on the 400 hall and ambulated independently throughout the facility. She was found outside the main entrance to the facility. No injuries were assessed. The investigation indicated the video tape of the occurrence showed Resident C exited through the front doors at 6:37 a.m. and strolled down the front sidewalk. The resident looked down the street and causally turned back. A staff member coming to work observed Resident C outside at 6:38 a.m. Video recording of the event showed the Wanderguard system did not sound when the resident exited the door, but did alarm when she re-entered the building. The system was inspected and found to have one antenna functioning, allowing for exit from the other door it was connected to. Both antenna's were reset. Video footage of the front door at 6:36 a.m., showed Resident C walking down the hall towards the front office area dressed on a bright pink sweat outfit. She abruptly turned and walked out the front door. The audio indicated the alarm did not sound as the resident exited the facility. An employee driving down the street observed Resident C outside at 6:38 a.m. and exited the car to assist the resident back into the facility. During an interview on 7/24/17 at 9:30 a.m., the facility Administrator indicated Resident C exited the front door and started walking door the sidewalk. When the resident was brought back into the facility the Wander guard alarm did not work. The Company was called and came to the facility. The company determined one of the door alarms' antennas of the double doors was not functioning. Two antennas were on the door, one on the door that one would usually enter the facility from was not working. the facility determined they had been testing the door on a regular basis but were only testing the door which one would normally exit the building from. Resident C exited the facility thru the door which one would normally enter from the outside. Both sides should have worked. 3. On 7/24/17 at 2:29 p.m., Resident M was observed sitting in a wheel chair in the 500 hallway. The resident was wearing a hospital gown. There was no Wanderguard in place to either wrist or either ankle. LPN #3 also checked the resident and his room and no Wanderguard device was present or located in the resident's room. The record for Resident M was reviewed on 7/24/17 at 3:05 p.m [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. Physician orders [REDACTED]. A Physician order, completed on 7/21/17, indicated a Wanderguard was to be in place and checked for placement every shift. An Elopement Risk Assessment, completed on 4/12/17, indicated Resident M was at high risk for elopement. The Wanderguard was not replaced on 4/12/17. The Quarterly MDS (Minimum Data Set) assessment, completed on 7/18/17, indicated Resident M had no cognitive deficits. During an interview on 7/24/17 at 3:33 p.m., the Director of Nursing indicated the Wanderguard should have been put back on when the resident returned from the hospital on [DATE]. 4. On 7/24/17 at 2:35 p.m., Resident K was observed in bed. LPN 3 was present and assessed the resident . No Wanderguard was observed in place or in the room. The record for Resident K was reviewed on 7/24/17 at 2:42 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, completed on 6/27/17, indicated Resident K had severely impaired cognitive skills. A Care Plan, last updated on 1/16/17, indicated the resident was an elopement risk as he wandered aimlessly around the facility and had a [DIAGNOSES REDACTED]. During an interview on 7/24/17 at 3:33 p.m., the Director of Nursing indicated the Wanderguard should have have been in place. Residents were to be assessed upon admission, quarterly, and as needed with any changes in condition. 5. On 7/26/17 at 2:25 p.m., the function off the Wanderguard system on the 300 Hall was checked by the Administrator. A Wander Guard sensor device was held up the exit door by the Administrator. The Administrator pushed on the door and the door opened and no alarm sounded. The Administrator indicated the doors should not have opened with the Wanderguard nearby. The 300 Hall Unit Manager walked Resident N from her room down the hall to the exit door. Resident N had a Wanderguard to her right ankle. The resident walked to up the door and staff pushed on the door. The door opened. No alarm sounded. Staff escorted the resident back down the hall. The record for Resident N was reviewed on 7/27/17 at 8:35 a.m. [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set), completed on 7/7/17, indicated the resident's cognitive skills were impaired. During an interview on 7/26/17 at 2:25 p.m., the facility Administrator indicated the new Wanderguard system was not working correctly when just tested . The facility titled, Pre-elopement/Wandering Assessment policy was received from the Director of Nursing on 7/24/17 at 10:48 a.m. The Director of Nursing identified the policy as the one currently being used in the facility. Residents were to be assessed upon admission, quarterly, and as needed with any changes in condition. Maintenance was required to complete alarm checks at least weekly. Residents with Wanderguards were to have them checked by caregivers to ensure alarms were functioning. This Federal tag relates to Complaints IN 849 and IN 394. 3.1-45(a)(2)

Based on record review and interview, the facility failed to thoroughly investigate an incident of choking to determine a root cause analysis as to where the resident was getting the food. The facility failed to ensure interventions were in place for the supervision for the resident who was on a mechanically altered diet, had a history of [REDACTED]. The facility failed to ensure the resident was supervised before and after meals resulting in another choking incident that led to the death of the resident for 1 of 3 residents reviewed for supervision. (Resident #56) In addition to the resident in immediate jeopardy, the facility failed to ensure food and/or snacks were removed from the resident's bedside table on the midnight shift resulting in the potential for harm that was not immediate jeopardy to 1 of 2 residents reviewed for supervision. (Resident #81) The immediate jeopardy began on [DATE] when there was no root cause analysis completed as to where the resident was getting the food from that led to another choking incident. The Administrator and the Interim Director of Nursing/Nurse Consultant were notified of the immediate jeopardy on [DATE] at 10:34 a.m. The immediate jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: 1. The closed record review for Resident #56 was on [DATE] at 3:00 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was unable to complete the resident interview for cognition. The resident had long and short term memory problems. The resident was moderately impaired for decision making and could locate his room, knew staff faces, and knew he was in a nursing home. The resident was independent with no staff assist for locomotion on and off the unit and walking in the corridors. The resident needed supervision with set up help only for eating. The Annual MDS assessment dated [DATE] indicated the resident was unable to complete the resident interview for cognition. The resident had long and short term memory problems. The resident was moderately impaired for decision making and could locate his room, knew staff faces, and knew he was in a nursing home. The resident needed supervision with set up help only with locomotion on and off the unit and how the resident walked in the corridors. The resident was totally dependent with one person physical assist for eating. The care plan was reviewed. The problem updated [DATE] indicated the resident displayed signs of behaviors as evidenced by eating other resident's food or drinking their coffee. The Nursing interventions were to observe assess for hunger, thirst needs, and assess resident's understanding of the situation. Assess resident's coping skills and support system The [DATE] Physician recap indicated a pureed diet with whole milk and double portions every meal with thin liquids. The original date was [DATE]. Nursing Progress Notes dated [DATE] at 1:00 a.m., indicated Called to room by CNA. Resident observed choking, face/fingers turning blue. Resident unable to speak. Resident waving hands in air, oxygen saturation 62%. Immediately started Heimlich maneuver. Oxygen saturation up to 74%, pieces of sandwich started to come out of mouth. 911 immediately called. Resident continued to clench teeth and would not allow staff to take out rest of sandwich particles from mouth. Resident began to swallow sandwich particles causing resident to gasp for air, again oxygen saturation decreased to 68%. Began Heimlich maneuver again, more sandwich particles came out. Resident uncooperative with care due to [DIAGNOSES REDACTED]. Ambulance arrived, blood pressure ,[DATE], pulse 78, respirations 20, resident left via two attendants on stretcher, alert and responsive. Transferred to stretcher, stand/pivot times two attendants. Another entry in Nursing Progress Notes dated [DATE] at 3:00 p.m., indicated Per medical records where entry mentions sandwich particles entry should have been written as food particles. After performing Heimlich for ,[DATE] minutes on resident, writer was exhausted and immediately after transfer began writing nurses notes to document entire event, during which the mistake of writing sandwich particles instead of food particles was made. Nursing Progress Notes dated [DATE] at 2:00 p.m., indicated the resident was admitted to the hospital with [REDACTED]. Nursing Progress Notes dated [DATE] at 3:00 p.m., indicated the resident arrived back to facility from the hospital. Hospice was at the facility to admit the resident to their service. Physician order [REDACTED]. Following Hospice admission, new Physician Order's dated [DATE] at 5:15 p.m., indicated DC (Discontinue) all labs, Pureed diet with nectar thickened liquids, patient needs to be fed. Small bites only. Supervised only. Crush all meds finely and administer in applesauce. A new care plan dated [DATE] was initiated which indicated High risk for aspiration. Eats food fast and in large amounts. Takes food off other resident's trays as well as dirty food carts. The Nursing interventions were All staff will monitor resident while up and about and redirect as necessary to prevent him from taking food. Staff will feed resident all meals in small proportion and monitor closely for signs and symptoms of aspiration. Nursing Progress Notes dated [DATE] at 1:17 a.m., Observed resident beginning to aspirate on Unit 3. Writer approached resident to assess resident condition, writer observed resident choking and skin color turning pale. Writer began administering Heimlich maneuver. Unit 4 Nurse entered situation monitoring pulse oximetry which was 65% at 1:20 a.m. 911 called. Continued administering Heimlich maneuver. Intermittent suctioning began with moderate success. Resident began clenching jaws which prevented further suctioning. Oxygen saturation down to 62%. Second call placed to 911 on location of ambulance. Dispatch explained regular crew on another emergency, have to dispatch another crew. Heimlich maneuver continued with intermittent sweeping of mouth. Removed minor bits of food particles. Intermittent suctioning continued. EMT arrived at 1:35 a.m., and took control of situation and began intubation before transferring resident out of facility to ER. The emergency room report dated [DATE] indicated The patient was in cardiac arrest upon arrival with ventricular escape rhythm. CPR was in process. The patient did have return of spontaneous circulation prior to arrival. Patient was intubated in route and received no sedation or paralysis. He has had no purposeful movement since return of pulses. Reviewed Physician order [REDACTED]. Interview with LPN #1 on [DATE] at 8:50 am indicated the resident did not really have behaviors he just ate really fast and needed to be supervised during meals because he also liked to take food off resident's meal trays. She indicated the resident was alert enough to know what was going on, he was also ambulatory. Interview with RN #1 the Director of Nursing (DoN) at the time of both choking incidents on [DATE] at 9:15 a.m. indicated the resident had Huntington's Chorea and wandered in and out of rooms. He also was observed many times to grab food and drink off of other resident's trays. She indicated after the choking incident on [DATE] there was a thorough investigation completed. She indicated the resident was found in his room on the floor. She believed the resident could have wandered into another resident's room and gotten a sandwich and ate it. She indicated the evening snacks were also left at the nurses station so she was not sure where the resident got the sandwich. The DoN knew it was not pureed food the resident had choked on. She indicated there was 1 nurse and 2 CNAS on Unit 3 where the resident resided working that night on the midnight shift. At the time of readmission, his diet order was changed to a pureed diet double portions with nectar thick liquids. The DoN indicated after the incident there was to be no food or drink left on the unit on all shifts. She indicated they kept the resident away from the main dining room and he was fed in his room by Nursing staff. She indicated after the resident came back he was a little weaker but still was looking for food and was still ambulatory. She indicated the resident was non verbal, did not speak and felt because of his Huntington's he did not always know what he was doing. The DoN indicated the resident was quick and was still able grab food off of trays and put it in his mouth before they could get to him. The DoN indicated there was a plan put into place. She had the Nurse Supervisor on ,[DATE] shift, to make sure he was not getting into any food left on resident trays. She indicated the ,[DATE] Nurse Supervisor had a checklist and would complete it and turn it into her every morning on how the meal trays were monitored and picked up after residents were through eating. She indicated there was also a Midnight Supervisor who also monitored the resident and if there was food left out. The DoN indicated the ,[DATE] Supervisor would give her a verbal report every morning. She also indicated the ,[DATE] Nurse Supervisor was not allowed to take a Unit or med cart for that very reason to monitor the residents and make sure left over meal trays were not left out and the food was taken back to the kitchen. The DoN indicated all of the written reports and the thorough investigation of the choking incident on [DATE] were unavailable for review. She indicated she had gone on vacation [DATE]-10 and when came back she was removed as the DoN and was moved to the in house dialysis. She did not know where any of the papers were or where any of the investigations were. She indicated the current Interim DoN was the DoN at the time of the second choking incident and she did not take part in any of that investigation. Interview with LPN #2 on [DATE] at 9:35 a.m., indicated he was the nurse taking care of the resident for both choking incidents. He indicated the resident had Huntington's disease and got up frequently at night sometimes more than 20 times a night. LPN #2 indicated the resident was independent for transfers and walked independently as well, however the staff tried to keep him on the unit before he got out of his room. He indicated the resident had a delayed thought process and would stop in the middle of doing things. LPN #2 indicated the first choking incident happened around 1:00 a.m. He indicated the resident got a hold of a sandwich of some sort, because the food that came out of his mouth was not pureed. He indicated he initiated the Heimlich on him and was able to remove the food, 911 was called and he left. The LPN indicated the resident was alert and responsive after the first choking incident. He indicated when the resident came back he was aware of his new diet of pureed food with double portions and thickened liquids and the resident had to be now supervised during meals at all times. The LPN indicated he frequently made rounds up and down the hall during his shift to check on the whereabouts of the resident. He indicated on [DATE] before the resident had choked another resident had asked him to assess her and take her vital signs. So he went into the resident's room. LPN #2 indicated the two CNAS assigned to the unit were in other resident rooms doing rounds. The LPN indicated after he was finished with the other resident, he left the room and returned to the nurses station to do charting. Shortly thereafter, he heard someone say Hey and at that time, he saw Resident #56 fall to the floor. He indicated the resident was in the intersection of unit 3 and the hallway coming from unit 4. The LPN indicated at that time he called for help and the nurse from unit 4 came down and helped him. 911 was called and he initiated the Heimlich maneuver. He indicated the resident was unresponsive at that time. LPN #2 indicated he had removed food particles from his mouth not pureed food. He indicated as soon as 911 got there, they took over and intubated the resident. The resident was still unresponsive when he was transferred out of the facility. He indicated later that night, he had found out the resident had taken food off a tray that was left out on unit 4. The LPN indicated there was no midnight supervisor working on [DATE]. Interview with the Interim DoN who was the Nurse Consultant on [DATE] 10:00 a.m., indicated there was no written investigation documented or available for review after the resident choked on [DATE]. She indicated when the Midnight Supervisor was terminated, the investigations with documentation of interviews, witnesses, and interventions disappeared and were nowhere to be found. She further indicated she did not start at the facility until [DATE]. Interview with the Administrator on [DATE] at 10:30 a.m., indicated RN #1 was the DoN at the time of both choking incidents. He indicated there was no ,[DATE] Supervisor in the facility in June or [DATE]. He indicated the Nurse, RN #1 was referring to was just another Nurse, not the Supervisor. He had indicated he had thought the DoN had taken care of the investigation and the plan of action to supervise the resident. 