Every finding on record at Springfield Nursing and Rehabilitation Center

Based on observation, interview, record review, review of the Lippincott Manual of Nursing Practice Ninth Edition, 2010, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement the appropriate infection prevention and control practices during wound care. The facility failed to identify and correct problems relating to infection prevention practices affecting 2 of 4 sampled residents reviewed for infection control, Resident (R) 1 and R3.The findings include:Review of the facility's policy titled, Infection Control, revised 10/2018, revealed staff was to prevent infections and maintain a safe, sanitary, and comfortable environment. According to the policy, all employees were expected to follow infection control procedures, use appropriate personal protective equipment (PPE), and support a clean, safe, and sanitary environment to reduce the risk of disease transmission. Review of the facility's policy titled, Hand Hygiene, no date, revealed proper hand hygiene was a fundamental infection prevention measure in resident care. According to the policy, healthcare workers were required to perform hand hygiene before and after resident contact, before and after glove use, before and after aseptic procedures, and after contact with contaminated wound dressings. Furthermore, the policy stated adherence to proper hand hygiene practices minimized the risk of cross-contamination, prevented the transmission of microorganisms, and promoted resident safety.Review of the facility's nursing standards of practice Lippincott Manual of Nursing Practice Ninth Edition, 2010, revealed nurses should follow aseptic (clean) technique during dressing changes to minimize contamination and reduce the risk of healthcare-associated infections. The procedure included preparing the resident and supplies, performing hand hygiene, using appropriate PPE, carefully removing the old dressing, and applying a new dressing. Additionally, after removing the contaminated dressing, soiled gloves should be removed and hand hygiene performed following the principles of moving from dirty to clean. Throughout the procedure, the nurse should maintain aseptic technique and prevent infection to support optimal wound healing.Review of R1's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 07/24/2024 with diagnoses to include cellulitis of left lower limb, peripheral vascular disease, and atherosclerotic heart disease.Review of R1's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/13/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 99, indicating R1 was unable to complete the interview.Review of R1's Order Report, dated 07/2026, found in the resident's EMR under the Orders tab, revealed a pressure wound treatment order included Dakin's External Solution 0.125% to cleanse wound to the left heel, pack with moistened rolled gauze, apply padding and an Ace (elastic) wrap, twice daily. Review of R3's admission Record, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 09/05/2023 with diagnoses to include abnormal weight loss, cerebral infarction, and multiple pressure ulcers.Review of R3's admission MDS, with an ARD of 06/16/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of seven out of 15, indicating R3 had severe cognitive impairment.Review of R3's Order Report, dated 07/2026, found in the resident's EMR under the Orders tab, revealed a pressure wound treatment order included cleanse wound with Dakin's External Solution 0.125%, apply Santyl (topical enzymatic) ointment, cover with border gauze, and change daily and as needed.1. Observation of Registered Nurse (RN) 1 performing R1's wound dressing on 07/21/2026 at 2:00 PM revealed RN1 gathered supplies from the treatment cart. The supplies included Dakin's solution, sterile gauze, rolled gauze, a calcium alginate dressing, and scissors. RN1 opened the sterile gauze package, poured Dakin's solution over the gauze to moisten it inside of its wrapper, and placed it on top of the treatment cart without a protective barrier. Scissors were obtained from the treatment cart drawer and used to cut the calcium alginate dressing. Before proceeding into the resident's room, RN1 returned the used scissors and opened calcium alginate dressing to the top drawer of the treatment cart. RN1 then put the supplies in the room on top of a bare, uncleaned bedside table. RN1 did not perform hand hygiene before she donned (put on) a gown and gloves. Further observation of RN1 performing R1's wound dressing on 07/21/2026 at 2:00 PM revealed RN1 removed an elastic wrap, gauze bandage, and a 4 x 4 inch gauze pad and placed the soiled dressings on the bed. The elastic wrap contained an approximately 1 inch blood tinged dried stain. She did not obtain a clean elastic wrap. The dressing over the heel was tinged with an approximately 3 inch round area of what appeared to be serosanguineous drainage. RN1 placed the soiled dressing directly on the bed linen. She did not change gloves or perform hand hygiene after removing the soiled dressings and before applying the clean dressing. RN1 applied the dampened sterile gauze to the wound, followed by rolled gauze, and reapplied the stained elastic wrap. Furthermore, while wearing the same contaminated gloves, RN1 touched the bed controls, bed linens, and R1. RN1 then removed the soiled dressings from the bed, discarded them, and doffed (removed) personal protective equipment.During an immediate interview on 07/21/2026 at 2:00 PM, RN1 stated the procedure was not a sterile procedure but infection control should be adhered to. She stated the resident was in enhanced barrier precautions (EBP), which required a gown and gloves during direct care. She stated she received infection control training and did nursing check offs upon hire and received ongoing infection control education. She stated following infection control protocols was important for resident safety and to prevent the spread of infection.2. Observation on 07/22/2026 at 10:50 AM revealed the Staff Development Coordinator (SDC), also a registered nurse, performed wound care for R3. The SDC changed her gloves several times throughout the dressing change procedure when she transitioned from the dirty field to the clean field. However, although she changed her gloves appropriately, she performed hand hygiene only once after removing the old dressing and before donning a new pair of gloves. No additional hand hygiene was observed between the three glove changes while handling the soiled dressing.During an interview with the SDC on 07/22/2026 at 2:25 PM, she stated she knew there was concern that she failed to perform hand hygiene between some glove changes during observation of R3's wound care. However, the SDC did not mention the cause of her breach of the infection control practice of proper hand hygiene. The SDC stated nursing staff was educated and checkoffs were performed regarding infection control practices, including proper hand hygiene, glove changes, equipment storage, and cleaning and disinfecting reusable instruments, such as scissors, between residents and uses. During the continued interview with the SDC on 07/22/2026 at 2:25 PM, she stated staff was expected to maintain a clean environment, use appropriate PPE, perform hand hygiene before and after wound care, and use aseptic technique throughout the dressing change. She stated wound care for residents with wounds on their heels generally required two staff members, so one person could maintain the affected extremity off the bed and prevent contamination while the other completed the dressing change. Additionally, the SDC stated staff was instructed to perform hand hygiene before beginning wound care, remove the soiled dressing into a waste receptacle while wearing gloves, remove and discard the contaminated gloves, perform hand hygiene, don clean gloves, and then apply the clean dressing to prevent cross-contamination. She stated if multiple dressings were being completed, staff was expected to repeat hand hygiene and glove changes between wounds. The SDC stated facility policy required hand hygiene after glove removal and before applying clean dressings. During a telephone interview with Advanced Practice Registered Nurse (APRN) 1 on 07/22/2026 at 9:17 AM, he stated wound care was performed using aseptic technique. APRN1 stated aseptic technique included performing hand hygiene, using clean gloves, maintaining clean supplies and equipment on a clean field, preventing cross-contamination, changing gloves after removing a soiled dressing, and completing the dressing change using standard infection-control practices. APRN1 stated nurses should remove the soiled dressing, change gloves, perform hand hygiene, don clean gloves, and then apply the clean dressing to prevent cross-contamination. Furthermore, he stated he expected nursing staff to use aseptic technique when changing wound dressings and to adhere to nursing standards of practice and infection control practices. He stated it was important for the safety of the resident and to prevent infection and harm to the resident.During an interview with the Director of Nursing (DON) on 07/22/2026 at 2:49 PM, she stated staff was expected to follow facility infection control policies, including performing hand hygiene before entering resident rooms, after exiting resident rooms, and whenever gloves became contaminated. The DON stated during dressing changes, staff should remove the soiled dressing and dispose of it appropriately and not place a soiled dressing on the resident's bed. Additionally, she stated nurses should remove contaminated gloves, perform hand hygiene, don clean gloves, and then apply the clean dressing to prevent cross-contamination. The DON stated staff received infection control education during orientation, annually, and more frequently when indicated. The DON stated following aseptic technique during dressing changes was important for the safety of the resident and to prevent infection.During an interview with the Administrator on 07/22/2026 at 2:55 PM, she stated staff was expected to do everything possible to prevent existing wounds from becoming infected. She stated staff was expected to follow all facility infection control policies. She stated policies directed staff to use the appropriate PPE based on the required precautions posted outside resident rooms, to disinfect shared equipment between resident use, to perform hand hygiene upon entering and exiting resident rooms, to change gloves when contaminated, and to perform hand hygiene between dirty and clean portions of care. Additionally, the Administrator stated following infection control practices and performing proper hand hygiene was important to prevent the spread of infection, particularly among residents with multidrug-resistant organisms.

Based on interview, record review, and review of the facility's documents and policy, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 12 of 14 sampled residents, Resident (R) 2, R7, R8, R9, R11, R12, R18, R20, R26, R42, R51, and R70.Review of those residents' admission packet document titled, Advance Directives Policy and Record, revealed the space indicating the resident had a Living Will, Declaration or Directive to Physicians was blank. Additionally, the facility could not provide documentation the residents or their representatives had been provided with written information on advance directives, how to formulate an advance directive, or had signed a declination to formulate an advance directive. The findings include:1. Review of R2's admission Face Sheet revealed the facility admitted R2 on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), cognitive communication deficit, and end stage renal disease.Review of R2's annual Minimum Data Assessment [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, indicating no cognitive impairment.Review of R2's document Resident Rights, dated [DATE] and signed by R2, revealed R2 had the right to participate in establishing the expected goals and outcomes of her care, the type, amount, frequency, and duration of care and any other factors related to the effectiveness of her plan of care.Review of R2's document Advance Directives Policy and Record, unsigned by R2 and indicating R2 was her own representative, revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.2. Review of R7's admission Face Sheet revealed the facility admitted R7 on [DATE] with diagnoses of left lower leg fracture, hypertension, and cerebral infarction.Review of R7's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 15 of15, indicating no cognitive impairment.Review of R7's document Resident Rights, undated and signed by R7's spouse, revealed R7 had the right to participate in establishing the expected goals and outcomes of her care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of her plan of care.Review of R7's document Advance Directives Policy and Record, unsigned by R7 and indicating R7 was her own representative, revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.3. Review of R8's admission Face Sheet revealed the facility admitted R8 on [DATE] with diagnoses of acute respiratory failure with hypoxia and peripheral vascular disease.Review of R8's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating no cognitive impairment.Review of R8's document Resident Rights, dated [DATE] and unsigned by R8, revealed R8 had the right to participate in establishing the expected goals and outcomes of his care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of his plan of care.Review of R8's document Advance Directives Policy and Record, unsigned by R8, revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.During an interview with R8 on [DATE] at 2:51 PM, he stated, What is an advance directive? R8 further stated he had a Power of Attorney (POA). He stated he was not in good shape when he arrived at the facility, and he could not remember if anything like that was discussed with him. R8 stated his brother and sister handled his affairs.During a telephone interview on [DATE] at 6:40 PM with R8's sister, she stated she did not recall staff discussing or providing written information about advance directives at the time of admission. She also stated she and her brother were R8's POAs, but R8 currently made all of his own medical decisions. R8's sister stated she could not recall if a copy of his POA was provided to the facility or if staff asked them to provide a copy. 4. Review of R9's admission Face Sheet revealed the facility admitted R9 on [DATE] and readmitted him on [DATE] with diagnoses of chronic respiratory failure, quadriplegia, mild intellectual disabilities, and epilepsy. Further review of the document revealed R9 was under state guardianship.Review of R9's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 99, indicating R9 was rarely/never understood.Review of R9's document Advance Directives Policy and Record, unsigned by R9 or his guardian, revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.5. Review of R11's admission Face Sheet revealed the facility admitted R11 on [DATE] with diagnoses of COPD, diabetes, and congestive heart failure (CHF).Review of R'11s quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating no cognitive impairment.During an interview on [DATE] at 1:29 PM with R11 and daughter, they both stated they remembered staff talking to them about a living will, advance directive, and power of attorney when R11 was admitted . However, they stated it was all verbal, and they received no paperwork explaining the differences.6. Review of R12's admission Face Sheet revealed the facility admitted R12 on [DATE] and readmitted her on [DATE] with diagnoses of COVID-19, traumatic below the knee amputation of right leg, and colostomy.Review of R12's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS' score of 15 of 15, indicating no cognitive impairment.During an interview on [DATE] at 1:37 PM with R12, she stated her sister handled everything for her. She asked the State Survey Agency (SSA) Surveyor to call her sister because she did not know anything about her advance directives.During a telephone interview on [DATE] at 10:34 AM with R12's sister, she stated R12 took care of her own affairs, and the only thing she remembered the facility discussing with her was R12's code status. R12's sister further stated she herself had formulated an advance directive for herself with her own daughter, so she knew what it was but as far as she knew R12 did not have one. R12's sister stated she would like it to be discussed with R12 and for her to be notified and provided with a copy so she would also have the information.7. Review of R18's admission Face Sheet revealed the facility admitted R18 on [DATE] and was readmitted on [DATE] with diagnoses of cerebral infarction, COPD, and cognitive communication deficit.Review of R18's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating no cognitive impairment.Review of R18's document Resident Rights, dated [DATE] and signed by R18, revealed R18 had the right to participate in establishing the expected goals and outcomes of his care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of his plan of care.Review of R18's document Advance Directives Policy and Record, unsigned by R18, revealed R18 was his self-representative. Further review of the document revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.During an interview on [DATE] at 1:00 PM with R18, he stated he did not remember any discussions with staff about code status, living will or power of attorney at the facility, and he did not know what they were. R18 stated his father made decisions for him, but he did not remember if his father signed any paperwork about it.During a telephone interview on [DATE] at 6:54 PM with R18's father and designated emergency contact, he stated the facility had discussed it with him and R18, but R18 was not able to understand any of it. R18's father further stated right now, R18 was still his own representative, and the family was discussing contacting a family friend who was a lawyer to begin the process for obtaining guardianship for R18. R18's father stated the facility did not provide him or R18 with any written information about formulating an advance directive, and he had not signed anything for R18 because R18 signed his own paperwork.8. Review of R20's admission Face Sheet revealed the facility admitted R20 on [DATE] and readmitted him on [DATE] with diagnoses of paraplegia, injury of the thoracic spinal cord, and hypertension.Review of R'20s admission MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating no cognitive impairment.Review of R20's document Resident Rights, dated [DATE] and signed by R20, revealed he had the right to participate in establishing the expected goals and outcomes of his care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of his plan of care.Review of R20's document Advance Directives Policy and Record, unsigned, revealed R20 was his own representative. Further review of the document revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank. 9. Review of R26's admission Face Sheet revealed the facility admitted R26 on [DATE] and was readmitted on [DATE] with diagnoses of unspecified dementia, abnormal weight loss, and dizziness with collapse. Further review of the document revealed R26 had a legal guardian.Review of R'26s quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of three of 15, indicating severe cognitive impairment.Review of R26's document Advance Directives Policy and Record, unsigned, revealed R26 had a guardian. Further review of the document revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were blank. The sections designated no advance directives and discussed with resident/representative were blank.In review of a text message received on [DATE] at 10:55 AM from R26's Guardian, she texted the facility had not provided her with written advance directive information for R26, and she had not been asked about it. 10. Review of R42's admission Face Sheet revealed the facility admitted R42 on [DATE] and readmitted him on [DATE] with diagnoses of methicillin resistant staphylococcus aureus (MRSA) infection, hip fracture, and diabetes. Review of R'42s quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 14 of 15, indicating no cognitive impairment.During an interview on [DATE] at 1:29 PM with R42, he stated he had not received any information on advance directives, living will or power of attorney. He stated, as long as he could keep his own mind, he wanted to make his own decisions.11. Review of R51's admission Face Sheet revealed the facility admitted R51 on [DATE] with diagnoses of multiple sclerosis, cerebral infarction with flaccid hemiplegia of the left side, and cognitive communication deficit. Further review of the document revealed R51 had a designated POA.Review of R51's annual MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 12 of 15, indicating moderate cognitive impairment.Review of R51's document Resident Rights, dated [DATE] and unsigned, revealed R51 had the right to participate in establishing the expected goals and outcomes of her care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of her plan of care.Review of R51's document Advance Directives Policy and Record, unsigned, revealed R51's POA was her brother. Further review revealed the Advance Directives sections designating living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare were dated as not received on [DATE]. The sections designated no advance directives and discussed with resident/representative were blank.During an interview on [DATE] at 1:35 PM with R51, she stated her brother was her POA and took care of all her decision making. She stated she did not recall any discussions about advance directives, or it being reviewed with her at any time.During a telephone interview on [DATE] at 6:48 PM with R51's brother/POA, he stated a discussion was held on admission about R51's advance directives. He stated he was sure that he received written information about it, but he was not sure where it was now.12. Review of R70's admission Face Sheet revealed the facility admitted R70 on [DATE] with diagnoses of COPD, chronic kidney disease, and repeated falls and multiple fractures of ribs.R70's admission MDS had not been completed.During an interview on [DATE] at 1:25 PM with R70, he stated he did not remember any staff discussing POA, advance directives, or code status with him. R70 stated his brother made decisions for him.During a telephone interview on [DATE] at 7:02 PM with R70's brother, he stated the admission process was all new to him, and he was not sure what the papers he had were about. He then put his wife on the telephone, and she stated all the paperwork they had was from the hospital, and the facility had not discussed advance directives or given them copies of any paperwork when R70 was admitted .During an interview on [DATE] at 3:59 PM with the admission Coordinator (AC), she stated she had been doing admissions for 11 years at the facility. She stated the only information she had for residents about advance directives was what she had been provided by corporate, and it was in the admission agreement paperwork. The AC stated the document she was referring to was Advance Directive Policy and Record. The AC stated on admission, she reviewed cardiopulmonary resuscitation (CPR) choices and the state Do Not Resuscitate form with the resident or their representative. Additionally, she stated she knew their sister facilities had the same paperwork and offered the resident and/or resident representative the same information. The AC stated her regional contact was currently creating a document to address and indicate if the resident had an advance directive or had chosen to decline to formulate an advance directive so the facility would be sure to honor the resident's or the resident representative's wishes for care.During an interview on [DATE] at 4:05 PM with the Social Services Director (SSD), she stated on admission she addressed code status with the resident or their representative and made sure that was charted. The SSD further stated code status was addressed with each resident or resident representative at the resident care conference at least quarterly, but advance directives were not. The SSD stated, if a resident did not have a clear advance directive or declination of one on file, there could be confusion if that resident had an emergent decline in condition and family or next of kin could not be immediately reached, resulting in the resident's wishes not being honored.During an interview on [DATE] at 2:57 PM with the Director of Nursing (DON), she stated she had worked at the facility for two and a half years this time around but had left and returned several times. The DON stated a resident's code status was charted on the Medication Administration Record/Treatment Administration Record (MAR/TAR) indicating if the resident was a Do Not Resuscitate (DNR) or a Full Code. She further stated the information on advance directives was given to the resident or resident representative by the AC and/or SSD and was included in a packet which was in the resident's admission packet. The DON stated there was a document in the packet which had an area on it stating the resident and/or their representative had the option to formulate or decline to formulate an advance directive, and there was also a place on the document to indicate if they had an advance directive. The DON stated it was important to know the resident's wishes to provide nursing care for the resident, share that information with the hospital when needed, and to honor the resident's wishes. The DON stated the resident's code status (whether they were a full code or a DNR) was reviewed at every care plan meeting which was quarterly, but she was not sure when advance directive choices were reviewed.During an interview on [DATE] at 3:14 PM with the Administrator, she stated she had worked at the facility for three weeks but had been an Administrator for 13 years. She stated the facility had adapted the admission packet to include the information about advance directives with a signature page for the resident or representative to sign. She stated she felt strongly the facility had provided education to the family and responsible party, and if they had not had it, the facility would have given them the information. The Administrator also stated it was important to honor the resident's and/or representative's wishes for resident care, and there was a difference between code status and advance directives. The Administrator stated resident code status was reviewed during care plan meetings, but the advance directives were not. She stated it was important to review advance directives with the resident's condition and cognition changes, so the resident's and their representative's care wishes were honored.