2. On [DATE] at 4:15 a.m., in room 410 bed one, the resident was observed in bed with his eyes closed. At that time, there was half of a hamburger sandwich on his over bed table. The room door was open. Continued observation at that time, Resident #81 who also resided in the room was observed in bed with his head under the blanket. Further observation of Resident #81's over bed table, there was an empty juice container, a package of opened cookies and one chocolate candy bar. Interview with LPN #3 the Unit 4 Nurse on [DATE] at 4:20 a.m., indicated the resident in 410 bed one happened to be up at the time she came on her shift. She indicated the hamburger sandwich was left over from supper and the resident indicated he still wanted to eat it. LPN #3 indicated Resident #81 who also resided in the same room was on some type of aspiration precautions. She indicated staff were supposed to supervise Resident #81 while he ate. She indicated Resident #81 was up around 2:30 a.m., to use the bathroom and was asked if he still wanted his cookies and he indicated yes, he still wanted them. On [DATE] at 4:17 a.m., in room 306 bed one the resident was observed in bed with his eyes closed. There was a package of graham crackers observed on the over bed table. Interview with the LPN #4 at that time, indicated the graham crackers should not have been on the resident's over bed table. The record for Resident #81 was reviewed [DATE] at 6:45 a.m. The resident's [DIAGNOSES REDACTED]. Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was a 6 indicating he was not alert and oriented. The resident needed limited assistance with one person physical assist with walking in the corridor and walking in the room. The resident needed supervision with set up help only with locomotion on and off the unit. The resident was on a mechanically altered diet. The current plan of care dated [DATE] indicated The resident has a swallowing problem related to difficulty with thin liquids is on thicken liquids. The Nursing approaches were to follow the prescribed diet. Instruct resident to eat in an upright position, to eat slowly, observe/document and report as needed for any signs or symptoms of dysphagia (difficulty swallowing), pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or concerns that appear during meals, and to chew each bit thoroughly. Interview with the Interim Director of Nursing (DoN)/Nurse Consultant on [DATE] at 6:30 a.m., indicated the hamburger sandwich should not have been left on the resident's over bed table. She further indicated the cookies and candy bar should not have been left on Resident #81's over bed table. She further indicated LPN #3 and LPN #4 had been inserviced on the system for tray pick up and snack distribution. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility had ensured Nursing staff were thoroughly inserviced on the new tray removal and snack distribution protocol. The facility also identified residents who were at risk for choking and aspiration and inserviced staff on precautions to prevent any accidents. The facility also put a system and new policy in place to investigate and determine the root cause analysis of all incidents, but non compliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because observation on [DATE] at 4:17 a.m., there were still residents with food on their over bed tables that could be seen from the hallway. 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed to ensure each resident received the necessary treatment and services related to identifying a significant change of condition for a resident who stopped eating, and had a decline in respiratory status that led to a hospitalization for 1 of 1 residents reviewed for hospitalization . (Resident #B) Finding includes: The closed record review for Resident #B was completed on 9/15/15 at 2:44 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident did not return back to the facility. The resident's [DIAGNOSES REDACTED]. Hospital Progress Notes dated 6/7/15 indicated the resident's weight was 119 pounds. He had a fluid intake on 6/7/15 of 1163 milliliters (ml). A Comprehensive Metabolic Panel (CMP) was drawn. The resident's Blood Urea Nitrogen (BUN) was 27 (normal was 8-23) and the [MEDICATION NAME] (CR) was .3 (normal level .7-1.2). The resident's assessment of lungs was normal breath sounds, no respiratory distress, no wheezing, no chest tenderness. The resident was alert and oriented times three and had normal motor function and normal sensory function. The Discharge Summary dated 6/10/15 indicated the patient was admitted with a [DIAGNOSES REDACTED]. During the course of his hospital stay unfortunately he was also diagnosed with [REDACTED]. After being seen by oncology it was determined he was too weak for [MEDICAL CONDITION] and might be better with hospice. He was stable for discharge from his medical bed and was transferred to a skilled nursing facility. The list of current medications to be taken was [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) .5 mg neb solution take 2 mls by neb twice a day and [MEDICATION NAME] (a combined medication used to treat [MEDICAL CONDITION]) .5-2.5 (3) milligram (mg)/3 ml solution take 3 ml by neb every 4 hours. Physician order [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME] an Antianxiety) .5 mg 1 three times a day for 30 days. [MEDICATION NAME] .5 mg neb solution take 2 mls by neb twice a day and [MEDICATION NAME] .5-2.5 (3) milligram (mg)/3 ml solution take 3 ml by neb every 4 hours. [MEDICATION NAME] 30 mg 1 tab twice a day for 15 days There was no current order for continuous oxygen A Complete Blood Count (CBC) and a CMP was to be drawn on 6/11/15 then every month. The lab data was reviewed and there was no evidence the above labs were drawn. The Nursing assessment dated [DATE] indicated the resident weighed 109 pounds. Nursing Progress Notes dated 6/10/15 at 2:45 p.m., indicated the resident was admitted to the facility. The resident was assessed as having labored breathing with substernal retractions. The resident also indicated he could not breathe. A Respiratory assessment completed by a Respiratory Therapist at the facility, dated 6/10/15 indicated the resident was visibly short of breath with severe substernal retractions. The resident was instructed on pursed lip breathing and was only able to speak in short phrases. The Respiratory Therapist recommended the following: [MEDICATION NAME] 3 ml nebulizer treatment every 4 hours. [MEDICATION NAME] .5 mg/2 ml nebulizer treatment twice a day. [MEDICATION NAME] 2.5 mg/3 ml nebulizer treatment every 2 hours prn (as needed) for increased shortness of breath. Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The [MEDICATION NAME] 2.5 mg/3 ml nebulizer treatment every 2 hours prn for increased shortness of breath was not transcribed onto the med sheet. Continued review of the MAR indicated [REDACTED]. The [MEDICATION NAME]/[MEDICATION NAME] treatment to be given every 4 hours was signed out as being administered on 6/11/15 at 5:00 a.m., 9:00 a.m., 1:00 p.m., and 5:00 p.m. The 9:00 p.m. and 1:00 a.m. times were blank. That same nebulizer treatment was signed out on 9:00 a.m., and 1:00 p.m. only for 6/12/15. The administration times were 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Nursing Progress Notes dated 6/10/15 at 7:00 p.m., indicated the resident was receiving oxygen at 10 liters per minute per nasal cannula. The resident had no appetite for supper. At 8:30 p.m., the resident indicated he could not breathe. He indicated if the Nurse could not do anything for him, then he wanted to go to the hospital. The Nurse checked the resident's oxygen saturation which was 95%. The resident was anxious and rapidly breathing. The Nurse then switched the oxygen concentrator to the oxygen tank to appease the resident. There was no documentation the Nurse offered a nebulizer treatment as ordered by the Physician. Nursing Progress Notes dated 6/11/15 at 1:00 a.m., indicated Resident received in bed with complaints of difficulty breathing and disorientation/confusion. Writer assess oxygen saturation which was at 96%. Writer and Nurse Supervisor began to assess if resident was oriented to his new surroundings. Resident responds 'yes'. Resident continued to be anxious stating to turn up the oxygen concentrator, informed resident of concentrator being set at 10 liters per minute already. Called (Physician name) requesting one time Intramuscular (IM) shot of 1 mg of [MEDICATION NAME] (an Antianxiety medication). MD gave verbal consent over the phone. IM shot of [MEDICATION NAME] administered with 20 gauge needle in resident's right deltoid. Will check back on resident in 5 minutes. (sic) At 1:05 a.m., Nursing Progress Notes indicated the resident's oxygen saturation was 98% and the resident had calmed down, there was noticeable decrease in anxiety. Again there was no documentation of any nebulizer treatments administered to the resident for increased shortness of breath. Physician order [REDACTED]. Nursing Progress Notes dated 6/11/15 at 9 a.m., indicated the resident had poor appetite. Nursing Progress Notes at 8:00 p.m., indicated appetite not present at this time, zero consumption of dinner at this time. Nursing Progress Notes dated 6/12/15 at 7:00 a.m., indicated the resident did not eat breakfast. Nursing Progress Notes dated 6/12/15 at 12:00 p.m., indicated the resident was only consuming occasional sips of fluid but refused lunch at this time. The dietary intake record for June 2015 indicated the resident ate 10% for breakfast, lunch, and dinner on 6/10/15, however, the resident was not in the facility for breakfast and lunch on 6/10/15. The resident consumed 10% of breakfast and lunch on 6/11/15 and supper for that day was not completed. The resident consumed 0% for breakfast on 6/12/15 and lunch was not completed. Nursing Progress Notes dated 6/12/15 at 2:00 a.m., indicated the resident was verbally responsive to speech. The resident's respirations were labored but with no signs of respiratory distress. The resident's lung sounds were clear. Another progress note at 2:05 a.m., indicated the resident was observed with the oxygen nasal cannula in his mouth. After several attempts to educate the resident about the proper use of the nasal cannula, the resident still refused to remove it from his mouth. The Physician was notified and indicated that once he was in his office he would call a prescription for [MEDICATION NAME] to the pharmacy and not to send the resident out to the hospital. There was no documentation the Nurse attempted to place an oxygen mask on the resident or offer a breathing treatment for [REDACTED]. Nursing Progress Notes dated 6/12/15 at 7:00 a.m., indicated the resident was observed with labored breathing with crackles noted to his lung sounds. The resident indicated I do not feel like eating. An entry at 9:00 a.m., indicated the resident was taking occasional sips of water. An entry at 12:00 p.m., indicated the resident refused lunch and was still only taking occasional sips of water. There was no documentation the resident's Physician was notified of the significant change in condition and the loss of appetite. Nursing Progress Note dated 6/12/15 at 3:00 p.m., indicated the resident's family was visiting the resident. The family member indicated the resident was knocked out. The family requested the Nurse send the resident out to the hospital immediately. The Nurse then called the ambulance service who arrived at the facility at 3:35 p.m. and the resident was taken to the emergency room . Review of Lab result drawn on 6/12/15 at 5:16 p.m., at the hospital indicated the BUN was 51 a high level (normal was 8-23) and the CR was .8 (.7-1.2) The Ambulance report dated 6/12/15 indicated Dispatched to above location for complaint of patient in respiratory distress. Upon arrival found patient In bed with a nasal cannula giving him 0 2 at 10 LPM. Nurses on scene seem unaware that EMS has been contacted and no one is able to state a history of the current illness. Patient's brother is at bedside and he also denies calling EMS. Patient is in obvious respiratory distress and has fatigued respirations. Floor nurse and facility administrator were located and they state that the patient was admitted two days prior from Methodist Hospital. Patient has dx of [MEDICAL CONDITION] and [MEDICAL CONDITION] fibrosis with a DNR/DN1 signed. They state that patient refused breathing treatments, NRB therapy (as prescribed by his MD), and had stopped eating on arrival. Nurse states that patient has exhibited a steady decline since his arrival and states that the patient's brother wants him taken to the ED for IV fluid maintenance and a higher level of care. Patient's DNR is signed and a copy was brought to the ED with the patient. Patient was lifted to the cot and secured. Vitals taken, No veins noted in patient's arms suitable for venipuncture. Left EJ attempted with no success. Patient is nonverbal, unable to lift his limbs due to weakness, and has a vacant stare.(sic) Interview with the Interim Director of Nursing/Nurse Consultant on 9/17/15 at 7:30 a.m., indicated the [MEDICATION NAME] IM should not have been given without further nursing assessment on 6/11/15 on the midnight shift. She indicated there was a lack of treatment as far as the nebulizer treatments were not given as ordered every 4 hours by the Doctor as well as the PRN order had not been transcribed onto the MAR. The DoN indicated the nurse on duty during the midnight shift on 6/12/15 should have offered and/or provided an oxygen mask or tried to give the resident a breathing treatment. She indicated if a resident stated they wanted to go to the hospital, Nursing should send the resident to the hospital. She indicated the nurse on duty on 6/12/15 should have notified the DoN at some point before the ambulance had been called and/or the resident's POA for further guidance for the resident. This Federal Tag relates to Complaint IN 655 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the necessary treatment and services were provided related to monitoring a hypoglycemic (low blood sugar) reaction and insulin administration which resulted in the resident being sent to the hospital for 1 of 3 residents reviewed for hospitalization of the 6 residents who met the criteria for hospitalization . The facility also failed to ensure the necessary treatment and services were provided related to bed positioning for 1 of 2 residents reviewed for positioning of the 2 residents who met the criteria for positioning. (Residents #38 and #82) Findings include: 1. The record for Resident #82 was reviewed on 6/13/13 at 8:00 a.m. The resident's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. glucose level was less than 100 mg/dl (milligrams/deciliter). [MEDICATION NAME] (a long acting insulin) 34 units was to be given at bedtime. On 3/8/13 at 7:30 a.m., a nursing progress note indicated the resident's blood glucose was 47 mg/dl. A boxed diabetic shake was given. Thirty minutes later the blood glucose was rechecked and found to be 27 mg/dl. A [MEDICATION NAME] (high glucose medication) injection was given. Thirty minutes later the blood glucose was rechecked and found to be 64 mg/dl. There was no evidence the Physician was notified of the low blood glucose levels. Review of the diabetic flowsheet dated 3/8/13, indicated the resident received the scheduled 10 units of [MEDICATION NAME] at 12 p.m. Review of the nursing progress notes dated 3/8/13 and the diabetic flowsheet dated 3/8/13 indicated there was no evidence a blood glucose level was obtained prior to the administration of the routine [MEDICATION NAME] insulin. On 3/8/13 at 1:00 p.m., nursing progress notes indicated the resident was asleep. On 3/8/13 at 2:30 p.m., the family was at the bedside and voiced concern about the resident sleeping. The nursing progress note indicated the Physician was phoned, "...regarding +4 [MEDICAL CONDITION], pain med dosage et (sic) blood glucose level. Awaiting return call from Dr. ". Review of the Nursing progress notes and the diabetic flowsheet dated 3/8/13 indicated there was no evidence that a blood glucose level was obtained at 2:30 p.m. on 3/8/13. On 3/8/13 at 2:45 p.m., a nursing progress note indicated the Physician was called again and awaiting return call. . A nursing progress note dated 3/8/13 at 3:20 p.m., indicated family voiced a concern that the resident was suddenly "groggy". A blood glucose level was obtained and found to be 49 mg/dl. The resident was eating with assistance from family. On 3/8/13 at 3:45 p.m., a nursing progress note indicated the resident's blood glucose was rechecked and found to be 55 mg/dl. At 4:16 p.m. on 3/8/13, a nursing progress note indicated there was a new physician's orders [REDACTED]. The resident's glucose level at 4:30 p.m. on 3/8/13 was 102 mg/dl. A nursing progress note dated 3/8/13 at 4:45 p.m., indicated the glucose level was 56 mg/dl. A nursing progress note dated 3/8/13 at 5:40 p.m., indicated a new Physician order [REDACTED]. A nursing progress note dated 3/8/13 at 5:52 p.m., indicated the glucose level was 58 mg/dl. On 3/8/13 at 6:00 p.m., the Physician gave orders for the resident to be sent to the emergency room to be evaluated. A nursing progress note dated 3/8/13 at 6:10 p.m., indicated the ambulance had arrived and the resident's glucose was checked again. The glucose level was 56 mg/dl. The resident was admitted to the hospital 3/8/13 and remained there until 3/23/13. The hospital Discharge Summary, dated 3/30/13, indicated: " Treatments & Course in Hospital With Complications If Any: Patient was admitted to the hospital with [REDACTED]. . . ...Discharge DX (diagnosis) was: [DIAGNOSES REDACTED] improved, diabetes mellitus, acute [MEDICAL CONDITION]" A care plan for Diabetes Mellitus updated on 2/25/13 indicated the resident was at risk for hypo/[MEDICAL CONDITION] (low or high blood sugar). Interventions included, but were not limited to, monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and notify the physician, and to assess and record blood glucose levels as ordered. Interview with the Restorative Nurse at 3:20 p.m. on 6/13/13, indicated if a blood glucose level was low in the morning and the POS indicated to hold insulin, the administration of the afternoon dose of insulin would be " a nursing judgment". Interview with the House Supervisor on 6/14/13 at 8:35 a.m., indicated the resident's blood glucose of 64 at 8:00 a.m. on 3/8/13 should have been rechecked again and the Physician should have been notified. She further indicated a blood glucose level should have been obtained prior to administering the noon insulin. She indicated the facility's policy for [DIAGNOSES REDACTED] was not followed. The Policy and Procedure for Management of [DIAGNOSES REDACTED] was received from the Restorative Nurse on 6/13/13 at 3:20 p.m. She indicated the policy was current. The policy indicated an asymptomatic and responsive resident with blood glucose less than 70 mg/dl should be given a rapidly absorbed glucose and the blood sugar rechecked in 15 minutes. If blood sugar still less than 70 mg/dl repeat oral glucose and recheck blood sugar in 15 minutes. 2. On 6/11/13 at 9:53 a.m., Resident #38 was observed in her room in bed. The resident appeared to be sleeping, she was leaning to her left side with her head against the wall. On 6/12 at 8:42 a.m. and 10:25 a.m., 6/13 at 9:30 a.m., and on 6/17/13 at 8:45 a.m., the resident was in her room in bed sleeping. The resident was positioned on her left side and her head was not on her pillow. She was curled up into a ball at this time (fetal position). The record for Resident #38 was reviewed on 6/12/13 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was totally dependent for bed mobility with one person assist (4/2). The plan of care dated 3/19/13, indicated the resident required full assistance with bathing, dressing, and transfers related to a [DIAGNOSES REDACTED]. Interview with the House Supervisor on 6/17/13 at 12:00 p.m., indicated the resident should have had extra positioning pillows while in bed to ensure proper positioning. 3.1-37(a)

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse and put safeguards in place in order to ensure a safe environment for the residents. In addition the facility failed to notify the Administrator and Indiana State Department of Health (ISDH) immediately. This deficient practice created a systemic failure which placed all 86 residents in the facility at risk for serious harm related to abuse. The Immediate Jeopardy began on 5/19/12 at 8:30pm when nursing staff was notified of an allegation of abuse and did not put safeguards in place to protect the resident (R33) and other residents in the facility during the investigation. The survey team notified the Administrator and Director of Nursing (DON) of the Immediate Jeopardy on 5/31/12 at 3:30pm. The Immediate Jeopardy was removed and corrected on 6/7/12 at 3:55pm. Findings include: On 5/31/12 at 2:30pm, the survey team discussed with the Administrator the following two allegations of abuse. The documentation was provided by the Administrator on 5/30/12 after the Administrator had asked one of the survey team member to speak to R33 and her family regarding the two allegations of abuse that occurred on 5/19/12. 1. Review of allegation of abuse by NA1 involving R33 that occurred on 5/19/12 at 8:30pm and approximately 10:50pm, revealed that the facility failed to: a. Report allegations of abuse to the Administrator immediately b. Conduct a thorough investigation c. Put safeguards in place during the investigation d. The facility allowed NA1 to continue to work with residents from 8:30pm to 11:06pm on 5/19/12 when NA1's time card documented that she clocked out and allowed NA1 to return to work on 5/24/12 even though a thorough investigation had not been completed. 2. On 5/30/12 at 2pm, the Administrator asked the surveyor if she would talk to R33's family and R33 about an incident that occurred on Saturday, May 19, 2012. Interview with the Administrator at this time revealed that R33 stated that a nurse aide (NA1) was rough with her during incontinence care. R33 alleged physical abuse. The Administrator stated that RN1 contacted her on 5/20/12 at 2:30pm about the incident. The Administrator informed RN1 to call the police and file an incident report. On 5/30/12 at 1:50pm, the surveyor interviewed R33 and R33's family who was visiting with R33. During the interview, R33's son#2 informed the surveyor that R33 had been assaulted by NA1 on 5/19/12 at approximately 11:20pm. The son#2 stated that R33 contacted him on Sunday, May 20th at approximately 1pm to inform him that NA1 came into the room to change R33's incontinence brief. R33 reported that during the change, R33 informed son#2 that she told NA1 not to change her brief and that she did not want it changed. However, NA1 insisted she knew how to change the brief even though R33 was resistant to the change. During the change, NA1 placed both her knees on the bed, one leg between R33's knees in order to change the brief. R33 became very fearful because she had knee surgery and was afraid NA1 might hit her knee. In addition, R33 had a central IV (intravenous line) in the left arm which she tried to protect while being moved from side to side in bed. NA1 moved the entire bed against the wall to help her stabilize the bed. During this procedure, R33 informed son#2 that she was very fearful of the CNA and told her to leave her alone. The son#2 stated that they wanted R33 evaluated at the emergency room since there was a scratch on R33's left anterior hand and marks on the back of her neck. Review of R33's Nurses Notes dated 5/21/12 at 9am revealed that the resident was sent to the emergency room for evaluation and treatment for [REDACTED]. During the interview with R33 on 5/30/12 at approximately 1:30pm in the presence of her family members, R33 validated the incident with NA1. R33 informed the surveyor that she told NA1 to be careful of her arm (IV) and her knee because of the surgery she had on my knee. She stated, "she rolled me side to side and pushed my bed against the concrete wall." R33 stated she was afraid she would get hurt. R33 also informed the surveyor that another CNA, NA2, was in the room at the time of the incident helping her roommate. R33 stated that NA2 heard what was going on and came over to my bed and told NA1 to stop. NA2 informed NA1 that she knew how to change my brief and would do it. R33 stated, "(NA1) told (NA2) that (NA1) that she knew how to do this, that (sic) she would do it, even though (R33) told her to stop. (NA1) was rough with me during the changing of my brief." On 5/30/12, R33's family met with the Administrator and was informed that she had conducted an investigation and determined that the incident did not occur. The Administrator stated to the survey team during this interview was that the reason she allowed NA1 to return to work was that when the Administrator interviewed R33, R33 stated that NA1 was no rougher with her than any of the other nurse aides. NA1 was placed on a suspension 5/20/12 following the incident and returned to work on 5/24/12. The family was very upset that NA1 was allowed to return to work on another unit and stated that R33 was fearful and did not feel comfortable in the facility. The son#1 further stated that he took R33 to the candy machine today and R33 saw NA1 working on another unit. Son#1 stated that NA1 looked at R33 and R33 was very uncomfortable. 3. 5/30/12 at 5:20pm - Interview with NA1 who stated that she worked the 3-11pm shift on 5/19/12. NA1 informed the survey team that earlier in the evening of 5/19/12 about 9:30pm, she had to get R33's shirt off. Before she could take shirt off R33 started crying abuse. Then around 11pm, she told R33 that she would help her, that she was wet and would need to have the incontinence brief changed. NA1 stated that she used the draw sheet to move R33 towards the wall. NA2 came in and R33 yelled that NA1 was too rough. NA1 left the room. NA1 stated that when she used the draw sheet to move R33, the table hit the wall when the bed moved. NA1 stated that she had R33 up and that she couldn't do too much. NA1 stated she put R33 down and left. NA1 stated she got a call Sunday from RN1 to let her know that she was under investigation and that she was to contact the Administrator on Monday. The survey team asked NA1 where she was when she provided R33 incontinence care and changed her incontinence brief. NA1 stated, "in between the two beds." The survey team asked NA1 whether she notified her charge nurse or the Administrator. NA1 stated, "No. (R33) was upset. She thought that (NA1) was rough." LPN3 was the charge nurse. R33 was afraid someone would touch the IV. R33 said NA 1 was abusing her. The survey team asked NA1 again, did she say rough or abuse. NA1 said that R33 said abuse. NA1 stated that she didn't abuse her. The survey team interviewed NA2 on 5/31/12 at 10:30am regarding R33 and the incident on 5/19/12. NA2 stated it was the end of shift around 10:50pm, and she and NA1 were making last rounds. We split up. NA2 stated she went into same room with NA1. There was a wood wall divider between the two residents' beds in that room. The privacy curtain was pulled and she could not see what was going on. NA2 went around the wood wall and the privacy curtain to see what was going on. NA2 stated she felt there was tension and that both R33 and NA1 were trying to tell me what was going on. R33 grabbed NA1's arm. NA2 stated she broke it up. R33 said she didn't want NA1 to do her. NA2 stated she said OK. NA2 will do you. R33 said again that she did not want NA1 to do her anymore. The survey team asked NA2 whether she saw NA1 kneeling in the bed with R33. NA2 stated, "No I never saw (NA1) on the bed" The survey team asked whether NA2 wrote a statement about the incidents on 5/19/12. NA2 stated that she did not write down the incident until the next day. The survey team asked NA2, why she wrote in her statement that she heard (R33) "complaining." NA2 stated that it meant both R33 and NA1 were trying to talk at the same time when she came around the wood partition and entered R33's cubicle curtain. The survey team interviewed RN1 on 5/31/12 at 11:15am. RN1 stated that one of the nurses (LPN1) came to get her about the abuse. RN1 stated that R33 told her that on 5/19/12 around 11:45pm, two nurse aides came in her room and that R33 did not know one of them. R33 stated that one nurse aide was real rough with her and caused the bed to hit the wall. R33 stated this nurse aide scratched her hand and neck. R33 stated that NA1 was on her knees in R33's bed. She wanted the police called. RN1 stated she was functioning as the facility's House Supervisor and LPN1 summoned me and told me that R33 was abused. RN1 stated that R33 said she was abused and that NA1 roughed her up a bit. RN1 stated that she called the Administrator, DON and ADON. RN1 stated that she thought that the midnight shift should have written a statement and that something should have been done before I got here on 5/20/12 for the day shift. The survey team asked RN1 again about her statement that when you learned a whole shift had passed and nothing had happened. RN1 stated, "I wondered why it wasn't brought up earlier." The survey team interviewed LPN1 on 5/31/12 at 11:45am. LPN1 stated that R33 came to the nurses station in her wheelchair and stated that the CNA on 3-11 was rough with her and that she didn't like how she talked to me. LPN1 stated that she told R33 that the facility had a Weekend Supervisor and that LPN1 would contact her to come to R33's room. The survey team interviewed LPN4 on 5/31/12 at 12:10pm. LPN4 stated that about 11:45pm on 5/19/12, R33 put her call light on. "(NA3) told me that (R33) wanted to talk to me." LPN4 stated she asked R33 what do you want to report and she said she had a grievance against one of the evening nurse aides. LPN4 stated she gave R33 the wrong paperwork. LPN4 stated she gave R33 the Behavior form to write her grievance. LPN5 saw the form and told me that R33 had the wrong form, so LPN4 state she got the right form which was called the Grievance/ Complaint form. LPN4 stated she took the Grievance/complaint form back into the room and asked R33 to fill out the correct form again. LPN4 stated she reviewed the paperwork and realized that R33 didn't tell her any of the information that was on the form, so LPN4 went back to R33's room to talk to R33 about it. Before LPN4 left, LPN4 stated that R33 put the call light back on and stated she wanted to tear the paper work up, LPN4 stated she gave R33 both the Behavior form and the Grievance/complaint forms back. The survey team asked LPN4 whether she was told at the change of shift of an abuse allegation that occurred on 5/19/12 during the 3-11 shift. LPN4 stated that the previous nurse did not share that information in report. The survey team asked LPN4 did she report to the 5/20/12 day charge nurse, LPN1, what had occurred on her shift. LPN4 stated that she did not report the information to LPN1. The survey team interviewed LPN5 on 5/31/12 at 1:05pm. LPN5 confirmed the information that LPN4 had already shared about the use of the wrong forms for R33 to document the incident that occurred on 5/19/12 during the 3-11 shift. 