Based on observation, interview, review of an article from the Cleveland Clinic, and review of the facility's policy, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards, which affected 1 of 4 medication carts. The findings include:Review of the facility's policy titled, Label/Store Drugs & Biologicals Standard of Practice, most recently revised 4/2025, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles and include the expiration date when applicable. Further review revealed expired and/or discontinued medication shall be removed from the medication storage area. Continued review revealed if a multi-dose vial had been opened or accessed, then it should be dated and discarded within 28 days unless the manufacturer specified a different date. Review of the Cleveland Clinic article, Is it Okay to Take Expired Medicine? at https://health.clevelandclinic.org/can-you-take-expired-medicine, dated 02/22/2024, revealed the expiration date of medications reflected the end of the time the manufacturer guaranteed their safety and efficacy. Further review revealed the risks of expired medicines included becoming weaker, such that they could not treat the condition properly, and they could contain harmful germs because the preservatives in them had broken down.Observation of the East Unit Back Hall medication cart on 01/07/2026 at 2:30 PM revealed four insulin pens (lowered blood sugar) were not labeled with an opened date or use by date. Further observation revealed an opened vial of Humulin 70/30 insulin with no resident name label or open/use by date and an opened unit bottle of UTI Stat, a liquid supplement that promoted urinary health, with manufacturer's expiration date of 06/27/2025.During interview with Registered Nurse (RN) 2 on 01/07/2026 at 2:38 PM, he stated multi-dose insulin pens were kept in the refrigerator; and then, upon removal to a medication cart, labeled with the opened date. He further stated insulin vials retrieved from the Cubex, a medication storage device, should be labeled with the resident's name and the opened date. He stated the importance of adding the opened date to the label was so the medication would not be used after it had expired and might not be effective. He stated expired medications should be removed from the cart by the expiration date to ensure they were not given to residents.During interview with the Unit Manager on 01/08/2026 at 10:00 AM, she stated when the nurse obtained a new insulin pen, the nurse should put the date opened on the package before storing it in the medication cart. She stated the reason for this was so the staff knew when the insulin expired. She stated it was important not to give insulin after the expired date because it might not be effective.During interview with the Director of Nursing (DON) on 01/08/2026 at 1:54 PM, she stated insulin pens should be dated when opened, and a vial taken from the Cubex should be labeled and dated. She also stated expired medications or supplements should be removed from the cart by the expiration date. She stated that was important because staff did not want to give residents medicine that might not be effective.During interview with the Administrator on 01/08/2026 at 3:04 PM, she stated her expectation was that staff followed policies and procedures based on regulatory guidelines, which was once a multi-dose medication was opened, the medication must be dated with the opened date. She stated the regulation's point was staff did not use a medication that was expired, so the medication still would be effective. She stated her expectation was that supplements should be removed from the cart by the expiration date.

Based on observation, interview, record review, review of a Centers for Disease Control and Prevention (CDC) article, and review of the facility's policy, the facility failed to ensure staff complied with gowning while administering medications via gastrostomy tube, while the resident was under Enhanced Barrier Precautions (EBP) for 1 of 30 sampled residents, Resident (R) 60. The findings include: Review of the facility's policy titled, Infection Control, last revised 10/2018, revealed no specific guidance for Enhanced Barrier Precautions (EBP).Review of the CDC's article, Enhanced Barrier in Skilled Nursing Facilities, https://www.cdc.gov/infection-control/media/pdfs/Webinar-EBPinNH-Nov2022-Slides-508.pdf, dated 11/15/2022, revealed the use of gown and gloves was indicated for residents during high contact care activities when they were at high risk of colonization with Multi Drug Resistant Organisms (MDRO). Further review revealed high contact care activities included device care or use for indwelling catheters, tracheostomies, central lines, or feeding tubes,Review of the facility's EBP signage posted on R60's room door revealed staff must wear gloves and gown when caring for or using feeding tubes, central lines, urinary catheters, and tracheostomies.Review of R60's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/04/2025, revealed the facility initially admitted R60 on 07/01/2012 with diagnoses including nontraumatic brain dysfunction, dementia, and Parkinson's disease. Further review revealed R60 took his nutrition from his g-tube.Observation of medication administration for R60 on 01/08/2026 at 8:59 AM revealed Registered Nurse (RN) 2 failed to don (put on) a protective gown prior to administering medication via gastrostomy tube (g-tube).During an interview with RN2 on 01/08/2026 at 9:12 AM, he stated it was expected to use a gown when giving medications via g-tube, but he just forgot. He further stated wearing a gown for medication administration was important to prevent cross-contamination.During an interview with the Assistant Director of Nursing (ADON) on 01/08/2026 at 1:21 PM, she stated the facility did not have a specific policy for administering medications via g-tube. She stated staff followed physician orders and standard of practice. She stated there was not a specific Enhanced Barrier Precautions policy, but they followed CDC guidelines. During additional interview with the ADON on 01/08/2026 at 2:44 PM, she stated having to gown to administer medications for residents who were under EBP and had a g-tube was controversial. She stated if the feeding tube had a stopcock, then the system stayed closed when switching from feeding to giving medications. However, she stated if the syringe was attached for medication administration and the stopcock was opened, then the system was open.During an interview with the Director of Nursing (DON) on 01/08/2026 at 2:52 PM, she stated the expectation was that staff would gown if caring for a g-tube, including giving medications.During an interview with the Administrator on 01/08/2026 at 3:04 PM, she stated her expectation was that all appropriate PPE was used when giving medications by g-tube.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to complete and submit Minimum Data Set (MDS) Assessments within the required timeframe. Review of the Final Validation Reports, dated 03/27/19 through 10/16/19, revealed seventeen (17) MDS Assessments were completed late and twenty-three (23) MDS records were submitted late. The findings include: Interview with the MDS Coordinator, on 10/16/19 at 3:52 PM, revealed the facility did not have a policy related to completing and transmitting MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Further Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) 208, Chapter 2, Assessments, revealed admission assessments must be completed on the fourteenth (14th) calendar day of the resident's admission (admitted + 13 calendar days). Additionally, significant change assessments must be completed on the fourteenth (14th) calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days) . Continued review revealed comprehensive assessments should be completed on the ARD plus fourteen (14) days. Additionally, quarterly assessments must be completed no later than fourteen (14) days after the ARD (ARD plus fourteen (14) calendar days). Further, discharge assessments must be closed on the discharge date plus fourteen (14) calendar days. Continued review revealed Entry Assessments should be closed on the Entry Date plus seven (7) calendar days Review of the Final Validation Reports (FVR), dated 03/27/19 through 10/16/19, revealed seventeen (17) MDS Assessments were completed late and twenty-three (23) MDS records were transmitted late. 03/27/19, revealed five (05) MDS records were submitted late and two (2) MDS Assessments were completed late. 04/04/19, revealed one (01) MDS record was submitted late and one (01) MDS Assessment was completed late. 04/10/19, revealed one (01) MDS record was submitted transmitted late. 04/18/19, revealed two (02) MDS Assessments were completed late. 05/01/19, revealed one (01) MDS record was submitted late and one (01) MDS Assessment was completed late. 05/07/19, revealed two (02) MDS records were submitted late. 05/15/19, revealed one (01) MDS record was submitted late. 05/22/19, revealed three (03) MDS records were submitted late. 05/30/19, revealed three (03) MDS records were submitted late and one (01) MDS Assessment was completed late. 06/05/19, revealed three (03) MDS records were submitted late. 06/24/19, revealed three (03) MDS records were submitted late and three (03) MDS Assessments were completed late. 07/24/19, revealed one (01) MDS Assessment was completed late. 08/04/19, revealed one (01) MDS record was submitted late and three (03) MDS Assessments were completed late. 10/01/19, revealed one (01) MDS Assessment was completed late. 10/16/19, revealed one (01) MDS Assessment was completed late. Continued interview with the MDS Coordinator/Licensed Practical Nurse (LPN), on 10/17/19 at 10:15 AM, revealed she had been working as the MDS Coordinator for three (03) years and had received ongoing training related to MDS Assessments and most recently received training two (02) weeks ago related to the RAI Guidelines. Per interview, she was not aware that each type of MDS Assessment had different timeframes for completion and submission/transmission until the State Surveyor inquired and she read the section of the MDS related to completion and submission timeframes. Additionally, the facility had a new Electronic Medical Record (EMR) since (MONTH) 2019 and the calendar she was familiar with was no longer available and she realized last week she was using the wrong report from the system to audit what Assessments needed to be closed and submitted. Further, due to the heavy workload, she was unable to complete her work per the timeframes and overtime was not approved. Per interview, the Regional Vice President of Reimbursement, was the MDS Supervisor; and she was supportive and would email weekly when MDS Assessments needed closed and submitted. Continued interview with the MDS Coordinator, revealed she gave the Assistant Director of Nursing (ADON) a list in Clinical meeting each morning of the MDS Assessments that were finished and she would sign them as being completed. Per interview, she submitted MDS records weekly and checked the FVR for accepted/rejected errors and printed the reports and placed them in a binder. Additionally, she did not look at the FVR for other error and assumed the MDS scrubber would catch errors before submission. Further, the assessments should have been completed and submitted per the RAI manual. Per interview, it was important to ensure the MDS Assessments were completed accurately and submitted timely because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care provided was the best care to meet the residents' needs. Interview with the Regional Vice Present of Reimbursement, on 10/17/19 at 1:47 PM, revealed she provided oversight and support with the MDS process in the facility. Per interview, she conducted spot checks for accuracy and timeliness and over the last year had identified late completion and late submissions of MDS Assessments. Additionally, she had been emailing the MDS Coordinator weekly system reports to ensure Assessments were completed and submitted per the RAI guidelines. Per interview, she was now monitoring more closely and had established an assigned day of the week for the facility to submit Assessments; which had helped with late Assessments. Continued interview revealed she expected the RAI manual to be followed to ensure the MDS Assessments were completed and submitted timely. Interview with the Director of Nursing (DON), on 10/17/19 at 10:35 AM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Continued interview revealed she expected the RAI manual to be followed and for MDS Assessments to be completed and submitted timely. Interview with the Administrator, on 10/17/19 at 315 PM, revealed the facility was to utilize the RAI Manual as a resource to ensure accuracy of the MDS Assessments. Per interview, it was important for MDS Assessments to be completed and submitted timely.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflects the resident's status for one (1) of sixteen (16) sampled residents (Resident #26). Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/19, revealed the resident receive one (1) anticoagulant medication within the last seven (07) days of the look back period. However, the resident's physician's orders [REDACTED]. Further, Resident #26's Quarterly MDS Assessment, dated 08/19/19, revealed the resident received antipsychotic medications seven (7) days during the last seven (7) day look back period. However, the Antipsychotic Medication Review question N0450, was coded that the resident did NOT receive antipsychotic medication and the gradual dose reduction (GDR) questions were skipped. The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for accuracy of assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the primary purpose of the MDS Assessment was to identify resident care problems, address resident problems in individualized care plans, and monitor the quality of care provided to residents. Additional review revealed the Assessment should be an accurate reflection of the resident's status. 1. Review of Resident #26's medical record revealed the facility admitted the resident on 01/10/19 with [DIAGNOSES REDACTED]. Review of Resident #26's physician's orders [REDACTED]. Review of Resident #22's MAR, dated (MONTH) 2019, revealed during the look back period for the Quarterly MDS Assessment, dated 08/19/19, the resident received one (01) [MEDICATION NAME] (antiplatelet inhibitor) seventy-five (75) mg dose, on 08/19/19. Further review of the MAR, revealed the resident received [MEDICATION NAME] (antipsychotic medication), 08/13/19 through 08/19/19 (seven days). Review of Resident #26's Quarterly MDS Assessment, dated 08/19/19, Section N, revealed the facility assessed the resident as receiving one (01) anticoagulant medication during the ARD look back period. However, review of the resident's physician's orders [REDACTED]. Further, the resident's Quarterly MDS Assessment, dated 08/19/19, Section N, revealed the resident received antipsychotic medication seven (7) days during the last seven (7) day look back period; however, the Antipsychotic Medication Review question N0450, was coded that the resident did NOT receive antipsychotic medication and the gradual dose reduction (GDR) questions were skipped. Interview with the MDS Coordinator, on 10/17/19 at 10:15 AM, revealed Resident #26's antiplatelet inhibitor medication should not have been included in the MDS as an anticoagulant medication. Per interview, she was not aware [MEDICATION NAME] was an antiplatelet inhibitor versus an anticoagulant medication. Further, Resident #26's [MEDICATION NAME] was an antipsychotic medication and the MDS Assessment should have been coded to include the GDR information related to the use of antipsychotic medication. Further, she did not code the GDR information related to use of the antipsychotic medication due to human error. Continued interview revealed it was important to ensure the MDS Assessment was completed accurately because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care provided was the best care to meet the residents' needs. Interview with the Director of Nursing (DON), on 10/17/19 at 10:35 AM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Continued interview revealed the MDS Assessments for Resident #26, should have been accurate related use of anticoagulant medication, and related to GDR attempts for antipsychotic medication use. Further, the MDS Assessments guided the development of the Comprehensive Care Plans and therefore the MDS Assessment was to be an accurate reflection of the resident's status in order for residents to receive appropriate services and individualized care. Interview with Vice Present of Reimbursement/Registered Nurse (RN), on 10/17/19 at 1:47 PM, revealed she expected the RAI manual to be followed to ensure the MDS Assessments were accurately completed. Further, it was important to have accurate MDS Assessments because the Assessments drove the care plan which was a guide in providing necessary and quality care. Interview with the Administrator, on 10/17/19 at 3:15 PM, revealed the facility was to utilize the RAI Manual as a resource to ensure accuracy of the MDS Assessments. Per interview, it was important for MDS Assessments to accurately reflect a resident's current status to ensure the Care Plan was developed or revised to address each resident's individual needs and to ensure resources were provided as necessary to meet resident care needs.

Based on interview, record review, and review of the and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for two (02) of sixteen (16) residents sampled residents (Resident #26 and Resident #35). Review of Resident #26's Comprehensive Care Plan (CCP), revised 06/15/19, revealed no documented evidence the CCP was revised after fall events on 07/11/19, 07/18/19 and 08/12/19, even though the Fall Investigations related to these falls identified specific fall interventions to be implemented to prevent falls of the same nature. In addition, review of Resident #35's CCP, dated 03/07/19, revealed no documented evidence the CCP was revised after the fall event on 08/16/19, even though the Fall Investigation related to this fall identified specific fall interventions to be implemented to prevent falls of the same nature. The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #26's clinical record revealed the facility admitted the resident on 01/10/19 with [DIAGNOSES REDACTED]. Review of Resident #26's CCP, initiated 01/21/19 and revised 06/15/19, revealed the resident was at risk for injury related to falls as evidence by Muscle weakness, Diabetes, Major [MEDICAL CONDITION], Sleep disorder, incontinence, Flaccid [MEDICAL CONDITION]/left side, cardiac problems, and decreased safety awareness. The goal stated the resident would transfer safety to and from all surfaces with assistance of two (2), and have no significant injury related to falls for ninety (90) days. The interventions included bilateral floor mats to floor, 01/15/19; pommel cushion, 01/18/19; therapy referral, 01/20/19; offer to bed after meals, 01/21/19; falling star program, 03/01/19; touch call light on right side, 04/30/19; and offer cool drinks, 06/05/19. Further review revealed an intervention, dated 06/05/19 to not leave alone in wheelchair in room. Review of the Fall Investigation, dated 07/11/19 at 4:15 PM, revealed Resident #26 sustained an unwitnessed fall in the room from his/her wheelchair. According to the Investigation, the resident attempted to transfer from wheelchair to bed. Further, the resident received no injury from the fall. Continued review revealed the resident stated he/she wheeled him/herself to the room and was trying to get in the bed. Per the Investigation, the immediate intervention was a low bed and the Interdisciplinary Team (IDT) intervention was a therapy referral and staff to assist the resident to lay down after meals and activities. However, there was no documented evidence the CCP was revised to include a low bed, therapy referral and staff to assist the resident to lay down after meals and activities. Review of the Fall Investigation, dated 07/18/19, no time noted, revealed Resident #26 sustained a fall in the hallway. According to the Investigation, the resident attempted to get up from his/her wheelchair unassisted after removing his/her pull away alarm. Further, the resident received no injury from the fall. Per the Investigation, the immediate intervention was to ensure the pull away alarm was out of the resident's reach. However, there was no documented evidence the CCP was revised to include ensuring the pull away alarm was out of the resident's reach. Review of the Fall Investigation, dated 08/12/19 at 5:00 PM, revealed Resident #26 sustained a fall in his/her room. According to the Investigation, the resident attempted to get into bed from his/her wheelchair unassisted. Continued review revealed the resident was in the common area awaiting dinner and was looking for a bathroom prior to the fall event. Per the Investigation, the immediate intervention was to resume pull away alarm and the IDT intervention was a three (03) day bowel and bladder re-assessment of toileting needs. However, there was no documented evidence the CCP was revised to include resuming the pull away alarm or a three (03) day bowel and bladder re-assessment of toileting needs. Review of Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (07) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed Resident #26 as requiring two (02) staff total assistance with transfers and was only able to stabilize balance between surfaces with staff assistance. Further review revealed the facility assessed the resident as requiring supervision with locomotion on the unit and as ambulation did not occur. 2. Review of Resident #35's clinical record revealed the facility admitted the resident on 09/09/16 with [DIAGNOSES REDACTED]. Review of Resident #35 CCP, dated 03/07/19, revealed he/she was at risk for injury related to falls as evidence by a history of falls, [MEDICAL CONDITION], Dementia, [MEDICAL CONDITIONS] drug use, [MEDICAL CONDITION], decreased safety awareness, and noncompliance with ambulatory device. The goal stated the resident would transfer safely to and from all surfaces; have no significant injury related to falls; and would have less than one (01) fall for ninety (90) days. The interventions, dated 03/01/19 included: rule out medical complications; periodic medication review; ensure safe environment; encourage and cue Resident to use walker; offer assistance as needed; falling star program; walker within reach; and ensure appropriate footwear. Further review revealed an intervention to transfer with limited assistance with walker, dated 09/06/19. Review of the Fall Investigation, dated 08/16/19 06:30 AM, revealed Resident #35 sustained an unwitnessed fall in the room from his/her bed. According to the Investigation, the resident attempted to transfer from bed to go to the bathroom. Further, the resident received no injury from the fall. Continued review revealed the resident stated he/she was cold and rolled off the bed onto the floor. Per the Investigation, the immediate intervention was nonskid socks. However, there was no documented evidence the CCP was revised to include use on nonskid socks. Review of Resident #35 Quarterly MDS Assessment, dated 09/02/19, revealed the facility assessed the resident as having a BIMS score of three (03) out of fifteen (15), revealing the resident was severely cognitively impaired. Additional review revealed the facility assessed Resident #35 as requiring one (1) staff for ambulation with a walker; and requiring limited assistance of one (1) staff for bed mobility, transfers and toileting. Further review revealed Resident #35 was assessed as always continent of bladder and bowel. Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed it was her responsibility to revise the CCP during morning clinical meeting each morning after review of fall events that occurred in the last twenty-four (24) hours. Additional interview revealed after review of Resident #26's and Resident #35's Fall Investigations, their CCPs should have been revised after each fall event to include interventions to prevent falls of the same nature and ensure a safe environment. Further, it was important to ensure the CCP was a current reflection of the residents' care needs to assure quality of care and services. Interview with the Region Vice President of Reimbursement, on 10/17/19 at 1:47 PM, revealed she expected the RAI Guidelines to be followed related to revision of the CCP. Additionally, it was important for the CCP to be revised after each fall event for all residents to prevent falls of the same nature and to provide safe care. Further, the CCP should have been revised for Resident #26 and Resident #35 after their fall events. Interview with the Director of Nursing (DON), on 10/17/19 at 2:20 PM, revealed she expected the RAI Manual Guidelines to be followed to ensure the CCP was revised as necessary. Additionally, she expected the CCP to be revised after each fall event for all residents to ensure the facility was providing safe, necessary care. Per interview, the facility changed Electronic Medical Record (EMR) systems in (MONTH) 2019 and the process in which the facility investigated and reviewed fall events changed. Additional interview revealed the new EMR system did not generate a twenty-four (24) hour list of Fall Investigations, like the old system did. Per interview, the facility identified this concern and started manually tracking falls on a white board. Further, the fall event for Resident #35 on 08/16/19 and fall events for Resident #26, on 07/11/19, 07/18/19 and 08/12/19 slipped through the cracks. Per interview, the facility failed to revise the CCP after the Fall Investigations. Interview with the Administrator, on 10/17/19 at 3:15 PM, revealed he expected the CCP to be revised with interventions after fall events per RAI guidelines. Further, it was important to ensure the CCP was revised to include fall interventions status [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards for two (2) of two (2) sampled residents reviewed for oxygen out of a total sample of sixteen (16) residents (Resident #32 and Resident #63). Observation on 10/15/19, revealed there was no date on the nasal cannula, oxygen tubing, nor the storage bag hanging on the oxygen concentrator to indicate when this equipment was last changed out for Resident #32. In addition, observation on 10/15/19, revealed there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or [MEDICAL CONDITION] mask to indicate when this equipment was last changed out for Resident #63. The findings include: Interview with the DON/Infection Control Nurse, on 10/17/19 At 3:25 PM, revealed she was unaware of a written policy related to dating and changing out bottles of sterile water for humidified oxygen needs, [MEDICAL CONDITION] mask, oxygen tubing, and nasal cannulas. However, she stated it was her expectation this oxygen equipment be changed weekly and dated. 1. Review of Resident #63's clinical record revealed the facility readmitted the resident on 09/23/19 with [DIAGNOSES REDACTED]. Review of Resident #63's physician's orders [REDACTED]. Further review revealed orders to change [MEDICAL CONDITION] Collar every Monday and change oxygen tubing every week per Respiratory Therapist and nursing as needed. Observation on 10/15/19 at 10:42 AM, and 11:47 AM, revealed Resident #63's oxygen was set at four (4) liters per [MEDICAL CONDITION] mask to the resident's [MEDICAL CONDITION]. However, there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or [MEDICAL CONDITION] mask. Interview with Registered Nurse (RN) #1, who entered Resident #63's room during this observation, confirmed there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or [MEDICAL CONDITION] mask. RN #1 stated the mask, oxygen tubing and sterile water should have been labeled with the date it was changed out. Continued interview revealed it was the Respiratory Therapist and the nurse's responsibility to ensure this equipment was changed out weekly and dated in order for staff to be aware of when it was last changed. RN #1 stated if the mask, tubing and sterile water was not changed out weekly, this could be an infection control issue as it could lead to a respiratory infection for the resident. 2. Review of Resident #32's clinical record revealed the facility admitted the resident on 02/01/18 with [DIAGNOSES REDACTED]. Review of Resident #32's physician's orders [REDACTED]. Further review revealed orders to change oxygen tubing every week per the Respiratory Therapist and nursing as needed. Observation on 10/15/19 at 12:27 PM, revealed Resident #32's nasal cannula and oxygen tubing was on the resident's bed. There was no date on the nasal cannula, oxygen tubing, nor the storage bag hanging on the oxygen concentrator, which was turned off. This was verified with the Director of Nursing (DON) who stepped into the room during the observation. Interview on 10/17/19 at 4:20 PM, with the Staff Development Coordinator, revealed nurses had received in-services from the Respiratory Therapist related to the need to change out and date oxygen masks, tubing, storage bag and sterile water for humidification at least weekly and as ordered. Interview with the Director of Nursing (DON/Infection Control Nurse, on 10/17/19 at 3:25 PM, revealed the Respiratory Therapist changed the bottles of sterile water for humidified oxygen, [MEDICAL CONDITION] mask, oxygen tubing, and nasal cannulas weekly. Per interview, the bottles of sterile water for humidified oxygen were changed out when empty by nursing as the bottles did not last a whole week. Further interview revealed it was her expectation bottles of sterile water for humidified oxygen needs, [MEDICAL CONDITION] mask, oxygen tubing, and nasal cannulas were dated when changed out. Further, the oxygen-tubing bag for storage of the tubing when not in use should be dated and changed out weekly as well. The DON stated it was important to date any oxygen equipment to ensure it was not used longer than a week in order to prevent infections which could affect the resident's health. Interview on 10/17/19 at 3:37 PM, with the Administrator, revealed he was not familiar with the facility protocol related to labeling and dating respiratory equipment as it was changed out. However, he stated the Respiratory Therapist and the nursing staff would be expected to change the respiratory equipment such as oxygen tubing according to facility protocol in order to prevent infection and illness.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure a resident who was discharged had a Discharge Summary that included all necessary information related to discharge for one of three (3) discharged sampled residents out of a total sample of sixteen (16) sampled residents (Resident #58). Resident #58 was discharged to another facility on 06/28/18; however, there was no documented evidence of a Discharge Summary which included: a recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); and a post-discharge plan of care developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist the resident to adjust to his or her new living environment. The findings include: Review of the facility's Policy titled Discharge Planning Standard of Practice, dated (MONTH) (YEAR), revealed the facility was to develop and implement an effective discharge planning process that focused on: the resident's discharge goals; effective transition to post-discharge care; and the reduction of factors leading to preventable readmissions. Continued review revealed the Discharge Summary should include a Discharge Form which was to be completed by the charge nurse or designee for anticipated discharge home or to another facility; a medication reconciliation of pre-discharge medication with post-discharge medication; and discharge teaching instructions. Review of the facility's Policy titled Transfer or Discharge Documentation Standard of Practice, dated (MONTH) (YEAR), revealed when a resident was transferred or discharged , details of the transfer or discharge would be documented in the medical record and appropriate information would be communicated to the receiving health care facility provider. Continued review revealed when a resident was transferred or discharged from the facility, the information documented in the medical record would include an appropriate notice provided to the resident and/or the legal representative; the date and time of the discharge; a summary of the resident's overall medical, physical, and mental condition; as well as the signature of the person recording the data in the medical record. Review of Resident #58's closed medical record revealed the facility admitted the resident on 04/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating severe cognitive impairment. Continued review of the closed medical record revealed the resident was discharged on [DATE]. Review of Social Worker #1's Progress Note, dated 6/22/18, revealed Resident #58's family requested information to be sent to another facility closer to the family. Continued review revealed Social Worker #1 sent information to the facility. However, there was no documentation indicating what information had been sent to the facility. Review of Resident #58's Comprehensive Care Plan, dated 06/05/18, and revised 06/22/18, and 06/27/18, revealed the resident's return to the community deemed not feasible at this time. The goal stated the resident would be accepting of and appropriate for long-term care. The interventions included: discuss desire to be discharged with representative quarterly and PRN (as needed). The interventions were updated on 06/22/18 to state the family requested information related to other facilities closer to home; and the family requested the resident be transferred to a facility closer to family. Further review revealed an update on 6/27/18, stating the receiving facility notified the facility they would accept the resident. A further update on 06/27/18, revealed the resident would be discharged on [DATE] to another facility; and the family would provide transport. Review of the Nurse's Note, dated 6/28/18, signed by Licensed Practical Nurse (LPN) #1, revealed Resident #58 was discharged with family. Further review revealed report was called to the receiving facility, and physician's orders [REDACTED]. However, there was no documented evidence other paperwork was sent to the receiving facility. Review of Resident #58's Discharge Instructions for Care dated 06/28/18, revealed the form was only completed to include the Resident #58's name, the date, and the name of the receiving facility. The form was not completed under the sections titled: Follow Up Physician Care for appointments; Medications; Treatments; Diet; Current Physical Status of Resident; and Referrals for Care. The form stated, The discharge instructions for care have been reviewed with me in a language I can understand, and my questions have been answered to my satisfaction. I have received the medications or prescriptions indicated above and acknowledge that the medications may not be in childproof containers. Under this was a line for the signature of the person receiving the instructions which was not signed. The form further stated,detach yellow copy-and there was a place to mark who received the instructions including the Resident or Responsible Party. However, this section was left blank indicating the copy of the discharge instructions was not presented to the Resident or Responsible Party. Interview on 8/23/18 at 8:46 AM with LPN #1, who was assigned to Resident #58 at the time of discharge on 06/28/18, revealed when a resident was being discharged to another facility, it was the nurse's responsibility to print off the current physician's orders [REDACTED]. She further stated it was also the nurse's responsibility to fill out the form titled Discharge Instructions for Care and this form should include a general overview of the care the resident was receiving. Per interview, if the resident was being transferred to another facility, report should be called to the receiving facility. She revealed the verbal report should include a review of the resident's diagnoses, level of assistance needed, diet, and how the resident took their medication. Continued interview revealed the nurse should document report was called to the receiving facility and the name of the person receiving report should be documented, but the specific information given in report did not have to be documented. She stated she had completed the Discharge Instructions for Care form for Resident #58. She further acknowledged she had not completed the form correctly because the sections including Follow Up Physician Care for appointments; Medications; Treatments; Diet; Current Physical Status of Resident; and Referrals for Care were left blank. Continued interview revealed the entire form should have been completed with a copy given to the resident's representative, and a copy sent with the resident to the receiving facility. She further stated she also should have filled in the date and time of discharge, and signed the form. Interview on 8/23/18 at 8:35 AM, with Social Worker #1, revealed if a resident was being transferred to another facility she was responsible for sending information to the receiving facility including the resident's Face Sheet, History and Physical, any recent laboratory values, Hospital Discharge Summaries, Consults, as well as any further information requested by the receiving facility. She stated she took this information from Resident #58's medical record to fax to the receiving facility; however, did not keep a copy of the documents she sent to the receiving facility and did not indicate in the medical record which documents were faxed to the receiving facility. Per interview, there was no documented evidence Resident #58's Face Sheet, History and Physical, recent labs, Hospital Discharge Summaries, Consults, or other information had been sent to the receiving facility. Interview on 8/23/18 at 10:03 AM, with the Director of Nursing (DON), revealed there was a folder which contained a check list for the nurses to ensure that all the appropriate documents were sent with the resident upon discharge. Per interview, it was her expectation the nurse discharging the resident ensured all necessary paper work was completed and sent with the resident to the receiving facility. Further interview revealed the nurse who was assigned at the time of discharge was to complete the Discharge Instructions for Care form which was to be filled out in all sections with a copy sent with the resident to the receiving facility or given to the resident or responsible party on the day of discharge. She stated the nurse should sign and date the form as well. Further interview revealed the nurse discharging the resident should document verbal report was called to the receiving facility and document the name of the person who received the verbal report, but documentation related to the specific information given per verbal report to the receiving facility was not necessary. Additional interview revealed Resident #58's Discharge Instructions for Care dated 06/28/18, was not completed accurately as the nurse failed to ensure all sections were completed. The DON acknowledged there was no documented evidence all necessary discharge summary information was sent to the receiving facility per the Social Worker and nursing. Interview on 8/23/18 at 10:14 AM, with the Administrator, revealed it was her expectation nursing staff fill out the discharge forms correctly. She further stated it was her expectation the social worker communicate with the resident, the resident's family, as well as the receiving facility in regards to a resident being transferred and document this communication. She stated it was the nurse's responsibility to fill out the entireDischarge Instructions for Care form when a resident was discharged . However, she further stated this form was not completed accurately for Resident #58. The Administrator acknowledged there was no documented evidence all necessary discharge summary information was sent to the receiving facility per the Social Worker and nursing.

Based on record review and interview, it was determined the facility failed to ensure each resident was seen by a Physician at least every thirty (30) days for the first ninety (90) days after admission, and at least every sixty (60) days thereafter, for thirteen (13) of fifteen (15) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13). The remaining two (2) sampled residents were admitted for less than thirty (30) days and the allowed time for the initial Physician visit had not expired. Allowing for every other visit to be made by a delegated non-physician practitioner, as permitted by Federal regulation, each resident should have had a face-to-face visit by the Physician at least every one hundred twenty (120) days. The findings include: The facility did not provide a written policy related to timing of Physician visits. During interview with the Administrator, on [DATE] at 7:11 PM, he stated it was his expectation for Physician visits to be timely and according to federal regulations. 1. Review of the clinical record revealed Resident #1 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed no documented evidence Resident #1 had been seen by the Physician within the last 120 days. 2. Clinical record review revealed Resident #2 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed no evidence Resident #2 had been seen by the Physician in the last 120 days. 3. Clinical record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Continued record review revealed no documented evidence the Physician had seen Resident #3 in the last 120 days. 4. Review of the clinical record revealed Resident #4 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed the last documented physician progress notes [REDACTED]. 5. Review of the clinical record revealed the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed no documented evidence the Physician had visited Resident #5 within the last 120 days. 6. Review of the clinical record revealed Resident #6 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the record revealed no documented evidence Resident #6 was seen by the Physician in the last 120 days. 7. Clinical record review revealed Resident #7 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed Resident #7 on [DATE] to have a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and interviewable. Continued review of the clinical record revealed no documented evidence the Physician had visited Resident #7 since [DATE]. Interview with Resident #7, on [DATE] at 11:00 AM, revealed although he/she was visited by the Nurse Practitioner pretty often, the resident did not see the Physician much and did not recall when he had last visited. 8. Clinical record review revealed Resident #8 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the record revealed no documented evidence of a Physician visit for Resident #8 since [DATE]. 9. Clinical record review revealed Resident #9 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Continued record review revealed no evidence Resident #9 was seen by the Physician since [DATE]. 10. Clinical record review revealed Resident #10 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed no documented evidence the Physician had conducted a face-to-face visit within the past 120 days. 11. Review of the clinical record revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record no documented evidence Resident #11 had been seen by the Physician since admission. Interview with the Physician, on [DATE] at 6:00 PM, revealed he had not conducted a face-to-face visit with Resident #11 since the resident was admitted . 12. Clinical record review revealed Resident #12 was admitted by the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Further review of the record revealed no documented evidence the Physician had seen Resident #12 since October of 2015. 13. Review of the clinical record revealed Resident #13 was admitted by the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the medical record revealed Resident #13 was last seen by the Physician on [DATE], a period greater than 120 days. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 2:40 PM, revealed the Physician came to the facility on ce a month. She stated she was not aware of how it was determined which residents were to be seen on any given visit, unless a particular resident had a problem which needed to be addressed, and she or the Physician would be notified. Continued interview revealed the facility needed to maintain a regulatory visit list, to coordinate which residents were due to be seen by the Physician, or could be seen by the APRN, in order to meet federal regulatory guidelines. She further stated the MDS nurse started working on such a list, but it never really got completed for use. Interview with the Minimum Data Set (MDS) Nurse, on [DATE] at 3:35 PM, revealed she was knowledgeable regarding the federal regulatory guidelines for timely Physician visits. She stated she had discussed the issue with the Director of Nursing (DON) and with the APRN, but no formal process for tracking when Physician visits were due had been developed. She further stated she was aware MDS staff in other facilities maintained up-to-date lists. Continued interview revealed it had not occurred to her to audit the clinical records to verify the visits were taking place as required. Interview with the DON, on [DATE] at 4:00 PM, revealed the Physician was in the facility, and had Progress Notes for his visits with residents on his computer and was in the process of printing them. She stated the Physician visited once a month and stayed all day, but she did not know who he saw, unless a specific request to see a particular resident was made, based on a medical problem. She further stated the facility did not have a system for determining when regulatory visits were due for each resident, or if the Physician was meeting the requirement. (*Note: the Physician did provide additional Progress Notes for all sampled residents, and other facility residents, which he printed from his computer. However, review of the additional notes did not change the findings.) Further interview with the Physician, on [DATE] at 6:00 PM, revealed he was the facility's Medical Director and was in the facility three (3) or four (4) times per month. He exhibited a clear understanding of the regulatory requirements for timely visits. However, the Physician stated, the facility maintained no schedule and it was impossible to track the movement of the residents, e.g. when they come or when they go, and when they were last seen by him or when they were due to be seen. He explained when he came to the facility to make rounds, he was provided a list of residents with concerns that needed to be evaluated, but it told him nothing about how long since he had last seen the resident. Continued interview revealed the facility had tried to make a system but it just hadn't worked out.