4. The surveyor asked the Administrator to review the allegations of abuse. During an interview with Administrator on 5/31/12 at 1:50pm, the survey team questioned whether the documents found in the investigative file were all of the Administrator's notes. The Administrator confirmed at this time that all of her notes were in the file. The survey team confirmed with the Administrator that her notes did not document the time she interviewed R33 and what R33 stated when the Administrator came to the building on 5/20/12 to begin the investigation. The Administrator stated that she should have written down exactly what R33 expressed when the Administrator came to the facility on [DATE] and interviewed R33. The survey team asked whether the Administrator interviewed each of the witnesses who had written statements, especially to obtain clarification of words or statement that they wrote. The Administrator stated, "No, I did not re-interview the witnesses or question them about what they wrote in their statement. I thought the statements were acceptable." The investigative file contained the following written statements from the witnesses on 5/19/12; 3-11 and 11-7am shift and from 5/20/12 the 7-3pm shift: NA1's statement indicated, "I first went to put (R33) to bed around 8:30pm. The first time she said I was abusing her was when I tried to take her shirt off because she had an IV (intravenous) in her arm. I didn't want to get into an altercation further than what was so I asked (NA2) to finish." Review of QMA1's statement indicated that the allegation of abuse occurred on 5/19/12 at 7pm. QMA1 wrote, "I was in the room regarding (R33} meds (medication) (R33) stated 'don't pull my shirt off my head.' The CNA continued to pull her shirt off in the wheelchair, (R33) stated, 'don't be rough & (and) if you don't like your job, you don't need it.' I did not see he CNA being rough with resident." Review of LPN3's statement revealed, "date of incident and time of incident left blank for both questions." LPN3 documented, "I was in the room of (R33) at 10pm to start IV therapy. Res (resident) was alert, verbal had discussion about the IV. This nurse returned to room (R33) @ (at) 10:45pm to flush & discontinue IV therapy res. Awake & verbal no mention of any altercation at this time." The Administrator confirmed at this time that there was no documentation in the investigative file to indicate that NA1, NA2 or the QMA1 reported this incident to the charge nurse, LPN3, or to herself, the Administrator. The Administrator also confirmed that she did not clarity what LPN3 meant in her statement regarding the words "altercation." Review of the remainder of NA1's statement indicated, "Upon last rounds I got to (R33) around 10:50pm, (R33) was the last resident to be tendend (sic) to considering we started doing rounds from low number to high. (R33) allowed me to pull her gown back to check her brief. She asked me what am I doing? I replied, 'You are wet and you have to be changed.' I position (sic) her bed so her turning back and forth wouldn't be difficult. It was only when I pulled her to her side to remove the dirty brief and the bed went to the wall, no lock mechanism was 'on' on (sic) her bed, She started pinching me. I already had her up and didn't want to drop her. (NA2) came in when I pushed the last part of the brief under (R33) and (NA2) asked 'what ' s going on?' I replied, 'I'm just putting her brief on.' (NA2) told (R33) I was done. The last statement (R33) told me was 'She didn't want me to take care of her anymore.' I replied, 'No problem ' and I left to finish my shift." The Administrator confirmed that NA1's statement was documented as May 20, 2012 between 10:30pm and 11:00pm. The Administrator confirmed that she did not clarify what NA1 meant in her statement that "she did not want to drop her." Review of NA2's statement documented as "5/19/12 time of incident. I entered the room close to 11:00pm I did check (R33's) roommate at Bed B. I went to (sic) if needed help (R33) was complaining and NA1 was telling her that she was doing her job and she was calling Mam (sic) let me finish I stop (R33) from (pinching her arm and I did not see her doing anything wrong but put her brief on (R33) was frustrated She said she will not do her any more as the resident requested." Review of NA3's statement dated 5/21/12 at 6:50am, "I, (NA3's name), was called into (R33's) room on Saturday, May 20, 2012 around 11:45-12am to answer (R33's) call-light. She asked if I knew the girls (aides) working the 3-11 shift. I replied, yes, (R33) further wanted to know their names because she had a complaint about her care. I informed her that I would get the nurse so she could make concerns known. I immediately reported to (LPN4) that (R33) wanted to make a report about (NA1) . No further action was required of me at that time. Later during the shift (11-7) (LPN4) reported to me that (R33) wanted the complaint papers back so she could tear them up." Review of LPN4's statement with no date record on the statement revealed, "At 11:45p aide NA3 called me to (R33's) room, (R33) said she had a grievance against an aide. I asked her what happened & she then told me that the aide was put (sic) her to bed she told the aide to be careful because of her PICC line in left arm. The aide told her she knew what she was doing & that she had been doing this for a long time. I gave (R33) the green form to fill out. As I read her statement on the form it was different from what she had told me I then went back to the resident (R33) to question the difference between what she had told me & what was written. She said nothing. I left the room. She put on her light again & said she wanted the forms back to tear up. I asked her was she sure. She said yes & I gave the form back to her." Review of the LPN5's statement revealed, "On 5/20/12 I went to Unit 500 to ask (LPN4) a question regarding another resident . At this time (LPN4) informed me that she had a situation going on with (R33) regarding an aide on 3-11 shift. At this time I entered the room with (LPN4) to witness the residents statement. (R33) observed calm laying in bed. (LPN4) asked (R33) what happened with the aide earlier, (R33) stated the aide (NA1) came into the room to assist her with care. (R33) told the aide to be careful cause she had a PICC line in her arm. The aide told (R33) 'I have been an aide for a long time. I know what I'm doing.' (LPN4) asked were there any other problem with the aide. (R33) said 'no.' (R33) gave (LPN4) a statement on a green sheet (behavior sheet) and we left the room. When we walk (sic) to the nurse's station I showed (LPN4) the resident's grievance form. (LPN4) took the form back into (R33's) room for her to fill out." Review of R33's Mood/Behavior report sheets revealed the following, " Date 5/19/12 Time: bedtime Location during behavior (R33's room) Behavior: She was changing bed 1 diaper. She came over to my bed pulling the sheet off me. She was very ruff. (sic) I told her I didn't want her to change me. She was pushing the bed over by the wall, She kept pushing the bed against the IV machine. She pushing (sic) me from side to side." The bottom of the form indicated R33's signature and the following, "Never touch me again I have a few phone to make. (sic)" Review of the "Resident Grievance/complaint form" revealed, "date: 5/19/12, She kept pushing side to side hard against the IV machine." The form identified, "If other person involved, name them: (NA2)." The form did not have a signature of the person filing the grievance/complaint. Review of LPN1's statement revealed, "Resident report (sic) to this writer that she was abused on 3-11 shift on 5/19/12 Unable to recall CNA's name. This writer immediately informed weekend supervisor." Review of RN1's statement revealed, "Date of incident 5/19/12, Time of incident: stated 11:40pm, 1:30pm Resident stated CNA 'physically abused' her on 3-11, 5/19/12 around 11:40pm. Stated that CNA scratched her on the hand et (and) neck, also pulled sheets et caused the bed et IV pole to hit the wall Resident also stated she asked the CNA not to touch her or the bed linen et she wants police called. (sic) (names of Administrator, Director of Nursing, Assistant Director of Nursing were all ntfd (notified) of resident's complaint. Son (name) also made aware also stated CNA was on her knees in the bed." Review of RN1's timeline revealed, "425pm (sic) Police here et took statements from RN and resident/son. Police also took written (copy) of resident's complaint. 445pm (sic) Police also spoke with 3-11 nurse LPN4, who worked the previous 11-7 shift." Review of the Administrator's investigative notes revealed no date on the paper, "11:45am (NA2) was changing roommate. Did not want assigned CNA taking care of her. NA2 told other aide she would take over. Other aide was pushing her to get diaper on. Push bed against wall. Kept saying leave me alone. (NA2) said she finish other. Scratches on back & one on l (left) hand. LPN3 got the nurse-(R33), (check mark) on 3-11 CNA." The Administrator confirmed at this time that this was all of the documentation of her investigation. The Administrator confirmed that there was no documentation in her notes that she questioned the witnesses or NA1 regarding R33's statement that NA1 was up in the bed between R33's knees changing R33's incontinence brief. The Administrator confirmed that NA1's statement indicated that she did not want to drop R33. The survey team shared with the Administrator that per NA1 and NA2's interviews, that R33 was never off of the bed. NA1 stated that she rolled R33 to her left side only, place the clean incontinence brief under R33 and then rolled R33 back onto her back. The Administrator confirmed at this time that she did not question NA1's written statement, should have reviewed the statement and documented in her notes exactly how NA1 turned R33 to remove the wet incontinence brief and place a clean brief under R33. The Administrator informed the survey team that she suspended NA1 from 5/20/12 to 5/24/12 at which time she allowed NA1 to return to work. The survey team questioned why NA1 was allowed to return to work. The Administrator stated at this time it was because the investigation was completed and she determined that abuse had not occurred. The survey team questioned the Administrator to explain how she determined that abuse had not occurred. The Administrator stated, "I interviewed (R33) and she stated that (NA1) was no rougher with her than any of the others." The survey team questioned the Administrator whether she had questioned R33 about her comment. The Administrator stated, "No, I did not." During the interview with the Administrator on 5/31/12 at 2pm, the survey team asked whether the Administrator had obtained a copy of the police report as specified in the facility's Abuse policy and to review the information in order to conduct a thorough investigation. The Administrator stated that she did not go to the police station to get the report. The survey team asked the Administrator whether she questioned QMA1 why the time she recorded the incident as occurring was 7pm, while NA1 stated the first allegation of abuse occurred at 8:30pm on 5/19/12 and the second incident occurred at around 10:50pm on 5/19/12. The Administrator stated that she did not question the recording of the time. On 5/31/12 at 2pm, the Administrator confirmed that based on what was documented in the investigative packet she (Administrator) was not notified immediately after the first allegation of abuse at 8:30pm on 5/19/12 or after the 10:50pm incident on 5/19/12. Further, the Administrator confirmed that ISDH was not notified until late in the afternoon on 5/20/12 and that NA1 should have been immediately sent home on 5/19/12 after the 8:30pm allegation of abuse in an effort to put safeguards in place to protect R33 and all of the residents in the facility. The Administrator showed the survey team NA1's time card and that NA1 was allowed to work until her shift finished at 11:06pm. The Immediate Jeopardy that began on 5/19/12 at 8:30pm was removed on 6/7/12 at 3:55pm when the facility implemented the following plan of action: a. The facility created an Investigative team, that consisted of the Administrator, DON and Nurse Consultant, who would be responsible for implementing the facility's Abuse policies, which would include a thorough investigation and reporting system. 1. The Administrator placed NA1 on suspension while a thorough investigation into the allegations of abuse were completed. 2. The Administrator developed a tool that identifies steps to take as soon as an allegation is identified. The tool included who to notify, how to complete the incident report and how to conduct a complete and thorough investigation. 3. Throughout the facility, the Administrator posted the Administrator's contact information and an Abuse algorithm that described step by step instructions relative to how to identify abuse, protect the resident and other residents in the facility and notification of the Administrator. 4. The Administrator developed an inservice education program that covered all of the aspects relative to investigating and reporting resident alleged abuse. The Administrator posted her personal cell phone number in all bulletin boards for more accessibility by staff and they were told to call that number any hour, day or night. a. The Administrator, DON, and ADON mandated that all employees that were on the premises on 6/1/12 through 6/6/12 attend an inservice and add their name to a sign in sheet. Those who were not on the premises were phoned at home to see if they could come to the facility to complete the inservice education. Those employees who could not come to the facility by 6/6/12 had to complete the inservice before they returned to work. 5. The Administrator developed an Investigation check list that was intended to be a tool to ensure policies, procedures and education programs were being implemented thoroughly. The check list included: the name of the person completing the audit, the date the audit was completed, and the step by step instructions for documenting the allegation of abuse, protection of resident(s), notification of the Administrator and State Agency immediately, how to conduct a thorough investigation, preparation of the final report, review of the investigative documentation by the Consultant Nurse and notification of appropriate agencies to include the State Agency by the 5th day after the reporting of the allegation. 6. The check list would be completed after every allegation of abuse as an ongoing process. To monitor the facility's performance and to ensure the plan of action was sustained, the Administrator or designee will audit all reports of abuse and neglect for completeness and thoroughness. The results of the check list monitoring and the audits will be reviewed and reported to the monthly Quality Committee meeting for review and recommendations. Quality Committee will determine if further audits are needed. After the facility implemented their plan of action to remove the Immediate Jeopardy at F225, the survey team reviewed all of the documents provided by the Administrator and conducted interviews in person and via telephone. Of the over 33 employees which consisted of staff from each department and all three shifts if applicable. The staff that were interviewed. They all understood how to identify and report alleged abuse and neglect immediately to the Administrator. The survey team verified that the facility had put safeguards in place, such as the removal of NA1 until a thorough investigation was completed, training of facility staff regarding the Abuse policy to notify the Administrator immediately of any allegation of abuse and to send the employee involved home immediately in order to protect all of the residents. The survey team conducted interviews with the Administration and they assured the survey team that this process would continue in the future.