Based on observation and interview, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as was possible. Observation during the environmental tour revealed exposed bolts with sharp edges at the base of the toilets in seven (7) resident bathrooms. The findings include: Interview with the Director of Nursing (DON), on 06/02/16 at 6:55 PM, revealed the facility did not have a policy regarding maintaining an environment free of accidents and hazards. She stated the facility followed federal guidelines. Observation during the environmental tour, on 06/02/16 at 2:15 PM, revealed exposed, sharp and rusty anchor bolts sticking up from the base of the toilets in the bathrooms for Rooms 12, 15, 17, 26, 32, 34 and 36. Interview with the Maintenance Supervisor, on 06/02/16 at 3:00 PM, revealed he had not considered how the exposed anchor bolts were a safety concern. Interview with the Administrator and the DON, on 06/02/16 at 7:11 PM, revealed the facility had never had an injury related to raised, exposed toilet bolts. The DON acknowledged there was a potential for injury due to the sharp and rusty condition of the exposed bolts.

Based on observation, interview and review of facility policy, it was determined the facility failed to provide food that was palatable and at the proper temperature. Group Interview conducted on 05/31/16, by the State Survey Agency, revealed complaints of hot food served cold, food being overcooked or undercooked, and food which was not palatable. In addition, observations on 05/31/16 of the dinner test tray, and 06/01/16 of the lunch test tray, revealed the point of service temperatures were not within proper range for hot and cold foods, and the food was not palatable. The findings include: Review of the facility's policy titled Test Trays, dated February 2015, revealed test trays were obtained by dietary management, several times on a monthly basis, to evaluate the accuracy of meal assembly and the qualitative aspects of the meal. Further review revealed the evaluation of the test tray began after the final resident meal was served. However, the Policy did not state the expectation for food temperatures at point of service. Review of the Food Code 2005, revealed cold and hot holding food temperatures should be at forty-one (41) degrees Fahrenheit or less for cold foods and one hundred thirty-five (135) degrees or greater for hot foods. 1. Group Interview conducted by the State Survey Agency, on 05/31/16 at 4:00 PM, revealed residents voiced complaints related to food as follows: Resident #7, who the facility assessed on the Annual Minimum Data Set (MDS) assessment dated [DATE], as having a Brief Interview for Mental Status (BIMS) of a twelve (12) indicating the resident had moderate cognitive impairment, stated the food was awful. Further interview revealed the food was cold, the meat was tough, and the portion sizes were getting smaller. I asked for a cheese sandwich and got three (3) slices of cold cheese on two (2) slices of bread. Resident #12, who the facility assessed on the Quarterly MDS dated [DATE], as having a BIMS of fifteen (15) indicating the resident was cognitively intact, revealed the food was either overcooked or raw and they received rice too often. Unsampled Resident C, who the facility assessed on the Quarterly MDS dated [DATE], as having a BIMS score of fifteen (15) indicating no cognitive impairment, revealed I wouldn't sit the tray down in front of a dog to eat. He/she stated the bacon and hamburger was often scorched, and although he/she had complained, the food was not getting any better. 2. Review of the Food Temperature Log, dated 05/31/16, for temperatures recorded on the dinner service line revealed the hot entrée was one hundred fifty (150) degrees Fahrenheit, vegetables one hundred sixty one (161) degrees Fahrenheit, starches one hundred eighty five (185) degrees Fahrenheit, hot beverages one hundred thirty five (135) degrees Fahrenheit and cold beverages thirty six (36) degrees Fahrenheit. Observation on 05/31/16 at 6:15 PM, of the dinner test tray temperatures revealed: fried chicken one hundred twenty nine (129) degrees Fahrenheit, mashed potatoes one hundred thirty five (135) degrees Fahrenheit, yellow squash one hundred nineteen (119) degrees Fahrenheit, and water and grape juice fifty (50) degrees Fahrenheit. The fried chicken, and squash were in the danger zone of above forty-one (41) degrees Fahrenheit to below one hundred thirty-five (135) degrees Fahrenheit. The State Survey Agency tasted the food items on the test tray, and noted the chicken tasted lukewarm, mashed potatoes were cold and very bland, and the squash was bland and watery. In addition, the juice and water were not at the appropriate temperature to be palatable of below forty-one degrees for cold food. Interview on 05/31/16 at 6:15 PM, with the Dietary Manager, who conducted the test tray, revealed she conducted test trays each month and was also responsible for calibrating the thermometers which were used to test temperatures of food in the kitchen. The Dietary Manager acknowledged the test tray temperatures were out of range for point of service. 3. Observation, on 06/01/16, at 12:45 PM, of the lunch test tray temperatures revealed: hamburger one hundred fifteen (115) degrees Fahrenheit, tater tots one hundred six (106) degrees Fahrenheit, chocolate pudding sixty nine (69) degrees Fahrenheit and koolaid and water sixty one (61) degrees Fahrenheit. The hamburger and tater tots were in the danger zone of greater than forty-one (41) degrees Fahrenheit and below one hundred thirty-five (135) degrees Fahrenheit and the koolaid and water were not at the appropriate temperatures below forty-one (41) degrees Fahrenheit for cold food. The State Survey Agency tasted the food items on the test tray, and noted the hamburger and tater tots were not hot, and the pudding was not cold. Interview on 06/01/16 at 12:45 PM, with the Registered Dietician (RD) who conducted the test tray, revealed she conducted test trays monthly at the facility and was unaware there was a concern with food temperatures; however, acknowledged the test tray temperatures were out of range of what they should be at point of service. Interview on 06/02/16 at 7:11 PM, with the Director of Nursing (DON) and Administrator, revealed food should be served at the proper temperature, whether hot or cold, and should taste good. Further interview revealed if food was not served at appropriate temperatures or was not palatable, the residents may not eat as they should, and there could be unwanted weight loss.

Based on observation and interview, it was determined the facility failed to prepare food under sanitary conditions. Observation of the kitchen on initial tour on 05/31/16, revealed there was an accumulation of dust in the vents above the food preparation area where kitchen appliances were located. The findings include: Observation on 5/31/16 at 11:45 AM, during initial tour of the kitchen, revealed an accumulation of dust like particles in the air vents, which was located above the food preparation area in which the mixer, slicer and toaster were located. The mixer and slicer were not in use and covered. The toaster was in use at the time of tour. Interview, on 5/31/16 at 6:00 PM, with the Dietary Manager, revealed she was unaware of the dusty air vents which was located over the food preparation area in the kitchen. Additionally, the Dietary Manager revealed maintenance was responsible for keeping the vents clean throughout the facility; however, she had not reported the need for the vents to be cleaned. Interview with the Administrator, revealed it was his expectation for the Dietary Department to keep the kitchen clean to prevent the danger of food contamination which could lead to forborne illness.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment, and to help prevent the transmission of disease and infection. Observation of the medication storage room on [DATE], revealed expired medical supplies. Also, observation on [DATE], revealed the ice scoop was placed inside the ice cooler, and then directly on the surface of the drink cart, prior to being used to scoop ice. Additionally observations during the environmental tour on [DATE], revealed six (6) resident bathrooms had call light pull cords which were long and directly touching the floor (Bathrooms in rooms #4, #5, #7, #11, #16, and #34). The findings include: Review of the facility Infection Control Policy, undated, revealed the objectives of the Policy was to prevent, detect, investigate and control infections in the facility; and maintain a safe, sanitary and comfortable environment for personnel, resident, visitors, and the general public. 1. Observation on [DATE] at 4:05 PM, revealed five (5) expired Universal Viral Transport Vials for Chlamydia (bacterial infection), Mycoplasma (bacterial infection) and Ureaplasm (bacterium infection), with an expiration date of [DATE], and four (4) 23 gauge butterfly small vein infusion sets, with an expiration date of [DATE] accessible for use. One of the expired 23 gauge butterfly infusion sets was on top of the Intravenous venipuncture cart, ready to be used. Interview on [DATE] at 6:00 PM, with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), revealed the medication rooms on both the west and east hallways were to be checked by the nursing supervisor on the evening shift for expired supplies. Further interview revealed staff were to properly dispose of any medical equipment which was expired, and staff needed to be re-educated. Continued interview revealed there was no check off sheet for checking the medical supplies for expiration dates. 2. Observation of the west hall, on [DATE] at 12:26 PM, revealed an ice cooler on top of a drink cart. The cooler was empty containing no ice, and there was an ice scoop inside the cooler with the handle of the cooler touching the floor of the cooler. Further observation revealed a Certified Nursing Assistant (CNA) took the cooler and filled it with ice, lying the ice scoop directly on the surface of the drink cart. Interview, on [DATE] at 5:35 PM, with Registered Nurse (RN) #1, revealed ice scoops should not be stored inside the coolers because the handle of the cooler could contaminate the inside of the cooler and also the ice scoops should not be placed directly on surfaces such as the drink cart because this could cause cross contamination. She stated the ice scoops were to be placed in the scoop holders when not in use. Interview on [DATE] at 7:11 PM, with the DON and Administrator, revealed ice scoops needed to be stored in the scoop holders in order to be kept clean and prevent cross contamination. 3. Observation on [DATE] at 2:15 PM, during the environmental tour, revealed call light pull cords were long and touching the floor in resident bathrooms for rooms #4, #5, #7, #11, #16, and #34. Observation of the call light pull cords and interview with the Maintenance Supervisor on [DATE] at 2:25 PM, revealed the call light pull cords in the resident bathrooms should not have been touching the bathroom floor and this was an infection control concern. Further interview, on [DATE] at 5:35 PM, with RN #1, revealed the call light pull cords located in resident bathrooms should not be touching the floor because the floor was contaminated and if a resident pulled the cord, the residents hands would be contaminated which could possibly cause an infection. Continued interview with RN #1, revealed staff should have contacted maintenance to correct the issue by shortening the cord. Further interview on [DATE] at 7:11 PM, with the DON and Administrator, revealed call light cords should be kept off of the floor, as it was an infection control concern for them to drag the floor.

Based on interview and review of facility policy, it was determined the facility failed to ensure each resident exercised their rights as citizens of the United States for two (2) of fifteen (15) sampled residents (Resident #7 and #12). Group Interview conducted by the State Survey Agency revealed Resident #7 and Resident #12 did not have the opportunity to vote in the recent Primary Election. The findings include: Review of the facility policy titled Voting Rights undated, revealed residents were encouraged to vote, and the facility would help residents exercise their right to vote, which could include voter registration, obtaining absentee ballots, or obtaining transportation to voting sites. Group Interview was conducted by the State Survey Agency on 05/31/16 at 4:00 PM. Resident #7 and Resident #12 revealed they were not provided the opportunity to vote in the 05/17/16 Primary Election. Further interview revealed they had not been made aware of any opportunities to vote, via absentee ballot or otherwise. Interview on 06/01/16 at 4:56 PM with the Activities Assistant, revealed she was responsible for obtaining absentee ballots for residents to vote. Continued interview revealed she did not realize she should have given residents the opportunity to vote in the Primary Election. Interview on 06/01/16 at 5:18 PM, with the Administrator, revealed the facility had a system to enable residents to vote, and the Activities staff had been responsible to ensure the residents had the opportunity to vote for years. Continued interview revealed residents should have been provided the opportunity to vote in the recent Primary Election. Interview with the Director of Nursing (DON), on 06/02/16 at 7:11 PM, revealed the residents were to be provided the opportunity to vote if they choose to do so.

Based on observation, interview, and record review, it was determined the facility failed to promote care for residents in a manner that maintained or enhanced each resident's dignity and respect for one (1) of fifteen (15) sampled residents (Resident #4). Resident #4 was observed to have long nasal hairs, and the resident revealed this bothered him/her, and he/she had asked staff several times for the nasal hairs to be trimmed. The findings include: A policy related to providing personal care to residents regarding grooming and shaving was requested; however not provided. Review of Resident #4's medical record revealed the facility admitted the resident on 04/25/14 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment date 01/08/16, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as requiring requiring extensive assistance, with two (2) plus persons physical assistance for personal hygiene including combing hair, brushing teeth, shaving, and washing/drying face and hands. Observation on 06/01/16 at 9:45 AM in Resident's # 4's room revealed the resident had long nasal hairs protruding out of the resident's bilateral nares approximately one eighth (1/8) inch, and a facial and neck beard which had grown approximately one sixteenth (1/16) inch. Interview with Resident #4 on 06/01/16 at 3:20 PM, revealed, they take care of me here for the most part. They use my electric shaver to shave me every two (2) days, if they don't they have to use a real razor. They use an attachment on my electric razor to trim my ear hairs, but nobody will trim my nasal hairs, I have asked several times and they are starting to bother me. Interview on 05/31/16 at 3: 55 PM with State Registered Nurse Aide (SRNA) #4, revealed she was regularly assigned to Resident #4. She stated it was facility policy for the men to be shaved every morning, as well as every time they received a shower. SRNA #4 further revealed sometimes the men did not want to be shaved and their requests were respected. Continued interview revealed Resident # 4 had never asked for his/her nose hairs to be trimmed, but she had shaved his ears and facial beard. SRNA #4 stated she had never trimmed nasal hairs and thought the nurses completed the task. Interview on 06/01/16 at 4:00 PM with the Unit Manager, of the nursing unit where Resident #4 resided, revealed He/she receives a shower twice a week, but I really don't know how often they shave or trim his/her nasal hairs. Further interview revealed she did not know who trimmed the resident's nasal hairs. Interview on 06/02/16 at 3:00 PM, with Licensed Practical Nurse (LPN) # 3, who was sometimes assigned to Resident # 4, revealed We don't really have any equipment here to do that (trim nasal hairs) I have never done it. We don't have a barber, but we do have a beautician who comes once a week. Interview on 06/02/16 at 5:00 PM, with the Director of Nursing (DON) revealed, I was not aware he/she had been denied services, we usually ask the beautician and she has the equipment to trim the resident's nasal hairs. I will look into this right away and re-educate the staff. It is my expectation that all of the residents have their personal grooming needs met to maintain their dignity. Further interview with the DON, on 06/02/16 at 7:11 PM, revealed residents could have facial hair if they so desired, but it was the facility's responsibility to ensure residents personal hygiene was maintained. Interview with the Administrator, on 06/02/16 at 7:11 PM, revealed it was his expectation that residents should always be neat and clean.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' call lights were within reach for one (1) of fifteen (15) sampled residents and two (2) unsampled residents. (Resident #10, and Unsampled Residents A and B). Additionally, call light cords were observed wrapped around safety bars in two (2) resident bathrooms, in a manner which prevented the call light system from being activated by pulling on the string from below the bar. The findings include: Interview with the Director of Nursing (DON), on 06/02/16 at 6:55 PM, revealed the facility did not have a written policy regarding call lights. She stated the facility followed federal guidelines related to call light accessibility by residents. 1. Review of the medical record revealed the facility admitted Resident #10 on 04/21/16 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 12/31/15, revealed the facility assessed Resident #10 to have a Brief Interview of Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment. Continued review of Section G for functional status revealed Resident #10 required the extensive assistance of two (2) staff for bed mobility, transfers and toileting. Observations, on 05/31/16 at 11:10 AM, 12:15 PM and 3:30 PM, revealed Resident #10 was lying in bed, with the call light lying in the floor, out of reach of the Resident. Interview with Certified Nurse Aide (CNA) #1, on 05/31/16 at 4:45 PM, revealed Resident #10's call light was not in reach but should be accessible at all times. She acknowledged it was her responsibility to check for proper placement of the call light each time she was in the room. Continued interview revealed she had made rounds on Resident #10 throughout the day, but had forgotten to check the call light each time before she left the room. 2. Review of the medical record revealed the facility admitted Unsampled Resident A on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 01/29/16, revealed the facility assessed Unsampled Resident A to have a BIMS score of zero (0), indicating severe cognitive impairment. Continued review of Section G for functional status revealed Unsampled Resident A required the extensive assistance of two (2) persons for bed mobility, transfers, and toileting. Observations of Unsampled Resident A, on 05/31/16 at 11:20 AM and 12:25 PM, revealed the resident was sitting in a Geri chair. Continued observation revealed the call light had been placed on the roommate's bed, out of reach of the resident. Further observation, on 06/02/16 at 2:15 PM, revealed Unsampled Resident A was sitting in a Geri chair. The resident's call light was observed to be lying in the floor and out of reach of the resident. 3. Medical record review revealed Unsampled Resident B was admitted by the facility on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 04/13/16, revealed the facility assessed Unsampled Resident B to have a BIMS score of three (3), which indicated severe cognitive impairment. Review of Section G for functional status revealed Unsampled Resident B required the extensive assistance of two (2) staff for bed mobility, transfers and toileting. Observation of Unsampled Resident B, on 06/02/16 at 2:20 PM, revealed the resident was lying in bed with his/her eyes closed, with the call light lying on the floor and out of reach of the resident. Interview with Licensed Practical Nurse (LPN) #1, on 06/02/16 at 6:00 PM, revealed all residents at the facility should have their call lights in reach at all times. Continued interview revealed it was important for the call lights to be accessible so residents could make their wants and needs known to staff. Interview with the Unit Manager, on 06/02/16 at 5:35 PM, revealed it was her expectation for all residents at the facility to have their call light within reach at all times. She stated it was important so residents could call staff for help if needed. 4. Observation during the environmental tour, on 06/02/16 beginning at 2:15 PM, revealed the call light pull cord in the resident bathrooms for rooms [ROOM NUMBERS] were tied around the safety bar. Continued observation revealed the call light system could not be activated by pulling on the end of the cord. Interview with the Maintenance Director, on 06/02/16 at 2:15 PM, revealed call light cords wrapped round the rails were not functional if pulled from the bottom. Interview with CNA #1, on 06/02/16 at 6:15 PM, revealed the call light pull cords in resident bathrooms should not have been wrapped around the safety bar. Continued interview with CNA #1 revealed when the call light pull cord was wrapped in this manner, it could prevent a resident who needed assistance from activating the system; therefore, the resident could not inform staff they needed help. Interview with the Unit Manager, on 06/02/16 at 5:35 PM, revealed the bathroom call light pull cords should never be wrapped around the safety bar, as the resident could not call for assistance when needed. Interview with the Administrator and the Director of Nursing (DON), on 06/02/16 at 7:11 PM, revealed it was their expectation for all staff to take responsibility for answering call lights. Further, the Administrator stated the call lights should always be within reach of the residents, and should not be wrapped around the bars in the bathroom. He explained a call light cord could not be pulled when wrapped around a bar, and impaired residents may not be able to unwrap the cord in order to call for help.

Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to develop a Comprehensive Care Plan related to an indwelling urinary catheter for one (1) of fifteen (15) sampled residents (Resident #11). The findings include: Interview with the Director of Nursing (DON), on 06/02/16 at 7:35 PM, revealed the facility did not utilize a written policy related to care planning, but followed the guidance outlined in the RAI User Manual. Review of the RAI user Manual Version 3.0, revised May 2011, revealed the Comprehensive Care Plan is an interdisciplinary communication tool which must include measurable objectives and time frames, and must describe the services necessary to attain or maintain the resident's highest practicable physical well-being. Continued review revealed the Care Plan should include interventions to address the individual's physical and functional needs. Further review revealed the facility's assessment of the resident should include consideration of the risks and benefits of an indwelling catheter, the potential for removal of the catheter, and consideration of complications resulting from the use of an indwelling catheter, and develop an individualized Care Plan based directly on these conclusions. Review of the clinical record revealed Resident #11 was admitted by the facility on 03/28/16 with [DIAGNOSES REDACTED]. Review of the comprehensive Care Plan for Resident #11 revealed no Problem/Need related to an indwelling catheter had been identified and documented by the facility, and no interventions for monitoring the resident's urinary output, maintaining the catheter, or observing for potential complications were included on the written plan of care. Observation of Resident #11 upon entering the facility, on 05/31/16 at 11:00 AM, revealed the resident was sitting in a wheelchair in the front lobby. A urinary catheter drainage bag was noted hanging underneath the wheelchair. Further observation, on 05/31/16 at 3:00 PM, revealed the catheter drainage bag remained in place beneath the resident's wheelchair. Subsequent observation, on 06/02/16 at 1:40 PM, revealed Resident #11 was in a high-back wheelchair in the front lobby of the facility. Continued observation revealed no catheter drainage bag was present. Interview with the Director of Nursing (DON), on 06/02/16 at 2:35 PM, revealed Resident #11 had a new order for the urinary catheter to be connected to a leg bag (secured under the resident's clothes) while the resident was up in the wheelchair. She acknowledged the resident's Comprehensive Care Plan did not include interventions related to the presence of an indwelling urinary catheter. The DON stated she typically audited all residents with catheters to ensure the Care Plan reflected appropriate interventions, but somehow Resident #11 had been overlooked. Further interview with the DON and the Administrator, on 06/02/16 at 7:11 PM, revealed Resident #11's Care Plan should contain interventions to ensure the catheter was flowing freely, was clean and intact, was not dragging the floor, was maintained in a manner to protect the resident's dignity and privacy, and was cleansed using proper hygiene. The DON stated the Care Plan was usually updated by the Interdisciplinary Team (IDT), but could not say how Resident #11 was missed. Subsequent post-survey interview with the DON, on 06/14/16 at 1:35 PM, revealed the Interdisciplinary Team (IDT) reviewed residents with urinary catheters in daily morning meetings, and ensured the Care Plans were updated accordingly. She explained initially the plan was to discontinue Resident #11's catheter soon after admission, and the IDT did not update the comprehensive Care Plan; however, due to the resident's underlying problem of a [MEDICAL CONDITION] bladder with [MEDICAL CONDITION], the resident required continued catheterization. The DON stated when it became clear the indwelling catheter would be continued, the IDT failed to update Resident #11's care plan regarding the catheter.