Based on interview and record review, the facility failed to operationalize the facility's Abuse policy and ensure that all allegations of abuse would be thoroughly investigated, that safeguards would be put into place to ensure a safe environment for the residents, report all allegations of abuse immediately to the Administrator and that a suspected employee would be immediately suspended until the investigation was completed. This deficient practice created a systemic failure which put all 86 residents in the facility at risk for serious harm related to abuse. The Immediate Jeopardy began on 5/19/12 at 8:30pm when nursing staff were aware that R33 felt she had been abused and did not implement the facility's Abuse policy to notify the Administrator immediately, conduct a thorough investigation, or put safeguards in place to protect residents during the investigation. The survey team notified the Administrator and Director of Nursing (DON) of the Immediate Jeopardy on 5/31/12 at 3:30pm. The Immediate Jeopardy was removed and corrected on 6/7/12 at 3:55pm. Findings include: 1. Review of the facility's Abuse policy dated 10/19/07 revealed, "Section IV, Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator ...Supervisor shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. Section V, ...Employees of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accuse (sic) of possible mistreatment shall not complete the shift as direct care provider to the resident. Section VI, item 5. Final investigation Report ...If there is a police report, attach the police report." A. Review of an allegation of abuse by NA1 involving R33 that occurred on 5/19/12 at 8:30pm and 10:50pm, revealed that the facility failed to operationalize the facility's Abuse policy regarding: 1.) Reporting allegations of abuse to the Administrator immediately 2.) Conducting a thorough investigation 3.) Putting safeguards in place during the investigation 4.) Allowing NA1 (alleged perpetrator) to continue to work with residents from 8:30pm to 11:06pm when NA1's time card documented that she clocked out and allowed NA1 to return to work on 5/24/12 even though a thorough investigation had not been completed in order to determine that abuse had or had not occurred. B. On 5/30/12 at 2pm, the Administrator asked the surveyor if she would talk to a family about an incident that occurred on Saturday, May 19, 2012 with R33. Interview with the Administrator at this time revealed that R33 stated that a nurse aide (NA1) was rough with her during incontinence care. R33, alleged physical abuse. The Administrator stated that RN 1 contacted her on 5/20/12 at 2:30pm about the incident. The Administrator informed RN1 to call the police and file an incident report. On 5/30/12 at 1:50pm, the surveyor interviewed R33's family who was visiting with R33. During the interview, R33's son#2 informed the surveyor that R33 had been assaulted by NA1 on 5/19/12 at approximately 11:20pm. The son#2 stated that R33 contacted him on Sunday, May 20th at approximately. 1pm to inform him that NA1 came into the room to change R33's incontinence brief. During the change, R33 informed son#2 that she told NA1 not to change her brief and that she did not want it changed. However, NA1 insisted she knew how to change the brief even though R33 was resistant to the change. During the change, NA1 placed both her knees on the bed, one leg between R33's knees in order to change the brief. R33 became very fearful because she had knee surgery and was afraid NA1 might hit her knee. In addition, R33 had a central IV line in the left arm which she tried to protect while being moved from side to side in bed. NA1 moved the entire bed against the wall to help her stabilize the bed. During this procedure, R33 informed son#2 that she was very fearful of the CNA and told her to leave her alone. The son#2 stated that they wanted R33 evaluated at the emergency room since there was a scratch on R33's left anterior hand and marks on the back of her neck. Review of R33's Nurses Notes dated 5/21/12 at 9am revealed that the resident was sent to the emergency room for evaluation and treatment for [REDACTED]. During the interview with R33 on 5/30/12 at approximately 1:30pm in the presence of her family members, R33 validated the incident with NA1. R33 informed the surveyor that she told NA1 to be careful of "my arm (IV) and my knee because of the surgery to my knee. (NA1) rolled me side to side and pushed my bed against the concrete wall. (R33) stated she was afraid she would get hurt." R33 also informed the surveyor that another CNA, "(NA2), was in the room at the time of the incident helping my roommate." R33 stated that "(NA2) heard what was going on and came over to my bed and told (NA1) to stop. (NA2) informed (NA1) that she knew how to change her brief and would do it. However (NA1) told (NA2) and (R33) that she knew how to do this, she will do it, even though (R33) told her to stop." R33 stated, "(NA1) was rough with me during the changing of my brief." On 5/30/12, R33's family met with the Administrator and was informed that she had conducted an investigation and determined that the incident did not occur. The NA1 was placed on a suspension 5/20/12 following the incident and returned to work on 5/24/12. The family was very upset that the NA1 was allowed to return to work on another unit and stated that R33 was fearful and did not feel comfortable in the facility. The son#1 further stated that he took R33 to the candy machine today and R33 saw NA1 working on another unit. Son#1 stated that NA1 looked at R33 and R33 was very uncomfortable. 3. 5/30/12 at 5:20pm - Interview with NA1 who stated she worked the 3-11pm shift on 5/19/12. NA1 informed the survey team that earlier in the evening of 5/19/12 about 9:30pm, she had to get R33's shirt off. Before she could take shirt off R33 started crying abuse. Then around 11pm NA1 stated she told R33 that she would help her, that she was wet and NA1 stated she had to change the incontinence brief. NA1 stated she used the draw sheet to move R33 towards the wall. NA2 came in and R33 yelled that NA1 was too rough. NA1 stated she left the room. When she used the draw sheet to move R33, the table hit the wall when the bed moved. NA1 stated she had her up, she couldn't do too much. NA1 stated she put her down and left. NA1 got a call Sunday from RN1 to let her know that she was under investigation and that she was to contact the Administrator on Monday. The survey team asked NA1 where she was when she provided R33 incontinence care and changed her incontinence brief. NA1 stated, "in between the two beds." The survey team asked NA1 whether she notified her charge nurse or the Administrator. NA1 stated, "No. (R33) was upset. (R33) thought I was rough. (LPN3) was the charge nurse. (R33) was afraid someone will touch the IV. (R33) said that (NA1) was abusing her." The survey team asked NA1 again, did R33 say rough or abuse. NA1 said that R33 said abuse. NA1 stated she didn't abuse her. The survey team interviewed NA2 on 5/31/12 at 10:30am regarding R33 and the incident on 5/19/12 NA2 stated it was the end of shift around 10:50pm, and NA1 and she were making last rounds. NA2 stated, "We split up." NA2 stated she went into same room with NA1. There was a wood wall divider between the two residents' beds in that room. The privacy curtain was pulled and she could not see what was going on. NA2 stated she went around the wood wall and the privacy curtain to see what was going on. NA2 stated that she felt there was tension and that both "(R33) and (NA1) was trying to tell me what was going on." NA2 stated that R33 grabbed NA1's arm. NA2 stated she broke it up. R33 said she didn't want NA1 to do her. NA2 said OK that she would do R33. R33 said again that she did not want NA1 to do her anymore. The survey team asked NA2 whether she saw NA1 kneeling in the bed with R33. NA2 stated, "No I never saw NA1 on the bed." The survey team asked whether NA2 wrote a statement about the incidents on 5/19/12. NA2 stated that she did not write down the incident until the next day. The survey team asked NA2, that in her written statement she wrote, she heard (R33) "complaining." NA2 stated that meant both R33 and NA1 were trying to talk at the same time when she came around the wood partition and entered R33's cubicle curtain. The survey team interviewed RN1 on 5/31/12 at 11:15am. RN1 stated that one of the nurses (LPN1) came to get her about the abuse. RN1 stated that R33 told her that on 5/19/12 around 11:45pm, two nurse aides came in her room and that R33 did not know one of them. R33 stated that one nurse aide was real rough with her and caused the bed to hit the wall. R33 stated this nurse aide scratched her hand and neck. R33 stated that NA1 was on her knees in R33's bed. She wanted the police called. RN1 stated she was functioning as the facility's House Supervisor and LPN1 summoned me and told me that R33 was abused. RN1 stated that R33 said she was abused and that NA1 roughed her up a bit. RN1 stated that she called the Administrator, DON and ADON. RN1 stated that she thought that the midnight shift should have written a statement and that something should have been done before I got here on 5/20/12 for the day shift. The survey team asked RN1 again about her statement that when you learned a whole shift had passed and nothing had happened. RN1 stated she wondered why it wasn't brought up earlier. The survey team interviewed LPN1 on 5/31/12 at 11:45am. LPN1 stated that R33 came to the nurses station in her wheelchair and stated that the CNA on 3-11 was rough with me and didn't like how she talked to me. LPN1 stated that she told R33 that the facility had a Weekend Supervisor and that LPN1 would contact her to come to R33's room. The survey team interviewed LPN4 on 5/31/12 at 12:10pm. LPN4 stated that about 11:45pm on 5/19/12, R33 put her call light on."(NA3) told me that (R33) wanted to talk to me. (LPN4) stated she asked (R33) what do you want to report and she said she had a grievance against one of the evening nurse aides." LPN4 stated she gave R33 the wrong paperwork. LPN4 stated she gave R33 the Behavior form to write her grievance. LPN5 saw the form and told me that the wrong form was given to R33, so LPN4 stated she got the right form called Grievance/ Complaint form. LPN4 stated she took the Grievance/complaint form back into the room and asked R33 to fill out the correct form again. LPN4 stated she reviewed the paperwork and realized that R33 didn't tell her any of the information that was on the form, so LPN4 stated she went back to R33's room to talk to her about it. Before LPN4 left, R33 put the call light back on and stated she wanted to tear the paper work up. LPN4 stated she gave R33 both the Behavior form and the Grievance/complaint forms. The survey team asked LPN4 whether she was told at the change of shift of an abuse allegation that occurred on the 5/19/12 during the 3-11 shift. LPN4 stated that the previous nurse did not share that information in report. The survey team asked LPN4 did she report to the 5/20/12 day charge nurse, LPN1 what had occurred on her shift. LPN4 stated that she did not report the information to LPN1. The survey team interviewed LPN5 on 5/31/12 at 1:05pm. LPN5 confirmed the information that LPN4 had already shared about the use of the wrong forms for R33 to document the incident that occurred on 5/19/12 during the 3-11 shift. 4. The surveyor asked the Administrator to review the allegations of abuse. Interview with Administrator on 5/31/12 at 1:50pm, the survey team questioned whether the documents found in the investigative file were all of the Administrator's notes. The Administrator confirmed at this time that all of her notes were in the file. The survey team confirmed with the Administrator that her notes did not document the time she interviewed R33 on 5/20/12 and what R33 stated when the Administrator came to the building on 5/20/12 to begin the investigation. The Administrator stated that she should have written down exactly what R33 expressed when the Administrator came to the facility on [DATE] to interview R33. The survey team asked whether the Administrator interviewed each of the witnesses who had written statements, especially to obtain clarification of words or statement that they wrote. The Administrator stated, "No, I did not re-interview the witnesses or question them about what they wrote in their statement. I thought the statements were acceptable." The investigative file contained the following written statements from the witnesses on 5/19/12; 3-11 and 11-7am shift and from 5/20/12 the 7-3pm shift: NA1's statement indicated, "I first went to put (R33) to bed around 8:30pm. The first time she said I was abusing her was when I tried to take her shift off because she had an IV (intravenous) in her arm. I didn't want to get into an altercation further than what is was so I asked (NA2) to finish." Review of QMA1's statement indicated that the allegation of abuse occurred on 5/19/12 at 7pm. QMA1 wrote, "I was in the room regarding (R33) meds (medication) stated don't pull my shirt off my head. The CNA continued to pull her shirt off in the wheelchair, (R33) stated don't be rough & (and) if you don't like your job, you don't need it. I did not see the CNA being rough with resident." Review of LPN3's statement revealed, "date of incident and time of incident left blank for both questions." LPN3 documented, "I was in the room of (R33) at 10pm to start IV therapy. Res (resident) was alert, verbal had discussion about the IV. This nurse returned to room (R33) @ (at) 10:45pm to flush & discontinue IV therapy res. Awake & verbal no mention of any altercation at this time." The Administrator confirmed at this time that there was no documentation in the investigative file to indicate that NA1, NA2 or the QMA1 reported this incident to the charge nurse, LPN3, or to herself, the Administrator. The Administrator also confirmed that she did not clarity what LPN3's meant in her statement regarding the word "altercation." Review of the remainder of NA1's statement indicated, "Upon last rounds I got to (R33) around 10:50pm, (R33) was the last resident to be tendend (sic) to considering we started doing rounds from low number to high. (R33) allowed me to pull her gown back to check her brief. She asked me what am I doing? I replied, 'You are wet and you have to be changed.' I position her bed so her turning back and forth wouldn't be difficult. It was only when I pulled her to her side to remove the dirty brief and the bed went to the wall, no lock mechanism was 'on' on (sic) her bed, She started pinching me. I already had her up and didn't want to drop her. (NA2) came in when I pushed the last part of the brief under (R33) and (NA2) asked 'what's going on?' I replied, 'I'm just putting her brief on.' (NA2) told (R33) I was done. The last statement (R33) told me was 'She didn't want me to take care of her anymore.' I replied 'No problem' and I left to finish my shift." The Administrator confirmed that NA1' statement was documented as May 20, 2012 with the time recorded as between 10:30pm and 11:00pm. The Administrator confirmed that she did not clarify what NA1 meant in her statement that "she did not want to drop her." Review of NA2's statement documented as "5/19/12 time of incident. I entered the room close to 11:00pm I did check R33's roommate at Bed B. I went to (sic) if needed help (R33) was complaining and (NA1) was telling her that she was doing her job and she was calling Mam (sic) let me finish I stop. (R33) from (pinching her arm and I did not see her doing anything wrong but putter her brief on (R33) was frustrated She said she will not do her any more as the resident requested." Review of NA3's statement dated 5/21/12 at 6:50am, "I, (NA3's name), was called into (R33's) room on Saturday, May 20, 2012 around 11:45-12am to answer (R33's) call-light. She asked if I knew the girls (aides) working the 3-11 shift. I replied, yes, (R33) further wanted to know their names because she had a complain about her care. I informed her that I would get the nurse so she could make concerns known. I immediately reported to (LPN4) that (R33) wanted to make a report about (NA1) . No further action was required of me at that time. Later during the shift (11-7) (LPN4) reported to me that (R33) wanted the complaint papers back so she could tear them up." Review of LPN4's statement with no date record on the statement revealed, "At 11:45p aide (NA3) called me to (R33's) room, (R33) said she had a grievance against a aide. I asked her what happened & she then told me that the aide was put her to bed she told the aide to be careful because of her PICC line in left arm the aide told her she knew what she was doing & that she had been doing this for a long time. I gave (R33) the green form to fill out as I read her statement on the form it was different from what she had told me I then went back to the resident (R33) to question the difference between what she had told me & what was written. She said nothing I left the room She put on her light again & said she wanted the forms back to tear up I asked her was she sure She said yes & I gave the form back to her." Review of the LPN5's statement revealed, "On 5/20/12 I went to Unit 500 to ask (LPN4) a question regarding another resident . At this time (LPN4) informed me that she had a situation going on with (R33) regarding an aide on 3-11 shift. At this time I entered the room with (LPN4) to witness the residents statement. (R33) observed calm laying in bed. (LPN4) asked (R33) what happened with the aide earlier, (R33) stated the aide (NA1) came into the room to assist her with care. (R33) told the aide to be careful cause sh had a PICC line in her arm. The aide told (R33) 'I have been an aide for a long time. I know what I'm doing.' (LPN4) asked were there any other problem with the aide. (R33) said 'no.' (R33) gave (LPN4) a statement on a green sheet (behavior sheet) and we left the room. When we walk to the nurse's station I showed (LPN4) the resident's grievance form. (LPN4) took the form back into (R33) ' s room for her to fill out." Review of R33's Mood/Behavior report sheets revealed the following, "Date 5/19/12 Time: bedtime Location during behavior (R33's room) Behavior She was changing bed 1 diaper. She came over to my bed pulling the sheet off me. She was very ruff. (sic) I told her I didn't (sic) want her to change me. She was pushing the bed over by the wall, She kept pushing the bed against the IV machine. She pushing me from side to side." The bottom of the form indicated R33's signature and the following, "Never touch me again I have a few phone to make. (sic)" Review of the "Resident Grievance/complaint form" revealed, "date: 5/19/12, She kept pushing side to side hard against the IV machine." The form identified, "If other person involved, name them: (NA2)." The form did not have a signature of the person filling the grievance/complaint. Review of LPN1's statement revealed, "Resident report to this writer that she was abused on 3-11 shift on 5/19/12 Unable to recall CNA's name. This writer immediately informed weekend supervisor." Review of RN1's statement revealed, "Date of incident 5/19/12 Time of incident: stated 11:40pm, 1:30pm Resident stated CNA 'physically abused ' her on 3-11 5/19/12 around 11:40pm Stated that CNA scratched her on the hand et (and) neck, also pulled sheets et caused the bed et IV pole to hit the wall Resident also stated she asked the CNA not to touch her or the bed linen et she wants police called. (names of Administrator, Director of Nursing, Assistant Director of Nursing were all ntfd( notified) of resident's complaint. Son (name) also made aware also stated CNA was on her knees in the bed." Review of RN1's timeline revealed "425pm (sic) Police here et took statements from RN and resident/son. Police also took written (copy) of resident's complaint. 