Based on observation, interview, record review, and review of the Lippincott Manual of Nursing Practice, Ninth Edition, it was determined the facility failed to provide necessary care and services to ensure each resident maintained or attained the highest practicable physical, mental, and psychosocial well-being for one (1) of fifteen (15) sampled residents (Resident #4). Resident #4 was ordered medicated shampoo treatment; however, the treatment was not transcribed correctly to the April 2016, and May 2016 Treatment Administration Records (TAR), and staff interviews revealed by reviewing the TARs, it could not be determined if the resident was receiving the treatment as ordered. The findings include: Review of the Lippincott Manual of Nursing Practice, Ninth Edition, Publishers, Lippincott, Williams and Wilkins, May 2013, revealed the practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. These standards provide patients with a means of measuring the quality of care they receive. Interview with the Director of Nursing (DON), on 06/02/16 at 7:35 PM, revealed this was the nursing reference which the facility followed related to standards of practice. Review of Resident #4's medical record revealed the facility admitted the resident on 04/25/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/08/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as requiring requiring extensive assistance, with two (2) plus persons physical assistance for Personal hygiene which included combing hair, brushing teeth, shaving, and washing/drying face and hands. Continued review of the MDS revealed the facility assessed the resident as requiring total dependence of one (1)person assistance for a body bath/shower, sponge bath, and transfers in/out of tub/shower. Observation on 06/01/16 at 9:45 AM of Resident #4, revealed the resident had a facial and neck beard which had grown approximately one sixteenth (1/16) inch, and redness to bilateral cheeks and scalp. Interview with Resident #4, on 06/01/16 at 3:20 PM, revealed the staff took care of him/her for the most part, but he/she did not remember if they used special shampoo or applied special shampoo to his/her face when staff assisted him/her with a shower. Resident #14 stated, my face and head still itches me. Record review revealed Resident #4 had received an order from a Dermatologist on 01/28/16 for [MEDICATION NAME] 2% Shampoo (prescription anti-fungal shampoo), wash face and scalp in shower three (3) times per week on shower days for the treatment of [REDACTED]. Observation of the Treatment Cart on 06/02/16 at 2:00 PM, revealed a bottle of [MEDICATION NAME] 2% Shampoo dated 01/30/16 for Resident #4, was still present on the treatment cart, and had been opened. Review of the Treatment Administration Record (TAR), dated April 2016, revealed the order was transcribed as [MEDICATION NAME] 2% Shampoo, wash face and scalp in shower three (3) times a week on shower days on Saturday and Wednesday on the 7:00 AM to 3:00 PM shift. The TAR was initialed documenting the treatment had been applied each day, 04/01/16 through 04/29/16. The days were not marked off on the TAR to indicate the shampoo was to be applied on any certain days. Review of the TAR, dated May 2016, revealed the physician's orders [REDACTED]. The TAR was initialed to indicate the treatment had been applied daily 05/02/16 through 05/14/16, 05/16/16 through 05/20/16, 05/22/16 through 05/26/16, and 05/30/16 through 05/31/16. The TAR was not marked off to indicate the shampoo was to be applied on any certain days. Review of the current ADL (Activities of Daily Living) Plan of Care, dated 08/17/15 until present, revealed the resident was to receive showers on Mondays and Thursdays. Interview and review of Resident #4's physician's orders [REDACTED].#1, on 06/02/16 at 4:30 PM, revealed she had been assigned to the resident on some days in April and May 2016, and had signed the TARs indicating the medicated shampoo had been administered; however, should not have signed the medication as being administered except on the exact shower days in which the resident received the shower and medicated shampoo. She further stated she did not know why the nurses who transcribed the orders to the TARs did not mark off the exact days in which the resident was to receive the medicated shampoo and showers; however, by reviewing the TAR, it could not be determined exactly when the resident received the treatment. Interview with LPN #3, on 06/02/16 at 3:00 PM, who was at times assigned to Resident #4, during the months of April and May 2016, revealed she administered the medicated shampoo to the resident; however, was also signing off on the April and May 2016 TARs on days when the treatment was not administered. Further interview revealed, I do not know why the nurses took the order off that way, it should have been written to more clearly document when the resident was to receive the shampoo three (3) times a week. The State Survey Agency placed a telephone call to Resident #4's dermatologist regarding the medicated shampoo order, with a message left to return the call; however, the telephone call was not returned. Further interview with the Director of Nursing (DON), on 06/02/16 at 7:35 PM, regarding the nursing transcription of Resident #4's medicated shampoo order to the April and May 2016 TARs, revealed, It was not set up in the system the right way, the nurses set the order up as For Your Information (FYI) and did not provide the proper documentation for when the medicated shampoo was to be administered as ordered, three (3) times a week. Further interview revealed she would need to re-educate the nursing staff regarding the transcription of physician's orders [REDACTED].#4 was receiving the ordered treatment.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure services were provided in accordance with each resident's care plan for one (1) of fifteen (15) sampled residents (Resident #10) and two (2) unsampled residents (Unsampled Residents A and B). Although the residents' comprehensive Care Plans revealed their call lights were to be within reach at all times, observations during the survey revealed the call lights were not within reach of the residents on multiple occasions. The findings include: Interview with the Director of Nursing (DON), on 06/02/16 at 6:55 PM, revealed the facility did not have a written policy regarding ensuring call lights were positioned within reach of residents. She stated the facility followed federal guidelines. Subsequent interview with the DON, on 06/02/16 at 7:35 PM, revealed the facility did not utilize a written policy related to following the Care Plan, but followed guidance outlined in the RAI User Manual and federal guidelines. Review of the RAI User Manual Version 3.0, revised May 2011, revealed Care Plan interventions should be designed to meet the individual resident's medical, nursing, mental and psychosocial needs. Continued review revealed the services provided by the facility must be consistent with each resident's written plan of care. 1. Review of the medical record revealed Resident #10 was admitted by the facility on 04/21/16, with [DIAGNOSES REDACTED]. Review of Resident #10's comprehensive Care Plan, dated 03/21/16, revealed the resident had a potential for injury from falls. The stated goal was for safe transfers to and from all surfaces, less than one (1) fall in ninety (90) days, and no significant injuries resulting from a fall. Interventions included call bell in reach. Observations, on 05/31/16 at 11:10 AM, 12:15 PM and 3:30 PM, revealed Resident #10 was lying in bed; however, the call light was observed to be lying in the floor, out of reach of the resident. Interview with Certified Nursing Assistant (CNA) #1, on 05/31/16 at 4:45 PM, revealed she had made rounds on Resident #10 throughout the day. She stated she was supposed to check to ensure the call light was placed within reach of the resident, as directed by the plan of care, but had forgotten to do 2. Review of the medical record revealed the facility admitted Unsampled Resident A on 07/01/12 with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's Comprehensive Care Plan, dated 03/17/16, revealed the resident was high risk for injury related to falls with the stated goal of no significant injuries from falls over the next ninety (90) days. Interventions included keep call light in reach of resident at all times. Observations of Unsampled Resident A, on 05/31/16 at 11:20 AM and 12:25 PM, revealed the resident was sitting in a Geri chair in his/her room; however, the call light was lying on the roommate's bed, out of reach of the resident. 3. Medical record review revealed the facility admitted Unsampled Resident B on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, with a problem onset date of 02/10/16, revealed Unsampled Resident B was at risk for injury related to falls, with the stated goal for the resident to have no significant injuries from falls. Interventions included call bell in reach. Interview with Licensed Practical Nurse (LPN) #1, on 06/02/16 at 6:00 PM, revealed the Care Plans were not followed when the call lights for Resident #10, and Unsampled Residents A and B, were not positioned within reach. She stated nurses and aides were responsible for ensuring proper placement of the call light each time they were in the room. Interview with the Unit Manager, on 06/02/16 at 5:35 PM, revealed it was her expectation for the Care Plan to be followed related to ensuring the resident's call lights were within reach at all times. She stated any staff entering a resident's room should confirm the call light was accessible before leaving the room. Continued interview with the Unit Manager revealed it was important for residents call light to be in reach so the residents could let staff know if they needed assistance. Interview with the Administrator and the DON, on 06/02/16 at 7:11 PM, revealed both held the expectation for staff to follow the Care Plans, to ensure each resident's needs were met.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure necessary care and services were provided for residents' physical well-beings for three (3) of eleven (11) sampled residents (Residents #4, #3, and #7). The facility failed to follow the bowel protocol for Resident #4 who did not have bowel elimination for four (4) days, from 10/29/13 through 11/01/13. On 11/01/13, Resident #4 was noted to have a distended firm abdomen and complained of abdominal pain. As a result, Resident #4 was admitted to the hospital on [DATE] and subsequently underwent a Hemicolectomy (surgical procedure to remove approximately half of the colon), on 11/07/13 for Colonic Volvulus (a twisting of a segment of colon resulting in obstruction). The resident was readmitted to the facility on [DATE]. In addition, the facility failed to provide documented evidence Resident #3 and #7 experienced bowel movements for periods ranging from five (5) to eight (8) days. Additionally, for these residents there was no documented evidence the facility followed its "Bowel Policy", regarding the administration of laxatives as ordered by the Physician and checking for bowel sounds daily until resolved for residents who had not had regular bowel movements. The findings include: Review of the facility policy titled, "Bowel Policy", undated, revealed it was the policy of the facility to ensure residents had sufficient bowel movements. Per the Policy, Nursing Administration was to check the Bowel Movement (BM) Alert from the AccuNurse Software Program Monday through Friday. The policy revealed if a resident had not had a BM in three (3) days the following protocol was to be implemented: laxative as ordered by the Physician or Physician Agent; check bowel sounds daily until resolved; and a hydration and pain assessment were to be conducted. Further review revealed if a resident had not had a BM by the fourth day, the Physician was to be notified for further orders and evaluation. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 07/01/12, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/04/13, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of a twelve (12) which indicated no cognitive impairment. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) persons for toileting and to be frequently incontinent of bowel and bladder. An interview was attempted with Resident #4, on 12/20/13 at 11:00 AM; however, the resident refused to be interviewed. Review of the facility Admission/Quarterly Data Set assessment form dated 09/28/13, revealed under the Gastrointestinal (GI) section the nurse assessed Resident #4 to be incontinent of bowel and have a history of constipation. Review of the Comprehensive Care Plan for Resident #4, dated 04/17/13 revealed revealed a care plan for the resident being at risk of alteration in bowel elimination as evidenced by constipation The goal stated the resident would have a normal bowel movement at least every three (3) days. Interventions included to administer medications as ordered, monitor bowel movements, perform bowel, hydration and pain assessments per protocol. Review of the Physician's Orders for October 2013 and November 2013, revealed the following orders: [MEDICATION NAME]-S (a laxative medication) 8.6-50 milligram (mg) tablets, one tablet twice a day scheduled; [MEDICATION NAME] (a laxative medication)17 GM's (grams) daily scheduled; [MEDICATION NAME] (a laxative medication) 10 mg's by mouth twice a day prn (as needed); and Milk of Magnesia (a laxative medication) 400 mg/5 milliliters (ml) suspension, give 30 ml by mouth twice a day prn for constipation. Review of the computerized "BM Report", revealed Resident #4 had a large BM on 10/28/13 which was documented at 1:15 PM. Continued review of the "BM Report" revealed no documented evidence the resident had BMs from 10/29/13 through 11/01/13 (4 days). Further review revealed staff had not documented each shift per the facility's policy. Interview, on 12/20/13 at 10:40 AM with Certified Nursing Assistant (CNA) #1, revealed CNAs were to document whether residents had BMs in the computer. She indicated CNAs could not look to see how many days a resident had gone without a BM, as they could not look at more than one (1) day of documentation in the computer. Review of the Interdisciplinary Team (IDT) Note dated 11/01/13, revealed Resident #4 had not had a BM for three (3) days. Continued review revealed staff was to assess the resident's bowel sounds every shift until resolved; and, pain and hydration assessments were to be completed one time. Additionally, further review of the IDT Note revealed laxatives were to be administered as ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, there was no documented evidence the [MEDICATION NAME] or MOM were administered from 10/29/13 through 11/02/13. Review of the MAR for November 2013, revealed documentation of initials on 11/01/13 which indicated a hydration and pain assessment were completed and signed off by Licensed Practical Nurse (LPN) #3. However, review revealed no documented evidence of an abdominal assessment for bowel sounds for 11/01/13 for the day shift, evening shift, or night shift, per the IDT note dated 11/01/13. Review of the Departmental Notes, on which nurses documented, from 10/29/13 through 11/02/13 revealed no documented evidence of an abdominal assessment which included bowel sounds; and, no reference to Resident #4 having no bowel movement during this time frame. Interview with LPN #2 on 12/19/13 at 3:00 PM, revealed she was assigned to Resident #4's care on 11/01/13 on the day shift. She stated on week days, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were to check the "BM Report" each morning and give nurses the list of residents who had not had a BM in three (3) days. According to LPN #2, nurses were to follow through with administering a laxative. She further stated on weekends nurses were responsible for checking the "BM Report". LPN #2 confirmed 11/01/13 was a Friday, and she would have received the list of residents' who had not had a BM from management. She indicated she did not remember Resident #4 being on the list she received; and, did not remember anyone instructing her to assess the resident or administer a laxative. The LPN stated she did remember giving Resident #4 his/her scheduled [MEDICATION NAME] the morning of 11/01/13 which the resident consumed. She stated Resident #4 drank some Sprite (a soft drink) later that day and vomited at approximately 2:30 PM. She indicated the vomitus was clear like the Sprite she/he had been drinking. LPN #2 stated after Resident #4 vomited she completed an abdominal assessment which revealed the resident's abdomen was not firm or distended, and there were positive bowel sounds. According to LPN #2, she notified the Advanced Registered Nurse Practitioner (ARNP) of Resident #4's vomiting, which she thought was the result of allergies and mucous and did not check the resident's "BM Report". LPN #2 stated she did not receive any new orders from the ARNP. Continued interview with LPN #2 revealed she was unable to find documented evidence of her abdominal assessment related to the vomiting or of the notification to the ARNP. The LPN stated this could have been related to the facility moving from paper charting to electronic charting and her documentation might have been lost. Further interview revealed nurses were to check for documentation by the CNAs each shift; however, did not do this daily. She stated she had not realized CNAs were not documenting whether residents had BMs each shift. Interview, on 12/20/13 at 10:40 AM with CNA #1, revealed she was assigned to Resident #4 on 11/01/13 on the day shift. She stated she did not remember the resident having any vomiting or complaints of abdominal pain. CNA #1 stated the CNAs checked on Resident #4 every two (2) hours for incontinence, because the resident did not alert staff when she/he was wet or had a BM. Interview, on 12/19/13 at 3:30 PM with LPN #3, who was assigned to the resident on 11/01/13 from 3:00 PM until 3:00 AM on 11/02/13, revealed nurses were to administer a laxative if a resident did not have a bowel movement in three (3) days; and, if the laxative was ineffective the nurse was to notify the Physician. She stated nurses received a list each day of residents requiring a prn laxative. LPN #3 stated she did not remember anything unusual about Resident #4 on 11/01/13. Additionally, she stated did not remember if she had completed a abdominal assessment on the resident that day. Interview, on 12/20/13 at 4:47 PM, with CNA #2, revealed she was assigned to Resident #4 on 11/01/13 on second shift. She stated she did not ever remember the resident having any abdominal distention or vomiting. Interview, on 12/20/13 at 5:00 PM with CNA #3, revealed she was assigned to Resident #4 from 11:00 PM on 11/01/13, through the morning of 11/02/13. She stated the resident had no complaints throughout the night; and, she was unaware of the resident having any abdominal distention, pain, or vomiting. Review of the SBAR (situation, background, assessment, request) form dated 11/02/13 and timed 4:30 AM, completed by LPN #1, revealed Resident #4 was experiencing abdominal pain and had vomiting with brown emesis. Review of the "Nursing Home to Hospital Transfer Form" dated 11/02/13 at 5:00 PM, completed by LPN #1, revealed Resident #4 was being transferred to the hospital related to the abdominal pain and vomiting. Interview, on 12/19/13 at 2:30 PM with LPN #1, revealed she normally worked day shift and part of the daily process was for nurses to check the AccuNurse computer program to review the "BM Report". She stated if nurses noted residents who had not had a BM in three (3) days the nurse was to administer a laxative or notify the Physician if a laxative was not ordered. She stated sometimes the IDT Notes related to the BMs were given to the second shift nurse to administer the laxative and follow up. LPN #1 further stated she arrived at work the morning of 11/02/13 at 3:00 AM, and was told by the CNA caring for Resident #4, she could not remember who this was, the resident was complaining of his/her "belly hurting". She stated she checked the resident's vital signs, completed a pain assessment, and an abdominal assessment. LPN #1 stated Resident #4's abdomen was "huge and hard as a rock"; and, the resident had hypoactive (abnormally inactive) bowel sounds. She stated she notified the Physician and sent Resident #4 to the ER as ordered. The LPN indicated she had not been notified of any concerns with Resident #4 when she received report from the previous shift. Interview and record review on 12/20/13 at 2:30 PM, with the ADON revealed the facility policy was not followed for this Resident #4, as there was no documented evidence a prn laxative was administered nor was an abdominal assessment completed on 11/01/13. She stated Resident #4 should have received a laxative on 11/01/13 which would have been the fourth (4th) day with no BM; and, nurses should have performed an abdominal assessment to check for bowel sounds, abdominal distention and abdominal pain. Review of the "Hospital Discharge Summary" dated 11/15/13, revealed Resident #4 presented to theER on [DATE] and was admitted to the hospital that day. Review of the Discharge Summary revealed Resident #4 received enemas to help relieve the ileus (a type of bowel obstruction) causing abdominal distention. Review revealed a KUB (Kidneys, Ureter, Bladder) X-Ray was performed on 11/06/13 which showed progression of the bowel distention and severe colonic distention. Continued review of the Discharge Summary revealed Resident #4 was taken to the Operating Room (OR) on 11/07/13, and was found to have a colonic volvulus (twisting of a segment of colon resulting in obstruction). Further review revealed an extensive Right Hemicolectomy (surgical procedure in which approximately half the colon is removed) was performed. The discharge [DIAGNOSES REDACTED]. Interview with Resident #4's ARNP on 12/20/13 at 2:20 PM, revealed it would be hard to say if a Volvulus could occur from not having a BM for five (5) days. She stated her expectation was residents would have a BM at least every three (3) days; however, that would also depend on what was normal for each resident. Further interview revealed the facility's bowel policy should have "caught" this resident not having had a bowel movement with follow through for laxatives as needed. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 07/01/12, with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status of a fourteen (14) which indicated the resident had no cognitive impairment. Further review of the MDS revealed the facility assessed Resident #3 to require extensive assist of two (2) persons for toileting; and, as frequently incontinent of urine and occasionally incontinent of bowel. Review of the Comprehensive Plan of Care for Resident #3, dated 04/22/13 revealed a bowel care plan related to resident being occasionally incontinent of bowel and a history of constipation. The goal stated the resident was to have a normal bowel movement at least every three (3) days. Interventions included monitor BMs, administer medications as ordered and perform bowel, hydration and pain assessments per protocol. Review of the Physician's Orders for December 2013 revealed orders for Senna 8.6 mg-50 mg, two (2) tablets at night; [MEDICATION NAME] 17 GM prn; MOM 400 mg/5 milliliters (ml) suspension, give 30 ml daily prn; and Bisac-Evac (a laxative medication) 10 mg suppositories one (1) daily prn. Review of the "BM Report" revealed Resident #3 had a large BM on 12/02/13; however, there was no documented evidence of another BM until 12/10/13, eight (8) days later. Further review of the "BM Report" revealed staff had not documented each shift. Review revealed documentation for only two (2) of the three (3) shifts for the dates of 12/05/13, 12/07/13, and 12/08/13. Interview, on 12/18/13 at 1:50 PM with Resident #3 revealed he/she had problems with constipation. Resident #3 stated staff asked every day if he/she had a BM. Resident #3 indicated the suppositories worked when he/she experienced constipation. Review of the IDT Note dated 12/06/13, revealed Resident #3 had not had a BM for the past three (3) days; and, bowel sounds were to be assessed until resolved. Further review revealed a pain and hydration assessment was to be completed one (1) time and the resident's laxatives were to be administered as ordered. Review of the MAR for December 2013, revealed Resident #3 did not receive a prn laxative until 12/09/13, seven (7) days after the last recorded BM. Review revealed the resident received MOM 400 mg/5 ml suspension, 30 ml's on that date. Continued review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the "Departmental Notes", which nurses documented on, dated 12/02/13 through 12/10/13 revealed no documented evidence Resident #3 had not had a BM during this time frame. Further interview on 12/20/13 at 6:00 PM with the ADON revealed if a resident did not have a BM in three (3) days, the bowel policy was to be followed. 3. Review of Resident #7's clinical record revealed the facility admitted the resident on 01/22/13, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #7 to have a BIMS score of six (6) which indicated the resident was cognitively impaired. Further review of the MDS revealed the facility assessed Resident #7 to require supervision of one (1) staff for toileting; and, to always be continent with bowel and bladder. Review of Resident #7's Comprehensive Plan of Care revealed a bowel elimination care plan initiated 08/20/13 related to constipation, with goals which included normal BMs at least every three (3) days. Continued review of the care plan revealed interventions which included to monitor BMs and administer medications as ordered. Review of the Physician's Orders revealed an order dated 02/12/13, for [MEDICATION NAME] Sodium 100 mg daily prn for constipation; and, an order dated 03/25/13, for Milk of Magnesia (MOM) 30 ml daily prn for constipation. Review of the "BM Report" revealed no documented evidence Resident #7 had a BM between 09/18/13 and 09/25/13, seven (7) days. Further review revealed no documented evidence of a BM between 10/29/13 and 11/03/13, five (5) days. Review of the MAR for the months of September, October and November 2013 revealed no documented evidence the [MEDICATION NAME] Sodium or the MOM were prn as per the Physician's Orders, and facility "Bowel Policy" which indicated if a resident had not had a BM in three (3) days laxatives were to be administered as ordered. Review of the IDT Notes for 09/18/13 through 09/25/13 and 10/29/13 through 11/03/13 revealed no documented evidence Resident #7's failure to have a bowel for more than three (3) days was identified, treated or monitored by the facility. Interview with Resident #7, on 12/19/13 at 10:45 AM, revealed he/she was able to ambulate to the bathroom and toilet independently. Continued interview revealed staff was not usually present when the resident toileted. Resident #7 stated staff "sometimes" asked if the resident had a bowel movement. Interview with the ADON, on 12/20/13 at 4:35 PM, revealed she acknowledged the IDT did not address Resident #7's lack of a bowel movement from 09/18/13 through 09/25/13; and, 10/29/13 through 11/03/13. She stated each instance should have been discussed and she was not sure why it had not been. She further stated Resident #7 was able to toilet independently. Continued interview revealed the aides were to ask each independent resident, every shift, if they had a bowel movement so it could be documented. Review of the MAR indicated [REDACTED]. Interview regarding the facility's policy and procedures, on 12/20/13 at 2:30 PM with the ADON, in the absence of the DON, revealed CNAs inputted residents' BMs in the computer; the DON "pulled" the "BM Report" Monday through Friday; and on weekends the shift nurse "pulled" the "BM Report". She stated the DON monitored to ensure residents did not go over three (3) days without a BM; and, also monitored to ensure the documentation was complete. Continued interview with the ADON, revealed the DON was to give the list of residents, who had not had a BM in three (3) days, to the nurse after the IDT meetings. According to the ADON, the Staff Development Nurse was in charge of ensuring nurses followed through with administering the laxatives. Interview with the Staff Development Nurse on 12/20/13 at 3:00 PM and 6:19 PM, revealed after the morning IDT Meetings, the DON would give her a "Clinical Review Tool" to give to each nurse that indicated which residents were to receive pain, hydration, and bowel assessments. She stated she would write the pain, hydration and bowel assessments to be done on the MAR. Further interview revealed she did not follow-up afterward to ensure prn laxatives were given as needed. According to the Staff Development Nurse, the DON followed up the day after the IDT meetings to ensure residents who were on the list for no BM in three (3) days had a bowel movement; and, if there had been no BM she would instruct the nurses to call the Physician. She indicated she had not inserviced staff related to the facility's bowel policy/protocol; or, performed staff inservices on bowel/abdominal assessments. Further interview with the ADON on 12/20/13 at 6:00 PM, revealed the facility had recognized previously there was a problem with staff not documenting residents' bowel movements. She stated the DON had talked to specific CNAs and nurses regarding this; however, she was unaware of any inservice related to the documentation of bowel movements. The DON was on leave during the abbreviated survey and was not available for interview.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure services provided were in accordance with each resident's written Plan of Care for three (3) of eleven (11) sampled residents (Residents #4, #3, and #7). Resident #4's Comprehensive Plan of Care stated the resident was at risk for constipation with interventions which included to monitor bowel movements. Record review revealed there was no documented evidence Resident #4 had a bowel movement from 10/29/13 through 11/01/13, four (4) days. On 11/02/13, the fifth day, Resident #4 was noted to have a distended firm abdomen and complained of abdominal pain. The resident was admitted to the hospital and subsequently underwent a Hemicolectomy (surgical procedure to remove approximately half of the colon) on 11/07/13. The resident was readmitted to the facility on [DATE]. In addition, there was no documented evidence Resident #3 and #7's Comprehensive Plans of Care were implemented related to monitoring bowel movements. There was no documented evidence these two (2) residents experienced bowel movements for periods ranging from five (5) to eight (8) days. (Refer to F309) The findings include: Review of the facility "Care Plan Policy", undated, revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas and risk factors associated with the problem areas. Continued review of the "Care Plan Policy" revealed the Comprehensive Care Plan was to aid in preventing or reducing declines in residents' functional status and functional levels; it was to enhance optimal functioning of the resident; and, reflect currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #4's clinical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #4 as having a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was not cognitively impaired. Further review of the MDS revealed the facility assessed the resident as being frequently incontinent of bowel and bladder and to require extensive assistance of two (2) persons for toileting. Review of the Comprehensive Plan of Care dated 04/17/13, revealed a care plan which indicated the resident was at risk for alteration in bowel elimination as evidenced by constipation. Review of this care plan revealed the goal stated the resident would have a normal bowel movement (BM) at least every three (3) days. Further review revealed the care plan interventions included to administer medications as ordered, monitor bowel movements, perform bowel, hydration and pain assessments per protocol. Review of the physician's orders [REDACTED]. Review of the "BM Report", revealed Resident #4 had a large BM on 10/28/13, and no documented evidence of another BM through 11/02/13 when the resident was transferred to the emergency room (ER) and admitted to the hospital. Review of the Interdisciplinary (IDT) Note dated 11/01/13, revealed Resident #4 had not had a BM for three (3) days. The Note revealed bowel sounds were to be done every shift until resolved; and, pain and hydration assessments were to be completed times one (1). Continued review revealed "laxatives as ordered". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR for November 2013 revealed no documented evidence of an assessment for bowel sounds on 11/01/13 for the day shift, evening shift, or night shift. In addition, review of the "Departmental Notes", which included nursing documentation, from 10/29/13 through 11/02/13, revealed there was no documented evidence of an abdominal assessment to include bowel sounds; and, no reference to Resident #4 having had no BMs. Interview, on 12/19/13 at 3:00 PM, with LPN #2 , who was assigned to the resident on 11/01/13 on the day shift, revealed on week days, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible to check the "BM Report" each morning; and, give nurses a list of residents who had not had a BM in three (3) days. She stated nurses were then to follow through with administering a laxative. LPN #2 stated nurses were to check the "BM Report" themselves on weekends. Continued interview with LPN #2 revealed on 11/01/13 she would have received the list of residents who had not had BMs for three (3) days. She stated she did not recall Resident #4 being on the list that day; and, did not remember having been instructed to assess the resident or administer a laxative. In addition, LPN #2 stated nurses were to check Certified Nursing Assistants (CNAs) documentation; but, did not do this daily. She indicated she was unaware the CNAs were not documenting if residents' had BMs each shift or not. Interview, on 12/20/13 at 10:40 AM, with CNA #1, who was assigned to Resident #4 on 11/01/13 on the day shift, revealed CNAs documented BMs in the computer; however, could not look to see how many days residents had gone without a BM. She indicated this was because CNAs could not look at more than one (1) day of documentation in the computer. Interview, on 12/19/13 at 3:30 PM with LPN #3, who was assigned to Resident #4 on 11/01/13 from 3:00 PM until 3:00 AM on 11/02/13, revealed nurses were to administer a laxative if a resident had not had a bowel movement in three (3) days. LPN #3 stated if the laxative was ineffective the nurse was to notify the Physician. She stated nurses received a list of who required a prn laxative each day. However, she indicated she did not recall receiving a list with Resident #4's name on 11/01/13. Further interview revealed she did not remember anything unusual about Resident #4 on 11/01/13; and, could not remember if she had completed an abdominal assessment on the resident that day. Interview, on 12/19/13 at 2:30 PM, with LPN #1 revealed she came to work the morning of 11/02/13 at 3:00 AM, and was told by a CNA Resident #4 was complaining of his/her "belly hurting". She stated she assessed the resident's vital signs, completed a pain assessment and an abdominal assessment. LPN #1 stated Resident #4's abdomen was swollen and hard; and, his/her bowel sounds were hypoactive (abnormally inactive). She stated she notified the healthcare provider and received orders to transfer Resident #4 to the ER. Continued interview revealed she had not received any information in report from the previous shift related to any concerns with Resident #4. LPN #1 stated she normally worked day shift and nurses were to check the computer to review the "BM Report" first thing in the morning to monitor residents' BMs; and, if a resident had not had a BM in three (3) days, the nurse was to administer a laxative or notify the Physician if a laxative was not already ordered. She indicated LPN #2 was on the "med cart" on 11/01/13, and should have offered Resident #4 a prn laxative if she had checked the "BM Report" and there had been no BM for three (3) days. Interview, on 12/20/13 at 2:30 PM with the ADON, revealed Resident #4's care plan had not been implemented as there was no documented evidence a prn laxative was administered or an abdominal assessment was completed 11/01/13. She stated Resident #4 should have received a laxative on 11/01/13, which would have been the fourth (4th) day with no BM; and, should have had an abdominal assessment performed to check for bowel sounds, abdominal distention and abdominal pain. Further interview with the ADON revealed the care plan should have been followed for this resident. 2. Review of Resident #3's clinical record revealed [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident had no cognitive deficits. Further review revealed the facility assessed Resident #3 as requiring extensive assist of two (2) persons for toileting and as frequently incontinent of urine and occasionally incontinent of bowel. Review of the Comprehensive Plan of Care dated 04/22/13, revealed a bowel care plan related to Resident #3 being occasionally incontinent of bowel and had a history of [REDACTED]. Further review of this care plan revealed interventions which included the following: medications as ordered, monitor BMs, perform bowel, hydration and pain assessments per protocol and notify the Physician as needed. Review of the physician's orders [REDACTED]. Review of the "BM Report", revealed the resident had a large BM on 12/02/13; however, there was no further documentation of a BM until 12/10/13, eight (8) days later. Review of the IDT Note written 12/06/13, revealed Resident #3 had no BM for the past three (3) days and bowel sounds were to be assessed until resolved. Continued review revealed a pain and hydration assessment was to be completed times one (1), and administer "laxatives as ordered". However, review of the MAR for December 2013 revealed Resident #3 did not receive MOM 30 ml's prn until 12/09/13, seven (7) days after the last documented BM. Continued review of the MAR, revealed pain assessments were completed all three shifts for 12/03/13, 12/04/13, 12/05/13 and 12/06/13; and, a hydration assessment was completed on 12/07/13. However, review revealed bowel sounds were only assessed sporadically from 12/06/13 through 12/10/13. Review of the "Departmental Notes", dated 12/02/13 through 12/10/13 revealed no documented evidence Resident #3 had no BM during this time frame. Interview with the ADON, in the absence of the DON on 12/20/13 at 6:00 PM, revealed if a resident had not had a bowel movement in three (3) days the bowel policy was to be implemented as per the resident's care plan. 3. Review of Resident #7's clinical record revealed the facility admitted the resident on 07/17/13, with [DIAGNOSES REDACTED]. Review of Resident #7's Comprehensive Plan of Care related to bowel elimination revealed it was initiated 08/20/13 with goals which included normal BMs at least every three (3) days. Further review revealed interventions included the monitoring of bowel movements and the administration of medications as ordered by the Physician. Review of the "BM Report" revealed no documented evidence Resident #7 had a bowel movement between 09/18/13 and 09/25/13; and, between 10/29/13 and 11/03/13. Review of the MAR for the months of September, October and November 2013 revealed no documented evidence the prn stool softener was administered as ordered between 09/18/13 and 09/25/13, or between 10/29/13 and 11/03/13, as per the Comprehensive Plan of Care. Review of the IDT notes revealed no documented evidence of discussion or further monitoring related to Resident #7's lack of bowel movements between 09/18/13 and 09/25/13, or between 10/29/13 and 11/03/13. Interview with the ADON on 12/20/13 at 4:35 PM, revealed Resident #7 toileted independently. The ADON stated the aides were supposed to ask the resident every shift whether he/she had a bowel movement. Continued interview revealed the ADON could not explain why the lack of documented bowel movements for Resident #7 was not discussed by the IDT on the specified dates, in order to ensure monitoring and implementation of appropriate interventions. She indicated the interventions in the Comprehensive Plan of Care should have been implemented. Interview regarding the facility's bowel monitoring process, on 12/20/13 at 2:30 PM with the ADON, in the absence of the DON, revealed CNAs inputted residents' BMs in the computer; the DON "pulled" the "BM Report" Monday through Friday; and on weekends the shift nurse "pulled" the "BM Report". She stated the DON monitored to ensure residents did not go over three (3) days without a BM; and, also monitored to ensure the documentation was complete. Continued interview with the ADON, revealed the DON was to give the list of residents, who had not had a BM in three (3) days, to the nurse after the IDT meetings. According to the ADON, the Staff Development Nurse was in charge of ensuring nurses followed through with administering the laxatives. An additional interview on 12/20/13 at 5:00 PM with the ADON revealed she was responsible for the monitoring of residents' BM when the DON wasn't in the facility Monday through Friday. She reiterated the shift nurse was responsible for the monitoring on weekends. The DON was on leave during the abbreviated survey and was not available for interview.