445pm (sic) Police also spoke with 3-11 nurse (LPN4), who worked the previous 11-7 shift." Review of the Administrator's investigative notes revealed no date of the paper, "11:45am (NA2) was changing roommate. Did not want assigned CNA taking care of her. (NA2) told other aide she would take over. Other aide was pushing her to get diaper on. Push bed against wall. Kept saying leave me along. (NA2) said she finish other. Scratches on back & one on l (left) hand. (LPN3) got the nurse-(R33), (check mark) on 3-11 CNA." The Administrator confirmed at this time that this was all of the documentation of her investigation. The Administrator confirmed that there was no documentation in her notes that she questioned the witnesses or NA1 regarding R33's statement that NA1 was up in the bed between R33's knees changing R33's incontinence brief. The Administrator confirmed that NA1's statement indicated that she did not want to drop R33. The survey team shared with the Administrator that per NA1 and NA2's interviews, that R33 was never off of the bed. NA1 stated that she rolled R33 to her left side only, placed the clean incontinence brief under R33 and then rolled R33 back onto her back. The Administrator confirmed at this time that she did not question NA1's written statement, should have reviewed the statement and documented in her notes exactly how NA1 turned R33 to remove the wet incontinence brief and place a clean brief under R33. The Administrator informed the survey team that she suspended NA1 from 5/20/12 to 5/24/12 at which time she allowed NA1 to return to work. The survey team questioned why NA1 was allowed to return to work. The Administrator stated at this time it was because the investigation was completed and she determined that abuse had not occurred. During the interview with the Administrator on 5/31/12 at 2pm, the survey team asked whether the Administrator had obtained a copy of the police report as specified in the facility's Abuse policy and to review the information in order to conduct a thorough investigation. The Administrator stated that she did not go to the police station to get the report. The survey team asked the Administrator whether she questioned QMA1 why the time she recorded the incident as occurring was 7pm, while NA1 stated the first allegation of abuse occurred at 8:30pm on 5/19/12 and the second incident occurred at around 10:50pm on 5/19/12. The Administrator stated that she did not question the recording of the time. On 5/31/12 at 2pm, the Administrator confirmed that based on what was documented in the investigative packet she (Administrator) was not notified immediately after the first allegation of abuse at 8:30pm on 5/19/12 or after the 10:50pm incident on 5/19/12. Further, the Administrator confirmed that ISDH was not notified until late in the afternoon on 5/20/12 and that NA1 should have been immediately sent home on 5/19/12 after the 8:30pm allegation of abuse in an effort to put safeguards in place to protect R33 and all of the residents in the facility. The Administrator showed the survey team NA1's time card and that NA1 was allowed to work until her shift finished at 11:06. The Immediate Jeopardy began on 5/19/12 at 8:30pm and was removed on 6/7/12 at 3:55pm when the facility implemented the following plan of action: a. The facility created an Investigative team, that consisted of the Administrator, DON and Nurse Consultant, who would be responsible for implementing the facility's Abuse policies, which would include a thorough investigation and reporting system. 1. The Administrator placed NA1 on suspension while an thorough investigation into the allegations of abuse was completed. 2. Developed a tool that identifies steps to take as soon as an allegation is identified. The tool included who to notify, how to complete the incident report and how to conduct a complete and thorough investigation. 3. Throughout the facility, the Administrator posted the Administrator's contact information and an Abuse algorithm that described step by step instructions relative to how to identify abuse, protect the resident and other residents in the facility and notification of the Administrator. 4. The Administrator developed an inservice education program that covered all of the aspects relative to investigating and reporting resident alleged abuse. The Administrator posted her personal cell phone number in all bulletin boards for more accessibility by staff and they were told to call that number any hour day or night. a. The Administrator, DON, and ADON mandated that all employees that were on the premises on 6/1/12 through 6/6/12 attend an inservice and add their name to a sign in sheet. Those who were not on the premises were phoned at home to see if they could come to the facility to complete the inservice education. Those employees who could not come to the facility by 6/6/12 had to complete the inservice before they returned to work. 5. The Administrator developed an Investigation check list that was intended to be a tool to ensure policies, procedures and education program were being implemented thoroughly. The check list included: the name of the person completing the audit, the date the audit was completed, and the step by step instructions for documenting the allegation of abuse, protection of resident(s), notification of the Administrator and State Agency immediately, how to conduct a thorough investigations, preparation of the final report, review of the investigative documentation by the Consultant Nurse and notification of appropriate agencies to include the State Agency by the 5th day after the reporting of the allegation. 6a. The check list would be completed after every allegation of abuse as an ongoing process. To monitor the facility's performance and to ensure the plan of action was sustained, the Administrator or designee will audit all reports of abuse and neglect for completeness and thoroughness. The results of the check list monitoring and the audits will be reviewed and reported to the monthly Quality Committee meeting for review and recommendations. Quality Committee will determine if further audits are needed. 6b. The Administrator will conduct audits with five employees weekly regarding the types of abuse and what they would do if they witnessed, heard about, or suspected abuse of a resident or misappropriation of a resident's property, and correct any in-correct responses immediately and report in the Quarterly QA meeting the results of these audits. After the facility implemented their plan of action to remove the Immediate Jeopardy at F226, the survey team reviewed all of the documents provided by the Administrator and conducted interviews in person and via telephone. Of the over 33 employees employed in every department of the facility and on all three shifts when applicable, all interviews revealed that they all understood how to identify and report alleged abuse and neglect immediately to the Administrator. The survey team also determined during the 33 employees interviews that all staff understood the Abuse policy, understood that when an abuse allegation occurred, the employee was to be sent home immediately until the investigation was completed in order to protect all of the residents in the facility. The survey team conducted interviews with the Administration and they assured the survey team that this process would continue in the future.

Based on record review and interview the facility failed to ensure residents received adequate supervision for 3 of 7 residents reviewed for behaviors in a sample of 11 related to a resident wandering into other resident's room with no interventions provided and a resident with territorial behavior to residents approaching his room with no interventions provided resulting in Resident #B approaching Resident #C's room, a confrontation between Resident #C and Resident #B, resulting in Resident #B falling, being taken to the hospital with multiple ecchymosis (bruises) on the face and a bilateral brain contusion (bruise) and subarachnoid hemorrhage (brain bleed) and subsequently dying. (Resident #B, Resident #C, and Resident #M) The Immediate Jeopardy began on [DATE] when Resident #B was walking past Resident #C's room, CNA #1 heard Resident #C yelling, heard a slap and thump and walked around the pulled room curtain to find Resident #B lying on the floor in the doorway of Resident #C's room. CNA #1 asked Resident #C what he had done and Resident #C, stated "you ain' t s---). The Administrator was notified of the immediate jeopardy at 11:55 a.m. on [DATE]. The immediate jeopardy was removed on [DATE] at 11:15 a.m., but non compliance remained at the lower scope and severity level of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings included: The closed record of Resident #B was reviewed on [DATE] at 7:14 p.m. Her [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A nursing note dated [DATE] at 3:40 a.m., indicated the resident was redirected from wandering into other resident's rooms and off of the unit during sleeping hours. A nursing note dated [DATE] at 5:00 p.m., indicated the resident was observed wandering in other resident's rooms on the unit. The resident's behavior was re-directed by staff at this time. A nursing note dated [DATE] at 1:15 p.m., indicated the resident continued to wander throughout the facility and in co-resident's rooms. The resident was redirected and diversions attempted with temporary results. A nursing note dated [DATE] at 9:30 p.m., indicated the resident was observed wandering on Unit 200 going in and out of other resident's room. The resident was redirected several times back to her room. A nursing note dated [DATE] at 12:00 p.m., indicated the resident requires constant redirection related to wandering often in other resident's room. A nursing note dated [DATE] at 5:30 p.m., indicated the resident was observed wandering in other resident's room on Unit 200. The resident was redirected by staff at this time. A nursing note dated [DATE] at 4:30 p.m., indicated the resident was noted wandering in other resident's room at this time. The resident was redirected to her room. A nursing note dated [DATE] at 6:00 p.m., indicated the resident was observed wandering towards Unit 300 and had attempted to go into another resident's room. The resident was redirected by staff at this time back to Unit 200. A nursing note dated [DATE] at 6:00 p.m., indicated the resident was observed wandering into room on Unit 300. The resident was redirected by staff at this time back to Unit 200. A nursing note dated [DATE] at 4:00 a.m., indicated resident received in bed asleep and slept the duration of the night until 3:50 a.m. The resident ambulated with a steady gait, no agitation was noted. at 6:30 a.m. a late entry was made for 4:15 a.m. indicating the resident was ambulating in the hallway in a pleasant mood. Care was provided by staff with no problems. The resident was given a toy doll and she began to talk to it, smile and sit with the baby. The resident was offered a puzzle, snacks and water and cooperated completely with staff. Some redirection was needed to keep the resident in eye sight of staff. At 6:30 a.m. the resident was observed laying on the ground in front of (Resident #C's room number) in the hallway on her left side. She did not respond to her name being called. Carotid pulse was palpable and emergency response was called (911). Pupils were fixed at 5. The resident remained unresponsive for 45 seconds. The resident began to make sounds that were not words and continued to do so for approximately 30 seconds. The resident then began to speak in complete sentences. The resident's right ear was observed to be bright red and warm to touch. The resident complained of pain to her ear. After the resident was responsive she began to try and get up but was directed to lay still. The resident complained of pain to the left side. The resident was taken to the hospital by ambulance for evaluation. The physician and family were notified. A hospital records provided by the facility and reviewed on [DATE] at 2:00 p.m., indicated on the H & P (History and Physical) Note on [DATE] the chief complaint of a subarachnoid hemorrhage. "(Resident #B's name and age) female admitted with history of Alzheimer's disease at present he (sic) was at the nursing home was pushed by another resident and fell down she was noted to have multiple ecchymosis on the face she was brought to the ER (emergency room ) where she was noted to have bilateral brain contusion and a subarachnoid hemorrhage she is now admitted to the ICU (Intensive Care Unit) for further treatment and already been seen by neurosurgeon. A physician Discharge Summary indicated an admitted of [DATE]. The hospital course: "patient was seen and evaluated in the ER, found to have brain contusion and SAH (subarachnoid hemorrhage), admitted to ICU, no intervention was recommended by neuro surgery service, patient was made DNR (Do Not Resuscitate), and started on comfort care, expired [DATE], 11:11 a.m. A social service note dated [DATE] indicated a mood/behavioral sheet for [DATE] was received indicating that the resident was wandering into other resident's rooms and cursing staff for re-directing her. A second mood behavior sheet indicated that the resident was exit seeking and cursing at others. A third mood/behavior sheet indicated the resident was wandering into other rooms and cursing at CNA's. Re-direction and 1:1 were used with resident. An Institute for Health Behavior Change, Clinical Assessment form dated [DATE] and signed by the Psychologist indicated a problem of the resident reportedly had been displaying altered mental status, she had been displaying irritable mood, was argumentative and was insensitive to others. She also intruded into the privacy of other residents. The approach was for behavioral interventions to manage problem behavior. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated The resident could be understood and understands others. She scored a 3 on her Brief Interview for Mental Status which indicated she was severely impaired cognitively. She had disorganized thinking and wandering occurred daily. Review of the Behavior Weekly Meet dated [DATE] and provided by the Social Service Director on [DATE] at 2:45 p.m. indicated Resident #B with a behavior problem of wandering and wandering into rooms. The current intervention was Psychiatrist and Psychologist. A Behavioral Management Documentation for [DATE] provided by the Social Service Director on [DATE] at 2:45 p.m., indicated [DATE] on the ,[DATE] shift a behavior of continuous pacing or wandering in the hallway. The interventions provided were re-direction, one-on-one, and gave food or snack. The interventions had a positive outcome. The resident's care plans were reviewed and there were no care plans regarding the resident's wandering into other resident's room. The resident's care plans included: taking medication for depression, adjustment to nursing home placement, potential for increasing confusion secondary to dementia, potential for increasing confusion secondary to Alzheimer's disease which was initiated on [DATE], potential to exhibit signs or emotional distress and verbally abusive which were initiated on [DATE], at nutritional risk and alteration in skin integrity which were initiated on [DATE], and elopement risk which was initiated on [DATE]. Interview with the Administrator on [DATE] at 9:00 a.m., indicated she would have to see if Resident #B had a care plan for wandering into other resident's rooms. The Administrator had no additional information to add during the survey process. Interview with the Social Service Director on [DATE] at 2:15 p.m., indicated Resident #B did wander into other resident's rooms. She indicated the resident was to be monitored, redirected, and one on one if possible. She indicated she would meet with the CNAs and discuss the issue but it was not documented. She could not educate Resident #B because she would not remember. She further indicated Resident #B did not wander at specific times of day it was all of the time. She also indicated Resident #B did not attempt to open doors she went into rooms where the door was open. She further indicated Resident #B had an incident with Resident # M when Resident #B entered Resident #M's room. At this time Resident #M yelled at Resident #B and when Resident #B would not leave her room she threw a cup of water with melted ice at Resident #B. The Social Service Director indicated at that time she indicated to staff to have a watchful eye on the resident. The Social Service Director indicated this was the same plan that was in place prior to the incident. She also indicated there was usually one CNA on the unit and sometime a nurse but other times a nurse floats between Units 200 and 300. She indicated if there was only one nurse and she was on Unit 300 and the CNA was in a room with another resident there would be no one to monitor Resident #B. There was no documentation in the resident's records of the incident of the resident entering another resident's room and having water thrown at her