Based on interview, record review, and facility policy review it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility's Administration failed to develop written policies to ensure safety and supervision of residents who smoked. The facility's Administration failed to have an effective system in place to ensure oxygen canisters were not in the designated smoking area; failed to ensure staff was trained to supervise residents while smoking; and, failed to ensure residents Comprehensive Care Plan interventions were implemented. On 10/14/13, Resident #1 and Unsampled Resident A were outside in the resident smoking area after the facility's scheduled resident smoke break. Resident #1 was wearing oxygen via a nasal cannula under his/her nose with the oxygen tank on the back of the motorized wheel chair he/she was sitting in. Two (2) staffs were taking a break and smoking in the designated resident smoking area and neither employee was supervising the residents in the smoking area. One of the employees gave his lighter to Unsampled Resident A who used it to light his/her cigarette. Unsampled Resident A then gave the lighter, he/she had obtained from the staff person, to Resident #1 who used it to light his/her cigarette. Resident #1's oxygen combusted and began to flame in the area of the nasal cannula under Resident #1's nose. Resident #1 was transferred to the hospital Emergency Department (ED) where he/she was diagnosed with [REDACTED]. The resident was treated for [REDACTED]. (Refer to F-282 and F323) The facility's failure to have an effective Administration to ensure safety and supervision of residents who smoked placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified at 42 CFR 483.20, Resident Assessment, F-282; 42 CFR 483.25, Quality of Care, F-323; 42 CFR 483.75, Administration F-490 and F-520 all at a Scope and Severity of a "J". The Immediate Jeopardy was identified on 10/17/13, and determined to exist on 10/14/13. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 10/21/13 and alleged removal of the Immediate Jeopardy on 10/18/13. On 10/24/13, the State Survey Agency verified the Immediate Jeopardy was removed on 10/18/13, as alleged. However, non-compliance continued to exist at 42 CFR 483.20, Resident Assessment, F-282; 42 CFR 483.25, Quality of Care, F-323; 42 CFR 483.75 Administration, F-490 and F-520 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC), and the facility's Quality Assurance monitors the Administration's oversight of the facility's systemic changes to maintain an environment as free of hazards as possible, to ensure adequate supervision to prevent accidents, and to adhere to each resident's Comprehensive Plan of Care. The findings include: Interview, on 10/16/13 at 11:15 AM, with the Administrator and Regional Nurse Consultant, revealed the facility did not have a written policy for smoking. Continued interview revealed the facility had "smoking rules" for residents. Review of the facility's "Smoking Rules", undated, revealed residents were to smoke only under direct staff supervision. Continued review revealed smoking materials were to be locked at the nurses station when not in use. Review of the facility's Admission Packet, section "Your Lifestyles" effective July 1, 2012, revealed residents could not keep combustibles in their rooms; matches and lighters could be obtained from staff. On 10/14/13, Resident #1 and Unsampled Resident A were in the residents' designated smoking area unsupervised. Both residents had a cigarette which they had obtained earlier. One (1) of the staff allowed Unsampled Resident A to borrow his lighter which the resident used to light his/her cigarette with. Unsampled Resident A then handed the lighter to Resident #1, who was wearing oxygen at four (4) liters per minute per nasal cannula via an oxygen tank on his/her wheelchair. Resident #1 lit his/her cigarette and the oxygen ignited and flamed in the area of the nasal cannula located under the resident's nose. Resident #1 sustained second [MEDICAL CONDITION] his/her face. Interview with Registered Nurse #1 who was present at the time of the incident revealed he knew Unsampled Resident A had a cigarette and he had allowed the resident to borrow his lighter. He further stated he was aware Resident #1 had his/her oxygen on at that time. Per interview, he had received education at the facility regarding safe smoking practices which included oxygen should not be in use in the smoking area. However, he allowed Resident #1 to stay in the smoking area with oxygen while he and Unsampled Resident A were smoking. Interviews with other direct care staff revealed it was a common practice for staff to leave the oxygen tank on Resident #1's wheelchair during the smoke break. Interviews also revealed staff frequently smoked in the area designated for residents. Interview, on 10/17/13 at 11:35 AM and 3:55 PM, with the Administrator revealed it was ultimately her responsibility to monitor to ensure safety of all residents and she did this by conducting daily rounds. Per interview she was aware staff smoked in the resident designated smoking area; however, she had not addressed this with staff. She stated staff should have been in the employee smoking area and not smoking around the residents. In addition, she stated residents should not have cigarettes in their possession, and staff should not give a lighter to any resident. According to the Administrator, Resident #1 and Unsampled Resident A were not appropriately supervised by staff while smoking on 10/14/13, after the morning scheduled resident smoke break. The Administrator stated she felt the root cause of the incident was that staff was permitted to smoke with the residents. She stated the intermingling of staff and residents created a relaxed environment that resulted in decreased staff to resident supervision. Interview with the Regional Nurse Consultant, on 10/17/13 at 4:15 PM, revealed, the Administrator and the Director of Nursing were ultimately responsible for monitoring to ensure effectiveness of the facility's "smoking rules" to ensure the safety of the residents. She indicated the "smoking rules" were posted on walls and at the nurse's station; however, she stated the rules were not specific. Additionally, she stated she felt the root cause of this incident involving Resident #1, was lack of supervision on the part of the two (2) employees and the fact that one employee gave a lighter to Unsampled Resident A. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 10/21/13 that alleged removal of the Immediate Jeopardy (IJ) effective 10/18/13. Review of the AOC revealed the facility implemented the following: 1) On 10/14/13, Resident #1 was transported to the Emergency Department for further evaluation and returned on the same date with topical medications for burns. 2) On 10/14/13 a head-to-toe assessment was performed on the residents in the area of the incident; Resident #1 and Unsampled Resident A. These residents were assessed by a licensed nurse. 3) One 10/14/13, the Medical Director was notified of the incident; and, all residents' responsible party were notified per letter of the "smoking rules". 4) On 10/14/13, a Quality Assurance (QA) Committee meeting was held with the Medical Director in attendance via phone. The incident was discussed and education was planned, developed and implemented. 5) On 10/14/13, the Regional Nurse Consultant provided education to the Administrator and Director of Nursing (DON) to include safe smoking practice. 6) Beginning 10/14/13, all staff was educated with written competencies regarding the facility's "smoking rules". 7) On 10/14/13, education was provided one-on-one by the Administrator to the four (4) identified residents who smoked regarding the facility's "smoking rules". 8) On 10/14/13, a communications letter was sent to all responsible parties regarding the facility's "smoking rules". 9) On 10/14/13, all residents that smoked were reassessed for safety by the Activities Director who normally performed these assessments. 10) Beginning 10/14/13, the facility's Nurse Consultant and Department Managers were to monitor resident/staff smoke breaks for twenty-four (24) hours to ensure safe smoking practice was adhered to. 11) On 10/14/13, residents' Comprehensive Care Plans were revised and updated for all residents who smoked by the Activity Director. The care plans were revised and updated to include smoking with supervision and wearing a smoking apron when smoking. 12) On 10/14/13, a one time audit of entrances/exits was completed by Administrator regarding "No Smoking" signs being posted. 13) On 10/14/13, fifteen (15) oxygen dependent residents were identified to ensure a "No Smoking Oxygen in Use" sign was posted at each resident room door. 14) On 10/14/13, the designated resident smoking area was observed by Regional Nurse Consultant to assure a fire blanket and extinguisher were readily available. 15) Beginning 10/14/13, the Administrator and/or DON was to audit all exit/entrances for four (4) weeks to assure all have "No Smoking" signs. 16) Beginning 10/14/13, all new hires will be educated regarding smoking rules and safety. 17) On 10/14/13, the Medical Director was notified by Administration of the audit findings. 18) On 10/15/13, a fire drill was completed to assess staff response. 19) Beginning 10/15/13, the Manager or a Licensed Nurse was to monitor smoking breaks for seven (7) days to ensure safe smoking practice was adhered to. 20) On 10/17/13, all employees were educated on the staff smoking policy and resident smoking policy which was "established" on 10/17/13. 21) Beginning 10/21/13, audit findings and plan will be reviewed weekly and ongoing until resolved. 22) All new admits will have a smoking assessment completed upon admission, quarterly and with any changes in smoking status. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Emergency Department records and interview on 10/16/13, with Resident #1 validated medical assessments and treatment completed by Emergency Department staff. 2) Review of the head-to-toe assessments dated 10/14/13, for the residents in the area of the incident, Resident #1 and Unsampled Resident A, indicated they were performed by licensed nursing staff. 3) Interview, on 10/16/13, with the Medical Director validated the immediate notification by facility staff of the incident. Resident has a BIMS score of 15 and is his/her own responsible party and was educated on the facility's "smoking rules". In addition, the facility mailed a letter to his/her family related to the facility's "smoking rules". 4) Review of Quality Assurance (QA) meeting notes with sign in sheet dated 10/14/13 validated the incident was discussed and education was developed. Review of educational program material revealed it was implemented. 5) Review of listed content of education revealed the Administrator and the DON were educated on 10/14/13, and this education included safe smoking practice. Interview with the Administrator and the DON on 10/24/13 validated the education. 6) Review of education sign-in sheets and post-test competencies revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they all had received education regarding safe smoking practice and smoking rules. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on safe smoking practice and smoking rules. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on safe smoking practice and smoking rules. 7) Interview, on 10/24/13, with three (3) of the four (4) residents who smoked, revealed all had been educated by the Administrator on safe smoking practice and the facility's smoking rules. 8) Review of the communications letter sent to all responsible parties revealed the letter addressed the facility's smoking rules. 9) Review of the updated resident smoking assessments completed on 10/14/13 revealed the four (4) smokers in the facility had been reassessed for safety by the Activity Director, who normally performed these smoking assessments. 10) Review of the audit reports dated 10/14/13 to 10/15/13, revealed smoking breaks were monitored by managers for twenty-four (24) hours. 11) Review of the Comprehensive Care Plans for all four (4) resident smokers validated revisions and updates were completed on 10/14/13. 12) Review of the audit of entrances/exits regarding posting of "No Smoking" signs revealed it was completed by the Administrator on 10/14/13. Surveyor observations revealed signs at entrances and exits on 10/22/13, 10/23/13 and 10/24/13. 13) Review of the audit identification of fifteen (15) oxygen dependent residents revealed they had been identified and observation of oxygen dependent resident door revealed "No Smoking Oxygen In Use" signs posted on their doors. 14) Review of the audit report for the Regional Nurse's audit of fire blanket and fire extinguisher revealed they were in place and ready for use. Observation of the designated resident smoking area revealed a fire blanket and extinguisher in place and ready for use. 15) Review of the "No Smoking" sign at exit/entrances audit dated 10/14/13, revealed the audits had been initiated on that date. Further review of the audits revealed the Administrator and/or DON had performed audits of this 10/18/13 to 10/23/13. 16) Review of two (2) new hire employee records revealed they had been educated on safe smoking education and smoking rules as this information was in the new hire packet. 17) Interview with the Medical Director on 10/16/13, verified his notification of audit findings by the Administrator. 18) Review of the fire drill assessment completed 10/15/13 revealed a fire drill was conducted that date and all staff responded "appropriately". Interview on 10/24/13 with Licensed Practical Nurse (LPN) #5 at 10:45 AM, LPN #2 at 11:55 AM, State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM, Housekeeping Staff #1 at 11:40 AM, SRNA ##11 at 4:35 PM, and the Director of Nursing (DON) at 2:30 PM revealed a fire drill had been conducted the prior week. Interviews with these staff revealed they had been educated on proper response during a fire drill. 19) Review of the audit reports dated 10/15/13 to 10/21/13, revealed smoking breaks were monitored by managers and/or licensed staff for seven (7) days. 20) Review of education sign-in sheets for 10/17/13 revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they had all been educated on the staff smoking policy and resident smoking policy. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on the staff smoking policy and resident smoking policy. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on the staff smoking policy and resident smoking policy. 21) Review of first audit, dated 10/17/13 and interview with Administrator revealed audits were ongoing until resolved. 22) Review of a new admit resident revealed a smoking assessment was completed on admission.