or of any interventions being put in place in regards to the resident wandering into other resident's rooms. Interview with the Administrator on [DATE] at 10:40 a.m., indicated the one-on-one intervention on the Behavior Documentation Form was for "a moment in time". The one-on-one would be stopped once the behavior ceases. Interview with the MDS Coordinator on [DATE] at 2:17 p.m., indicated when the resident's MDS was completed she did not understand if areas triggered it was her responsibility to make sure a care plan was in place. She further indicated different sections of the MDS are completed by different staff members such as Social Service. She also indicated when the MDS for [DATE] was completed and the wandering triggered she did not know she needed to complete a care plan or provide a reason as to why the care plan was not completed. The record for Resident #M was reviewed on [DATE] at 2:50 p.m. The resident's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], indicated the resident made herself understood and had the ability to understand. She scored a 15 on the Brief Interview of Mental Status indicating she was cognitively intact. Interview with Resident #M on [DATE] at 2:30 p.m. with the Social Service Director present, indicated the resident self propelled her wheelchair to her room which was located at the end of Unit 200 by the exit door. She was the only resident in the room. Resident #M indicated she had a lot of pain in her feet due to gout. She indicated they hurt very much, she also indicated that she had just quit smoking and she wanted to smoke so being frustrated with all of her issues, "I was getting tired of residents coming in my room." Resident #M stated that one day Resident #B entered my room and she came all the way in my room, the door was always open, so she would always walk in my room. She would walk towards my bed and closet and say "that's not your s--- those are my clothes, this is not your room, this is my room". One day when I was so frustrated and in pain, I just got tired of her coming in so there was a cup of melted ice and water in it. I Took the cup of water and threw it at her. Resident #M state, "I did not hit her with the water." The water was just enough to make her "shutter' and get scared enough that she left the room. Resident #M indicated the Social Service Director was the only person who came down after the incident and talked to her about it. After the incident Resident #B would still come in the room but would talk to her and they offered each other food. Both Resident #M and the Social Service Director indicated the incident took place on approximately [DATE]. Upon exiting the room of Resident #M, the Social Service Director indicated she had not documented the incident between Resident #B and Resident #M. There was no documentation in the resident's record of the incident between Resident #M and Resident #B. The record for Resident #C was reviewed on [DATE] at 6:55 p.m. His [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A nursing note dated [DATE] at 6:30 a.m., indicated the resident was observed in the doorway yelling and cursing at another resident. The resident became aggressive with staff with fists clenched. When the resident was directed to have a seat the resident refused but after 2 more attempts at redirection the resident sat down and calmed down. The physician and family were made aware and the resident was sent to the hospital. There was nothing observed to have caused agitated state in resident. Staff did not see or hear any provocation. At 6:55 a.m. the resident was calm and in his room. There were no aggressive behaviors noted. A social service note dated [DATE] indicated a quarterly note for [DATE] to [DATE]. The resident does get highly agitated at times. The triggers are not yet identified. He appears to show agitation infrequently. A social service note dated [DATE] indicated, the Social Service Director was informed that the resident pushed another resident which caused her fall on the floor and hit her head. the Social Service Director met with the resident after he had come back from being sent to the ER. the resident was informed that he hurt someone. The resident said, "So what, I don't care." The resident had a 1:1 with staff. The resident met with the Psychiatrist and was given a [DIAGNOSES REDACTED]. An activity note dated [DATE] indicated, Resident #C had to be redirected because he is territorial. He likes to have things his way. Review of Resident #C's care plans, indicated a problem of being very prone to belligerence and combative behavior towards staff and other patients related to his dementia. The care plan was dated [DATE]. The interventions included, but were not limited to, approach calmly and be aware of sudden belligerence, listen to the resident attentively. Encourage the resident to discuss his interest of concerns, attempt to refocus behaviors to something positive, inform the resident when the behavior is inappropriate, and document all inappropriate conversations with the resident. The quarterly Minimum Data Set assessment dated [DATE], indicated the resident could understand others and could be understood. He scored a 5 on his Brief Interview of Mental Status which indicated he was severely cognitively impaired. He had no behaviors. An Initial Reportable Incident form reviewed on [DATE] at 2:00 p.m., indicated the incident took place on [DATE] at 6:30 a.m. involving residents involved were Resident #B and Resident #C. Resident #C was cursing and yelling while standing over Resident #B and pushed her and she fell to the floor hitting her head. Staff went to her assistance and Resident #C was redirected to sit down while staff attended to Resident #B. Both residents were sent to the hospital to be evaluated. Type of injury/injuries: Possible head injury to Resident #B and Resident #C's injuries were unknown. Immediate Action Taken: Both patients were separated and provided medical assistance. Prevention Measure taken: Monitor patients at all times and monitor for changes in behavior. A follow up Reportable incident form was reviewed on [DATE] at 2:10 p.m., indicated the incident occurred on [DATE] at 6:30 a.m. The resident's involved were Resident #B and Resident #C. A brief description of the incident: Resident #B was on the ground in front of (Room number of Resident #C) in the hall. She was non-responsive for under one minute. Her right ear was red and she complained of pain to the left side. Resident #C was standing over her yelling and cursing. CNA #1 was in Resident #C's room packing the other resident's belongings. There were no witnesses to the occurrence. 911 was called and two police officers were sent out with paramedics. The police were appraised of the situation. Type of Injury/Injuries: Resident #B was evaluated at the hospital with a [DIAGNOSES REDACTED]. Immediate action taken: Resident #C was put on behavior watch until a bed was available in the Geropsych unit so he could have further evaluation. Preventive Measures Taken: All staff were re-in-serviced on behavior and wander management as part of dementia training. A written interview provided with the reportable incidents from CNA #1 indicated, I was in Resident #C's room packing his roommates clothes into boxed. "I hear (sic) when (Resident #B's name) hit the floor by (Resident #C's name) pushing her down. He kept used (sic) bad words and stand over her until I got more help to help me sit him down." I did not hear Resident #B say anything to Resident #C. He had been in a bad mood ever since I washed him up and got him dressed. A written interview provided with the reportable incident form by LPN #3 for Resident #B, indicated " I saw the aid (sic) come to the end of the hallway of Unit 2 and call for help. Both (Maintenance Manager's name) and I ran over and saw (Resident #B's name) laying on the ground on her left shoulder. She did not respond when I called her name. I felt her pulse and ran to call 911. The CNA stayed with (Resident #B's name) at that time. When assessing her she began to babble and try (sic) to get up. She was instructed to remain still and cooperated with staff. She began to talk clearly and tried to get up more and became agitated. The pain in her left side kept her down. Ambulance arrived & (and) resident was confused & agitated. A separate written interview provided with the reportable incident forms by LPN #3 for Resident #C, indicated "Resident was observed standing up in his doorway with fists clenched, cursing and yelling at (Resident #B's name) who was laying on the ground unresponsive. (Maintenance Manager's name) ran over to assist and (Resident #C's name) continued to be aggressive with him. (Resident #C's name) was directed to sit down and close his door while staff attended to (Resident #B's name). At first he refused but after stern direction he did sit down and close (sic) his door. Resident was taken to (name of hospital)." Interview with CNA #1 on [DATE] at 12:50 p.m., indicated she was in the room of Resident #C helping his roommate pack his belongings. The curtain was pulled and she had her back to the door. She indicated she did not see Resident #C touch or make any contact with Resident #B. She heard Resident #C said,"you ain' t s---." She then heard a "slap or clap" sound she went around the curtain and (Resident #B) was on the floor. She further indicated she thought the sound she heard was Resident #C making contact with Resident #B not Resident #B hitting the floor. She asked Resident #C what did you do and the resident responded "you ain' t s---." She also indicated Resident #C had been fussy that morning. She indicated he would get irate at time and he would cuss and fuss. She never saw him out of control. Interview with LPN #1 on [DATE] at 7:35 p.m., indicated Resident #C was very territorial about his room. He would sit in a chair by the door and when residents would get near his door he would yell. Resident #B yelled and used profanity. She would exit seek and go into other resident's room. She had tried to get into Resident #C's room and he would yell and she would move away or staff would come and redirect. She never saw Resident #C touch anyone. Interview with LPN #2 on [DATE] at 11:41, indicated Resident #C was very territorial and did not like other resident's by his door. She also indicated Resident #B would wander and go into resident's rooms and when she would get to Resident #C's room he would yell at her. She then indicated staff would go to her and redirect her. She never saw Resident #C touch anyone. Interview with the Administrator on [DATE] at 9:00 a.m., in regard to the resident's care plan related to combativeness, indicated she would provided additional information. The Administrator provided no additional information during the survey process. Interview with the MDS Coordinator on [DATE] at 12:00 p.m. indicated the care plan related to combativeness for Resident #C was completed after the incident on [DATE]. However, when she was going to obtained the care plans she was told a date needed to be in place and she put the date of his last review which was [DATE]. The Behavior Management Policy identified by the Social Service Director as current on [DATE] was reviewed on [DATE] at 9:30 a.m. The policy indicated: "The program is designed to assess and monitor the residents when they are acting out of character. There will be mood/behavior report sheets on the units and on the Social Service door. These half forms can be filled out by all staff: dietary, housekeeping and etc. The form should be turned into nursing. Once nursing is aware of the behavior, a behavior assessment form will be completed and placed in the resident's chart with documentation from nursing. The green sheet will then be attached to the 24 Hour Report for Social Services. There will be a behaviors book, in which every resident on the Behavior Management program will have a behavior management documentation form what twill need to be filled out every shift. Nursing will document behaviors every shift in resident's chart. (No exceptions) Once all medical concerns are ruled out the resident will be placed on a behavior program. If there has been no behavior after thirty days the resident will be dropped from the program. After three months, it may be determined that the behavior is a part of the resident's life style and we will continue to use appropriate resources. The Immediate Jeopardy began on [DATE] when Resident #B was walking past Resident #C's room, CNA #1 heard Resident #C yelling, heard a slap and thump and walked around the pulled room curtain to find Resident #B lying on the floor in the doorway of Resident #C's room. CNA #1 asked Resident #C what he had done and Resident #C, stated "you ain' t s---). The Administrator was notified of the immediate jeopardy at 11:55 a.m. on [DATE]. The immediate jeopardy was removed on [DATE] at 11:15 a.m., but non compliance remained at the lower scope and severity level of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. The immediate jeopardy that began on [DATE] was removed on [DATE] when through observations, interviews and record reviewed, the facility had completed all staff in-service on appropriate behavior tracking, interventions and wandering residents which included but was not limited to, interventions on wandering, long-term interventions in response to wandering, how to manage behaviors, behavior management documentation record, residents with new or worsening behavioral symptoms, reviewed all resident with behaviors or a [DIAGNOSES REDACTED]. Resident #C was put on one-on-one monitoring. Care cards were initialized for residents and staff was in-serviced on the care cards. The Care cared include behaviors and interventions to be used in regards to the behaviors. The facility reviewed the existing pre-screening practice and implemented a pre-screening questionnaire and assessment to be completed prior to admission, any change or new behavior will be reviewed at the daily morning meeting. The Administrator, Director of Nursing, and Social Service Director will review all residents with behaviors at weekly Quality Improvement Behavior meeting to monitor appropriateness of placement and care for the residents with behaviors and make recommendations as needed.. The behavior management form was updated. The Director of Nursing or designee will review the 24-hour nursing report 5 times per week to ensure behaviors are dealt with appropriately. The Behavior Management Policy was updated. Interviews were conducted with nursing staff, activity staff, dietary staff, housekeeping staff, and administrative staff on the process of responding to resident's with behaviors, how to and whom to report resident behaviors, and what would be done when behaviors continues or new behaviors were exhibited. This Federal tag relates to complaint IN 351. 3XXX,[DATE](a)(2)

Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to 9 of 9 residents who were identified as an elopement risk related to the application of a Wanderguard bracelet as well as monitoring for the presence of the bracelet and the functioning ability. The facility also failed to ensure a system was in place to inform staff of who was an elopement risk as well as who wore a Wanderguard bracelet for 3 of 3 Nursing Units. (Residents #21, #44, #49, #20, #25, #55, #3, #14, and #54) (Units 3, 4, & 5) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/31/11 and began on 5/5/11. The facility Administrator was notified of the Immediate Jeopardy on 5/31/11. The Immediate Jeopardy was removed on 6/2/11, but the facility remained out of compliance at the level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because the facility plans to continue to inservice all staff on the elopement policy and responsibilities of the new alarms placed on exit doors and monitor compliance with checking the placement and functioning of wanderguards every shift. Findings include: The untitled policy was provided by the Assistant Director of Nursing on 5/31/11 at 11:15 a.m., she indicated the policy was current. The policy indicated: -Elopement Risk Assessment Forms will be filled out with all admissions/readmissions, quarterly and significant change in condition. -A registered nurse will obtain a physician's order for use of the Watchmate bracelet and will document what reason for application of the bracelet is the resident's clinical record. -Document the application and location of the Watchmate bracelet in the resident's clinical record -A picture of the resident will be taken and posted at each nursing station and receptionist desk -The Restorative Nurse will maintain a list of all residents at risk for elopement, including the resident's room number. A resident care sheet (identifying elopement risk residents) will be distributed to the management team and each unit. - The Restorative Nurse or designee will check Watchmate bracelets monthly. Please refer to Watchmate/Transmitter testing policy. Review of the User Instruction guide for the "Wanderguard Departure Alert System" provided by the Administrator on 5/31/11 at 5:15 p.m. indicated, "Test each signaling device before using. Thereafter, test the device daily and record the results in the resident's records. . . Make daily inspections to confirm the band is in place and is not damaged in any way." 1. On 5/31/11 at 1:30 p.m., Resident #21 was observed in his room in bed. The resident resided on Unit 3. There was no wanderguard (a device to prevent a resident from eloping) observed on either of the resident's ankles or wrists. The record for Resident #21 was reviewed on 5/31/11 at 12:50 p.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Wandering and Elopement Risk assessment dated [DATE], indicated the resident had a history of [REDACTED]. The section on the Risk Assessment listed "No identifiable risk for wandering/elopement, high risk for wandering, and high risk for elopement" was blank. The form indicated if the resident was a new admission with episodes of elopement, [DIAGNOSES REDACTED]. The section for care plan interventions was blank. The form was signed as completed by the nurse on 5/5/11 with no documentation of what interventions were to be implemented. The Social Work Progress Notes completed at the Acute Care Facility prior to admission to this facility indicated the resident was admitted from a nursing home that refuses to take him back due to aggressive behaviors that the facility believes places their staff in harms way and could also endanger the resident. Continued documentation indicated the resident kept trying to escape from the facility via any means necessary to go bike riding. A Physician's order, dated 5/6/11 at 10:30 a.m., indicated the resident may have Wanderguard, history of agitated and aggressive behavior, and may have psychiatric evaluation. There was no documentation in the Nursing Progress Notes on 5/6/11 to indicate if the Wanderguard had been applied. Review of the Nursing Progress Notes 5/6-5/31/11, indicated there was no documentation to indicate the resident had a Wanderguard in place. An entry in the Nursing Progress Notes, dated 5/20/11 at 7:15 a.m., indicated the resident was sitting in the Main Dining Room. The next entry at 8:00 a.m., indicated the resident was observed by staff climbing the fence in the large patio. The resident was redirected by staff and observed to have a cut to the left hand palm area. The Physician was notified and the resident was transferred to the emergency room and returned to the facility with 8 sutures to his hand. A Behavior Assessment Form completed by the Social Service Director on 5/20/11, indicated the resident attempted to leave the facility. Documentation completed by the Social Service Director, indicated the resident had a Wanderguard. The summary indicated the resident had a history of [REDACTED]. A care plan was initiated on 5/20/11 by the Social Service Director, with the problem of "Resident tried to leave facility." The interventions/approaches indicated, "encourage to express reason for attempts to leave, if attempts to leave place on monitoring, refer to counseling, involve family and they may need to visit, and resident to continue with wanderguard." The facility "Fax/Incident Report" dated 5/20/11, indicated the preventative measures that were taken were every 15 minute checks, one on one monitoring, and wanderguard. Interview with LPN #2 on 5/31/11 at 3:00 p.m., indicated the resident did not currently have a Wanderguard in place. When asked if he had ever had a Wanderguard in place since admission, the LPN indicated no. She further indicated there was no list at the Nurses' Station to identify who was an elopement risk and who had a Wanderguard. The Social Service Director was present in the Nurses' Station at this time and made no comment. The LPN went on to name the residents who did have wanderguards on Unit 3. The Wanderguard Check or Change List for May 2011 provided by the Health Information Manager on 5/31/11 at 1:15 p.m., indicated the resident's name was not on the list. Interview with the Health Information Manager at the time, indicated the list contained all the names of the residents who were currently utilizing a Wanderguard. Interview with the Administrator on 5/31/11 at 4:20 p.m., indicated the door to the patio which the resident walked out of, did not have an alarm that a wanderguard would have activated. The Administrator indicated the resident was still on the premises as he trying to climb the fence. The Administrator indicated at this time, the Social Service Director was to check for placement of all the Wanderguards weekly Interview with the Social Service Director on 5/31/11 at 4:30 p.m., indicated the resident was to have a Wanderguard on admission. The Social Service Director indicated that she had not been checking the placement of all of the wanderguards weekly. The Administrator indicated at 4:30 p.m., LPN #2 was a float nurse in the facility so she would not know who had wanderguards and who didn't. He further indicated there was no list at the Nurses' Stations to indicate who had wanderguards and who didn't. At 1:45 p.m., on 5/31/11, during the wanderguard functioning tests, the wanderguard alarming unit attached to the front door of the 300 unit was observed without a "green" light, the green light indicates the door alarm is functioning. Interview with Maintenance Employee #1 on 5/31/11 at 1:50 p.m., indicated he last checked the door on Friday 5/27/11. He indicated the wanderguard door alarm is not functioning if the green light is not on. He indicated the Maintenance Supervisor checks the wanderguard door units routinely. He indicated the Maintenance Supervisor was not in the facility. 2. On 5/31/11 at 12:45 p.m., indicated Resident #44 was observed in the Main Dining Room. The resident had a wanderguard bracelet on her left ankle. The record for Resident #44 was reviewed on 5/31/11 at 11:10 a.m. The resident had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident resided on Unit 4. Review of the Social Service Progress Notes indicated the last documentation of any elopement attempts made by the resident was on 7/23/10. This note indicated the resident attempted to leave the facility unescorted. Review of the June 2011 Physician Order Sheet indicated, "Wanderguard monitoring D/T (due to) elopement risk." The form titled, "Wandering Elopement Risk Assessment," dated 9/30/10, was reviewed. It indicated that for the section stating the onset and duration of wandering behavior indicated "Resident wanders sporadically." The section stating frequency of wandering behavior indicated "no particular time of day or eve. (evening)". The section stating any precipitating factors such as hunger, toileting, delusions was marked "no, looking for my husband or daughter." The next quarterly review of the "Wandering Elopement Risk Assessment" was dated 1/26/11 and indicated, "wanderguard is intact. Staff monitors whenever she ambulates." There was no documentation that a quarterly assessment was completed since 1/26/11. Review of the care plans for Resident #44 indicated a "Wanderguard Monitoring" care plan with the initial date of 8/16/09 and a final revision date of 4/10/11, indicated (Resident's name) has attempted to elope from the facility. She has a [DIAGNOSES REDACTED]. The goal indicated the resident will not leave the facility unescorted thru the next review period. Interventions included: -re-direct the resident when she is approaching an exit -document any elopement attempts -complete elopement assessments -fit with wanderguard device -monitor device (operational, fitted properly) -complete monitoring sheet -re-assess quarterly Review of the record indicated no documentation that the wanderguard was checked for proper placement or function on a daily, weekly or monthly basis. LPN #1 was working on the 400 hall on the day shift on 5/31/11. She was identified as the charge nurse for the unit by the Assistant Director of Nursing on 5/31/11 at 8:45 a.m. On 5/31/11 at 11:45 a.m., LPN #1 was interviewed. She indicated she does not check the function of the wanderguards. She indicated she does not know who does check the function of the wanderguards. She could not locate a list of residents with wanderguards on the 400 unit. She indicated there was no documentation of wanderguard placement checks or of wanderguard function checks in Resident #44's clinical record. She did indicate that the Health Information Manger applied the wanderguards. 3. On 5/31/11 at 12:46 p.m., Resident #49 was observed in the Main Dining Room. A wanderguard bracelet was in place to the resident's right ankle. The record for Resident #49 was reviewed on 5/31/11 at 10:55 a.m. The resident had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident resided on Unit 4. The form titled, "Wandering Elopement Risk Assessment," dated 3/4/11, was reviewed. It indicated that the resident had [DIAGNOSES REDACTED]. The next quarterly review of the "Wandering Elopement Risk Assessment" was dated 4/10/11 and indicated, "on 4/10/11 exit seeking has wanderguard - easily redirected." Review of the physician orders dated March, April, and May 2011 indicated there was no physician's order for a wanderguard. Review of the Nurse's Notes, dated 4/10/11 at 3:14 p.m., indicated "Resident exit seeking at this time . . . bilateral ankle bracelets (wanderguards) remain in place." The Nurse's Notes, dated 5/5/11 at 1 p.m., indicated, "noted resident outside of facility door, wanderguard malfunctioned staff returned resident from main entrance walkway. Resident very cooperative, gait steady, q (every) 15 minute elopement monitoring started." Review of the care plans for Resident #49 indicated a care plan with the initial date of 5/7/11, indicated resident will make no attempt to leave the facility. The goal indicated the resident will remain calm and voice concerns to social worker about feelings and reasons for inappropriate behavior. Interventions included: -convey attitude of caring -reinforce positive behavior -set firm guidelines -do not attempt to be judgmental -get family involved with care -refer to psychologist and psychiatrist There was no documentation on the above care plan related to the resident having a wanderguard in place or monitoring for placement of the wanderguard bracelet. Review of the record indicated no documentation that the wanderguard was checked for proper placement or function on a daily, weekly or monthly basis. LPN #1 was working on the 400 hall on the day shift on 5/31/11. She was identified as the charge nurse for the unit by the Assistant Director of Nursing on 5/31/11 at 8:45 a.m. On 5/31/11 at 11:45 a.m., LPN #1 was interviewed. She indicated she does not check the function of the wanderguards. She indicated she does not know who does check the function of the wanderguards. She could not locate a list of residents with wanderguards on the 400 unit. She indicated there was no documentation of wanderguard placement checks or of wanderguard function checks in the Resident #49's clinical record. She indicated there was no physician order for [REDACTED]. She indicated that the Health Information Manager applied the wanderguards. LPN #2 was interviewed on 5/31/11 at 12:45 p.m., regarding placement and checking of the wanderguards. She indicated, "whoever puts them on tells the nurse and the nurse tries to tell the CNAs." She indicated she does not check the placement of the wanderguards every shift, they get checked periodically but she does not document that the wanderguard placement was checked. Interview with CNA #1 on 5/31/11 at 12:45 p.m., indicated she was not aware of which residents had wanderguards in place. Interview with CNA #2 on 5/31/11 at 12:48 p.m., indicated she did not know which residents had wanderguards in place. Interview with the Health Information Manager on 5/31/11 at 1:15 p.m., indicated she had a list of all the residents with wanderguards. She stated that she checks them every 2 or 3 months, and replaces them every 90 days. She indicated she is the person who activates the wanderguards before they are applied. She indicated she gives the wanderguards to the nursing staff to apply. Review of the form titled, "Wanderguard Check or Change Every 90 days" provided by the Health Information Manger on 5/31/11 at 1:15 p.m., indicated the wanderguards were checked or replaced on 5/3/11. The form titled, "Wanderguard" indicated the wanderguards were changed on 2/26/10, 5/12/10, 8/9/10, 11/10/10/ and 2/25/11. There was no documentation that the function of the wanderguards was checked every month or every 2 months. The residents on the "Wanderguard Check or Change Every 90 days" form were observed to have the function of their wanderguards checked on 5/31/11 between 1:15 p.m.. and 2:10 p.m., by the Health Information Manager. The wanderguards were all functioning. Interview with the Administrator on 5/31/11 at 4:20 p.m., indicated the Social worker was to be checking the wanderguard placement on each resident weekly. He also indicated the wanderguards are good for 90 days, there is no need to check monthly. Interview with the Administrator 5/31/11 at 4:50 p.m., indicated there were no lists or pictures of residents with wanderguards at the nurses's station. 4. When interviewed on 5/31/11 at 1:05 p.m., LPN #3 (who was working on Unit 5) indicated there should be a list of residents with wanderguards at the Nurses' Station. The LPN was unable to locate the list at this time. 5. On 5/31/11 at 2:00 p.m., Resident #54 was observed with a wanderguard in place. The record for Resident #54 was reviewed on 6/1/11 at 9:50 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident resided on Unit 4. The last Elopement Risk Assessment for the resident was completed on 8/14/10. A care plan initiated on 8/16/09 indicated the resident had attempted to elope from the facility. The care plan was last updated on 4/18/11. The care plan also indicated the resident had a [DIAGNOSES REDACTED]. There was no documentation in the resident's clinical record of the resident's wanderguard being checked on a daily, weekly, or monthly basis. 6. On 5/31/11 at 1:47 p.m., Resident #14 was observed with a wanderguard in place. The record for Resident #14 was reviewed on 6/1/11 at 11:05 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident resided on Unit 3. A "Wandering and Elopement Risk Assessment" was completed on 10/7/10. The assessment indicated the resident had episodes of elopement and pacing with absence of safety awareness/judgement skills and a wanderguard was in place. A 4/2/11 quarterly review indicated the resident continued to wear the wanderguard. A care plan initiated on 4/3/10 indicated the resident has attempted to leave the facility and had a [DIAGNOSES REDACTED]. There was no documentation in the resident's clinical record of the wanderguard being checked on a daily, weekly, or monthly basis. 7. On 5/31/11 at 1:53 p.m., Resident #3 was observed with a wanderguard in place. The record for Resident #3 was reviewed on 6/1/11 at 11:00 a.m. The resident's [DIAGNOSES REDACTED]. The resident resided on Unit 3. A Wandering and Elopement Risk Assessment" was completed on 10/25/10. The assessment indicated displayed restlessness, anxiety, aggression, delusions, and psychosis. The assessment was reviewed on 12/20/10 and 3/11/11 and both reviews indicated the resident had a wanderguard in place. A care plan initialed on 8/16/09 indicated the resident had attempted to elope form the facility. The care plan was last updated on 3/29/11. Care plan interventions included for staff monitor the wanderguard device to ensure it is fitted properly and operational. There was no documentation in the resident's clinical record of the wanderguard being checked on a daily, weekly, or monthly basis. 8. On 5/31/11 at 1:40 p.m., Resident #55 was observed with a wanderguard in place. The record for Resident #55 was reviewed on 6/1/11 at 11:00 a.m. The resident's [DIAGNOSES REDACTED]. The resident resided on Unit 4. A "Wandering and Elopement Risk Assessment" was completed on 9/16/10. The assessment indicated the resident wanders. Quarterly reviews dated 12/7/10 and 3/7/11 indicated the resident made no attempts to elope. A care plan initiated on 8/22/09 indicated the resident was at risk for elopement from the facility. The care plan was last updated on 5/17/11. Care plan interventions included for the resident to have a wanderguard in place. There was no documentation in the resident's clinical record of the wanderguard being checked on a daily, weekly, or monthly basis. 9. On 5/31/11 at 1:50 p.m., Resident #25 was observed with a wanderguard in place. The record for Resident #25 was reviewed on 6/1/11 at 10:12 a.m. The resident's [DIAGNOSES REDACTED]. The resident resided on Unit 3. A "Wandering and Elopement Risk Assessment" was completed on 4/6/11. The assessment indicated the resident had a history of [REDACTED]. A 4/6/11 "Behavior Assessment" indicated the attempts to leave the facility and is exit seeking. An undated care plan indicated the resident had attempted to leave the facility. Care plan interventions included the resident was to continue with a wanderguard. The 5/11 Nurses' Notes were reviewed. An entry made on 5/11/11 at 11:15 a.m., indicated the resident opened the back door causing the door alarm and his ankle alarm to sound. There was no documentation in the resident's clinical record of the wanderguard being checked on a daily, weekly, or monthly basis. 10. On 5/31/11 at 1:30 p.m., Resident #20 was observed with a wanderguard in place. The record for Resident #20 was reviewed on 6/1/11 at 10:12 a.m. The resident's [DIAGNOSES REDACTED]. The resident resided on Unit 3. A "Wandering and Elopement Risk Assessment" completed on 10/15/10 indicated the resident had a history of [REDACTED]. A care plan initiated on 1/18/10 indicated the resident had eloped from the facility and has a [DIAGNOSES REDACTED]. The care plan was last updated on 4/21/11. Care plan interventions include for the resident to be fitted with a wanderguard and for staff to monitor the device to ensure it was operational, fitted properly, and in place. There was no documentation in the resident's clinical record of the wanderguard being checked on a daily, weekly, or monthly basis. An Immediate Jeopardy was identified on 5/31/11 at 5:15 p.m. The Immediate Jeopardy began on 5/5/11 when a resident with a known history of elopement attempts was admitted to the facility. Physician orders were obtained on 5/6/11 for the resident to have a wanderguard in place and this was not implemented at the time of the survey. The facility policies and protocols for monitoring the wanderguard were not followed for 8 of 9 residents with wanderguards in place at the time of the survey and 1 of 9 with a physician's order for a wanderguard. The Immediate Jeopardy was removed on 6/2/11 at 12:25 p.m., when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that steps taken removed the immediacy of the problem. The facility's immediate plan was reviewed by the survey team and supervisor. Ongoing documentation of inservicing to staff members was observed and documents of verification of the inservicing was reviewed. Staff members from all three shifts were interviewed on 6/1/11 and 6/2/11 and were able to verbalize information identified in the facility immediate plan. Observations on all three shifts were made of staff members responding to door alarms and awareness of the location of the new alarms initiated as part of the plan. Updated Elopement books were observed on the Nursing Units and the two other locations identified in the facility's plan. The clinical records of the (9) residents who currently have wanderguards indicated the placement and functioning of the alarms had been completed on each shift as identified in the facilities plan. Documentation of ongoing door alarms checks completed by Maintenance employees was reviewed. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. 3.1-45(a)(2)