Based on interview, record review and review of the facility's, "Smoking Rules", it was determined the facility failed to have an effective system to maintain an environment that was as free from accident hazards over which the facility had control; and, failed to provide supervision and monitoring to each resident to prevent avoidable accidents. The facility failed to ensure procedures were implemented to ensure residents safety during resident and staff smoking breaks for one (1) of seven (7) sampled residents (Resident #1) and one (1) of two (2) Unsampled Residents (Unsampled Resident A). On 10/14/13, Resident #1 and Unsampled Resident A were outside in the resident smoking area after the facility's scheduled resident smoke break. Resident #1 was wearing a nasal cannula under his/her nose for oxygen therapy with the oxygen tank attached to the back of the motorized wheel chair. Registered Nurse (RN) #1 and the Admissions Director (AD) were outside in the resident smoking area for their employee break. Neither employee was watching the residents in the smoking area. Resident #1 and Unsampled Resident A each lit a cigarette they had previously obtained. Resident #1's oxygen became combustible and began to flame at the nasal cannula area under Resident #1's nose. Resident #1 was transferred to the hospital Emergency Department (ED) where he/she was diagnosed with [REDACTED]. The resident was treated for [REDACTED]. The facility's failure to ensure an effective system was in place to maintain an environment that was as free from accident hazards over which the facility had control, to provide supervision and monitoring to each resident to prevent avoidable accidents and, to ensure policy and procedures were implemented to ensure residents' safety during resident and staff smoking breaks was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 10/17/13 and determined to exist on 10/14/13. The facility was notified of the Immediate Jeopardy on 10/17/13. An acceptable Credible Allegation of Compliance (AOC) was received on 10/21/13 alleging removal of the Immediate Jeopardy on 10/18/13. On 10/24/13, the State Survey Agency verified the Immediate Jeopardy was removed on 10/18/13 as alleged with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-323 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and, the facility's Quality Assurance monitors the effectiveness of systemic changes to maintain an environment as free of hazards as possible and, to ensure adequate supervision to prevent accidents. The findings include: Interview, on 10/16/13 at 11:15 AM, with the Administrator and Nurse Consultant revealed the facility did not have a written policy for smoking. Further interview revealed the facility did have "Smoking Rules" for residents. Continued interview revealed upon orientation staff was oriented to the appropriate staff smoking areas of the facility. Review of the facility's "Smoking Rules" undated, revealed residents should smoke only under direct staff supervision. Continued review revealed smoking materials should be locked at the Nurses Station when not in use. Further review revealed combustible items should not be kept in residents' rooms. Review of the facility's "Admission Packet", section "Your Lifestyles", effective 07/01/12, revealed the facility did not allow combustible items to be kept in residents' rooms; however matches and lighters were available from the staff. Review of the facility's "Initial Report" dated 10/14/13, revealed two (2) residents were sitting outside after the scheduled resident smoke break. A nurse came out to smoke, one (1) of the residents asked the nurse for a lighter which the nurse gave to the resident. When the resident "struck" the lighter, the oxygen the resident was wearing ignited. The nurse "grabbed" the oxygen off of the resident and extinguished the flame. The resident was "immediately" assessed by the Nurse Practitioner (NP) who ordered the resident sent to the "emergency room " for evaluation. Record review revealed the facility admitted Resident #1 initially on 12/13/12, and readmitted the resident on 09/11/13, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and was interviewable. Record review revealed Resident #1 had been assessed as a tobacco user on 09/26/13. Review of the "Safe Smoking Evaluation" assessment performed on 09/26/13 revealed the facility assessed Resident #1 to require supervision at all times when smoking. Continued record review revealed Resident #1 had a physician's orders [REDACTED]. Review of Resident #1's Comprehensive Care Plan for Injury, dated 09/24/13 revealed smoking was listed as a potential to cause injury with the interventions of oxygen to be off if resident was smoking and, the resident was to smoke with supervision during scheduled smoking times. Record review revealed the facility admitted Unsampled Resident A on 10/04/13, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Unsampled Resident A to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and was interviewable. Further review of the MDS revealed the facility assessed Unsampled Resident A to use tobacco. Review of Unsampled Resident A's Comprehensive Care Plan for Activities, dated 10/09/13 revealed the resident was to be supervised while smoking. Interview, on 10/16/13 at 5:09 PM, with Resident #1 revealed he/she did smoke cigarettes. Resident #1 indicated on 10/14/13, after the morning resident smoke break, he/she went back outside with his/her nasal cannula on delivering oxygen therapy from the oxygen canister. Resident #1 stated staff and Unsampled Resident A were outside. According to Resident #1, Unsampled Resident A had borrowed a lighter from Registered Nurse (RN) #1, and lit his/her cigarette with it. Resident #1 stated Unsampled Resident A then passed the lighter to him/her to light his/her cigarette. Resident #1 stated his/her oxygen caught on fire and burned his/her nose and face. Resident #1 further stated he/she had forgotten his/her oxygen was on. Continued interview revealed, Resident #1 had removed two (2) cigarettes from the smoking box prior to the incident, however declined to further discuss the cigarettes. Interview, on 10/16/13 at 4:54 PM, with Unsampled Resident A revealed he/she was outside after the facility's scheduled resident smoke break on 10/14/13. He/She stated Resident #1 "jeopardized" his/her life "by almost blowing up". Unsampled Resident A stated he/she declined to reveal where he/she obtained the cigarette to smoke on 10/14/13 and, indicated the lighter used was removed from the smoke box. Unsampled Resident A also declined to reveal where Resident #1 obtained the lighter used to light his/her cigarette on 10/14/13. Unsampled Resident A declined to give further comment. Interview, on 10/16/13 at 8:23 PM, with Registered Nurse (RN) #1 revealed on 10/14/13, he was taking his employee break outside in the facility's resident smoking area, after the facility's scheduled morning resident smoke break. RN #1 stated he was smoking and talking with the Admissions Director (AD), Resident #1 and Unsampled Resident A. He stated he knew Unsampled Resident A had a cigarette and allowed the resident to borrow his lighter. RN #1 stated he was aware Resident #1 had his/her oxygen on at that time. However, he indicated he was not supervising Resident #1. According to RN #1, he did not see Resident #1 obtain the lighter from Unsampled Resident A. RN #1 stated he heard a "hissing" sound and observed Resident #1 had flames around his/her nose and face. RN #1 indicated he removed the nasal cannula from Resident #1 and extinguished the flames. He stated then he went to care for Resident #1. He stated he had previously seen Resident #1 smoking with the oxygen tubing off; however, the oxygen tank was on his/her wheelchair. RN #1 stated he had been educated in orientation regarding safe smoking practices which included oxygen should not be in use in the smoking area. He stated he was not aware of a written smoking policy; however, was aware of the facility's "smoking rules". RN #1 stated residents should always be supervised during smoking. Interview, on 10/17/13 at 10:40 AM, with the Admissions Director (AD) revealed she was outside in the resident smoking area on her employee break on 10/14/13, after the facility's scheduled morning resident smoke break. She stated this was "customary" for her to do as no one had told her she couldn't and she had seen other staff smoke there. The AD stated she was smoking an electronic cigarette and talking with RN #1. She stated Unsampled Resident A and Resident #1 were also in the smoking area. According to the AD, she saw Unsampled Resident A smoking; however, Resident #1 had his/her back to her and she did not see Resident #1 light his/her cigarette. She indicated she did not see the oxygen canister attached to the back of Resident #1's wheel chair. The AD indicated she was preparing to go back into the facility, when she heard "a sound". She stated she immediately looked towards Resident #1 and saw that RN #1 had removed Resident #1's oxygen tubing. The AD stated Resident #1 started "wiping" his/her face. She stated she observed Resident #1 to have a black area around his/her nose. The AD stated she had been educated in orientation regarding safe smoking practices which included oxygen should not be in use or in an area where smoking was occurring. She stated she was not aware of a written smoking policy; however, was aware of the facility's "smoking rules". In addition, she stated residents should be supervised during smoking. Interview, on 10/17/13 at 12:15 PM, with State Registered Nursing Assistant (SRNA) #1 revealed, before the incident of Resident #1 catching himself/herself on fire, it was common practice for the supervising staff and other staff to smoke with residents during residents' smoke breaks. She stated she had allowed Resident #1 to light his/her own cigarettes before the incident and others had also allowed this. SRNA #1 stated she was not given guidelines for monitoring of residents during smoke breaks; just shadowed another SRNA. She stated it was a common practice for her to leave the oxygen tank on Resident #1's wheelchair and she had seen others do this also. According to the SRNA, she had signed a paper indicating oxygen tanks were to be removed from wheelchairs and not taken into the designated resident smoking area prior to the incident involving Resident #1. Interview, on 10/17/13 at 3:28 PM, with Licensed Practical Nurse (LPN) #2 revealed she could see Resident #1 leaving his/her oxygen on when he/she smoked. She stated Resident #1 had told her "in the past" there wasn't "enough oxygen to blow me up". LPN #2 stated Resident #1 now says he/she was wrong about the oxygen. Interview, on 10/17/13 at 11:35 AM and 3:55 PM, with the Administrator revealed staff was oriented to designated smoking areas during new employee orientation. She stated she was aware staff was smoking in the resident designated smoking area. According to the Administrator, there was no written policy for staff not to smoke in the resident designated area; however, the facility had written "smoking rules". She indicated it was her responsibility to monitor to ensure safety of residents. The Administrator stated Resident #1 and Unsampled Resident A were not appropriately supervised by staff while smoking on 10/14/13, after the morning facility scheduled resident smoke break. She reported staff should have been in the employee smoking area and not smoking around the residents. Further interview revealed residents should not have cigarettes in their possession and staff should not have given a lighter to any resident. She stated she felt the root cause of the incident was that staff was permitted to smoke with the residents. In addition, she stated this intermingling of staff and residents created a relaxed environment that resulted in decreased resident supervision by staff. Interview, on 10/17/13 at 4:15 PM, with the facility's Regional Nurse Consultant revealed the Administrator and the Director of Nursing (DON) were ultimately responsible for monitoring effectiveness of the smoking rules to ensure the safety of residents who smoked. She stated the smoking rules were posted on the wall and at the nursing station desk. The Regional Nurse Consultant stated the smoking rules were not specific. According to the Regional Nurse Consultant, she felt the root cause of this incident was two (2) employees were outside not supervising the residents and one (1) employee gave a lighter to a resident to use. She stated no oxygen tanks should be near when residents were smoking in the designated area. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 10/21/13 that alleged removal of the Immediate Jeopardy (IJ) effective 10/18/13. Review of the AOC revealed the facility implemented the following: 1) On 10/14/13, Resident #1 was transported to the Emergency Department for further evaluation and returned on the same date with topical medications for burns. 2) On 10/14/13, a head-to-toe assessment was performed on the residents in the area of the incident; Resident #1 and Unsampled Resident A. These residents were assessed by a licensed nurse. 3) One 10/14/13, the Medical Director was notified of the incident; and, all residents' responsible party were notified per letter of the "smoking rules". 4) On 10/14/13, a Quality Assurance (QA) Committee meeting was held with the Medical Director in attendance via phone. The incident was discussed and education was planned, developed and implemented. 5) On 10/14/13, the Regional Nurse Consultant provided education to the Administrator and Director of Nursing (DON) to include safe smoking practice. 6) Beginning 10/14/13, all staff was educated with written competencies regarding the facility's "smoking rules". 7) On 10/14/13, education was provided one-on-one by the Administrator to the four (4) identified residents who smoked regarding the facility's "smoking rules". 8) On 10/14/13, a communications letter was sent to all responsible parties regarding the facility's "smoking rules". 9) On 10/14/13, all residents that smoked were reassessed for safety by the Activities Director who normally performed these assessments. 10) Beginning 10/14/13, the facility's Nurse Consultant and Department Managers were to monitor resident/staff smoke breaks for twenty-four (24) hours to ensure safe smoking practice was adhered to. 11) On 10/14/13, residents' Comprehensive Care Plans were revised and updated for all residents who smoked by the Activity Director. The care plans were revised and updated to include smoking with supervision and wearing a smoking apron when smoking. 12) On 10/14/13, a one time audit of entrances/exits was completed by Administrator regarding "No Smoking" signs being posted. 13) On 10/14/13, fifteen (15) oxygen dependent residents were identified to ensure a "No Smoking Oxygen in Use" sign was posted at each resident room door. 14) On 10/14/13, the designated resident smoking area was observed by Regional Nurse Consultant to assure a fire blanket and extinguisher were readily available. 15) Beginning 10/14/13, the Administrator and/or DON was to audit all exit/entrances for four (4) weeks to assure all have "No Smoking" signs. 16) Beginning 10/14/13, all new hires will be educated regarding smoking rules and safety. 17) On 10/14/13, the Medical Director was notified by Administration of the audit findings. 18) On 10/15/13, a fire drill was completed to assess staff response. 19) Beginning 10/15/13, the Manager or a Licensed Nurse was to monitor smoking breaks for seven (7) days to ensure safe smoking practice was adhered to. 20) On 10/17/13, all employees were educated on the staff smoking policy and resident smoking policy which was "established" on 10/17/13. 21) Beginning 10/21/13, audit findings and plan will be reviewed weekly and ongoing until resolved. 22) All new admits will have a smoking assessment completed upon admission, quarterly and with any changes in smoking status. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Emergency Department records and interview on 10/16/13, with Resident #1 validated medical assessments and treatment completed by Emergency Department staff. 2) Review of the head-to-toe assessments dated 10/14/13, for the residents in the area of the incident, Resident #1 and Unsampled Resident A, indicated they were performed by licensed nursing staff. 3) Interview, on 10/16/13, with the Medical Director validated the immediate notification by facility staff of the incident. Resident has a BIMS score of 15 and is his/her own responsible party and was educated on the facility's "smoking rules". In addition, the facility mailed a letter to his/her family related to the facility's "smoking rules". 4) Review of Quality Assurance (QA) meeting notes with sign in sheet dated 10/14/13 validated the incident was discussed and education was developed. Review of educational program material revealed it was implemented. 5) Review of listed content of education revealed the Administrator and the DON were educated on 10/14/13, and this education included safe smoking practice. Interview with the Administrator and the DON on 10/24/13 validated the education. 6) Review of education sign-in sheets and post-test competencies revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they all had received education regarding safe smoking practice and smoking rules. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on safe smoking practice and smoking rules. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on safe smoking practice and smoking rules. 7) Interview, on 10/24/13, with three (3) of the four (4) residents who smoked, revealed all had been educated by the Administrator on safe smoking practice and the facility's smoking rules. 8) Review of the communications letter sent to all responsible parties revealed the letter addressed the facility's smoking rules. 9) Review of the updated resident smoking assessments completed on 10/14/13 revealed the four (4) smokers in the facility had been reassessed for safety by the Activity Director, who normally performed these smoking assessments. 10) Review of the audit reports dated 10/14/13 to 10/15/13, revealed smoking breaks were monitored by managers for twenty-four (24) hours. 11) Review of the Comprehensive Care Plans for all four (4) resident smokers validated revisions and updates were completed on 10/14/13. 12) Review of the audit of entrances/exits regarding posting of "No Smoking" signs revealed it was completed by the Administrator on 10/14/13. Surveyor observations revealed signs at entrances and exits on 10/22/13, 10/23/13 and 10/24/13. 13) Review of the audit identification of fifteen (15) oxygen dependent residents revealed they had been identified and observation of oxygen dependent resident door revealed "No Smoking Oxygen In Use" signs posted on their doors. 14) Review of the audit report for the Regional Nurse's audit of fire blanket and fire extinguisher revealed they were in place and ready for use. Observation of the designated resident smoking area revealed a fire blanket and extinguisher in place and ready for use. 15) Review of the "No Smoking" sign at exit/entrances audit dated 10/14/13, revealed the audits had been initiated on that date. Further review of the audits revealed the Administrator and/or DON had performed audits of this 10/18/13 to 10/23/13. 16) Review of two (2) new hire employee records revealed they had been educated on safe smoking education and smoking rules as this information was in the new hire packet. 17) Interview with the Medical Director on 10/16/13, verified his notification of audit findings by the Administrator. 18) Review of the fire drill assessment completed 10/15/13 revealed a fire drill was conducted that date and all staff responded "appropriately". Interview on 10/24/13 with Licensed Practical Nurse (LPN) #5 at 10:45 AM, LPN #2 at 11:55 AM, State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM, Housekeeping Staff #1 at 11:40 AM, SRNA ##11 at 4:35 PM, and the Director of Nursing (DON) at 2:30 PM revealed a fire drill had been conducted the prior week. Interviews with these staff revealed they had been educated on proper response during a fire drill. 19) Review of the audit reports dated 10/15/13 to 10/21/13, revealed smoking breaks were monitored by managers and/or licensed staff for seven (7) days. 20) Review of education sign-in sheets for 10/17/13 revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they had all been educated on the staff smoking policy and resident smoking policy. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on the staff smoking policy and resident smoking policy. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on the staff smoking policy and resident smoking policy. 21) Review of first audit, dated 10/17/13 and interview with Administrator revealed audits were ongoing until resolved. 22) Review of a new admit resident revealed a smoking assessment was completed on admission.

Based on observation and interview, it was determined the facility failed to ensure residents' environment remained as free of accident hazards as possible for fourteen (14) of the facility's thirty-five (35) resident rooms. The facility failed to ensure the television cable wiring was off the floor, which was a potential fall hazard, for residents in rooms #1, 4, 9, 12, 13, 17, 24, 25, 27, 28, 29, 35, 37 and 38. The findings include: Observations during the initial tour, on 12/10/13 at 10:05 AM, revealed resident rooms 24, 25, 27, 28, 29, 37 and 38 had television cable wiring lying on the residents' rooms floor, causing a potential tripping or injury hazard to residents, staff and visitors. Continued observation, on 12/11/13 at 8:56 AM, revealed resident rooms 1, 4, 9, 12, 13 and 17 also had television cable wiring lying on the floor, which could be a potential fall hazard to residents, staff and visitors. Subsequent observation, on 12/11/13 at 9:04 AM, revealed a resident in room 25, bed B sitting up beside the bed in a glider chair with the television cable wiring coiled three (3) times in the area of the resident's feet and chair. Interview with the Maintenance Director on 12/11/13 at 10:13 AM, revealed the television cable wiring had "been like that" for a while. Continued interview revealed the television cable wiring lying on the floor could be a safety issue for residents, staff or visitors. Interview with the Regional Nurse Coordinator on 12/11/13 at 10:46 AM, revealed the television cable wiring lying on the floor could potentially be a safety issue for residents. She stated she did "not know what else to do with the cable". Interview with the Administrator on 12/11/13 at 10:46 AM, revealed the television cable wiring lying on the floor in the resident rooms could be a safety issue; however, "so could the rolling of bedside tables". She indicated she did not know how long the television cable wiring had been on the floor. Additional interview on 12/11/13 at 3:37 PM, with the Administrator, revealed the television cable wiring had not been identified as a potential hazard during the rounds. Continued interview revealed the Administrator felt "there was no way to list or identify all potential hazards".

Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure care plan interventions were implemented for one (1) of seven (7) sampled residents (Resident #1) and one (1) of two (2) unsampled residents (Unsampled Resident A). The facility assessed Resident #1 and Unsampled Resident A to require Comprehensive Care Plans for potential risk for injury related to smoking. Resident #1's care plan indicated interventions related to smoking included he/she was to be supervised when smoking and his/her oxygen was to be removed prior to smoking. Additionally, the potential risk for injury care plan for Unsampled Resident A indicated the resident required supervision when smoking. However, the facility failed to ensure implementation of these interventions related to smoking. On 10/14/13, Resident #1 and Unsampled Resident A were outside in the resident smoking area after the facility's scheduled resident smoke break. Resident #1 was wearing a nasal cannula under his/her nose for oxygen therapy with the oxygen tank attached to the back of the motorized wheel chair. Registered Nurse (RN) #1 and the Admissions Director (AD) were outside in the resident smoking area for their employee break; however, neither employee was monitoring the residents in the smoking area. Resident #1 and Unsampled Resident A each lit a cigarette they had previously obtained. Resident #1's oxygen became flammable and caught fire at the nasal cannula area under Resident #1's nose. Resident #1 was transferred to the hospital Emergency Department (ED) where he/she was diagnosed with [REDACTED]. The resident was treated for [REDACTED]. (Refer to F-323) The facility's failure to implement Comprehensive Care Plan interventions to ensure residents' safety was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 10/17/13 and, was determined to exist on 10/14/13. The facility was notified of the Immediate Jeopardy on 10/17/13. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 10/21/13 alleging removal of the Immediate Jeopardy on 10/18/13. On 10/24/13, the State Survey Agency verified the Immediate Jeopardy was removed on 10/18/13 as alleged with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F-282 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of systemic changes to ensure each resident's Comprehensive Care Plan is implemented. The findings include: Review of the facility's policy titled, "Care Plan Policy Statement" undated, revealed the facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, developed and maintained a Comprehensive Care Plan for each resident that identified the highest level of functioning the resident may be expected to attain. Continued review of the policy revealed the care plan should identify the professional services responsible for each element of care. Further review revealed current standards of practice were recognized for problem areas and conditions. Review of the facility's "Initial Report" dated 10/14/13, revealed two (2) residents were sitting outside after the scheduled resident smoke break. A nurse was present and one of the residents asked to borrow the nurse's lighter. The nurse gave the lighter to the resident and the resident lit a cigarette. The resident's oxygen, which he/she was wearing via a nasal cannula, ignited. The nurse removed the resident's oxygen and extinguished the flame. A Nurse Practitioner (NP) was notified and assessed the resident. The NP ordered the resident to be sent "immediately" to the hospital "emergency room " for evaluation. Record review revealed Resident #1 had an admission date of [DATE] and a re-admission date of [DATE]. Record review revealed Resident #1 had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview Mental Status (BIMS) of fifteen (15), which indicated the resident had no cognitive impairments and was interviewable. Record review revealed Resident #1 had been assessed as a tobacco user on 09/26/13. Review of a physician's orders [REDACTED]. Continued review of the care plan revealed interventions included the resident's oxygen was to be off if he/she was smoking and Resident #1 was to smoke with supervision during scheduled smoking times. Record review revealed Unsampled Resident A had an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Unsampled Resident A to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated he/she had no cognitive impairment and was interviewable. Further review of the MDS revealed the facility assessed Unsampled Resident A to use tobacco. Review of Unsampled Resident A's Comprehensive Care Plan for Activities dated 10/09/13, revealed the resident was to be supervised while smoking. Interview, on 10/16/13 at 5:09 PM, with Resident #1 revealed on 10/14/13, after the morning resident smoke break, he/she had gone back outside with his/her nasal cannula on delivering oxygen therapy and the oxygen canister on the back of the motorized wheelchair. Continued interview revealed Unsampled Resident A had borrowed a lighter from Registered Nurse (RN) #1 and passed the lighter to him/her to light his/her cigarette. According to Resident #1, his/her oxygen caught on fire and burned his/her nose and face. The resident further stated he/she had forgotten his/her oxygen was on at this time. Interview, on 10/16/13 at 4:54 PM, with Unsampled Resident A revealed he/she was outside after the facility's scheduled resident smoke break on 10/14/13. Unsampled Resident A indicated he/she did not want to disclose where he/she had obtained the cigarette. The resident additionally indicated he/she removed the lighter from the smoke box which contained smoking supplies. Unsampled Resident A also declined to reveal where Resident #1 obtained the lighter. Unsampled Resident A declined to give further comment regarding the incident. Interview, on 10/16/13 at 8:23 PM, with Registered Nurse (RN) #1, revealed on 10/14/13, he was outside after the scheduled morning resident smoke break and, saw Resident #1 and Unsampled Resident A in the designated resident smoking area. He stated Unsampled Resident A borrowed his lighter. According to RN #1, he did not see Resident #1 obtain the lighter from Unsampled Resident A. The RN stated he heard a "hissing" noise and saw Resident #1 with flames around his/her nose and face. He stated in hindsight he should have removed the oxygen from Resident #1 as per his/her care plan. Additionally, he stated he knew the residents should have been supervised during smoking, as per their care plans. Interview, on 10/17/13 at 10:40 AM, with the Admissions Director (AD) revealed on 10/14/13 she was outside with RN #1 taking a break. She stated Unsampled Resident A and Resident #1 were also outside in the smoking area. The AD stated she saw Unsampled Resident A smoking; however, she stated she did not see Resident #1 light his/her cigarette and did not see the oxygen canister attached to the back of Resident #1's wheel chair. Further interview revealed she had been educated in orientation regarding safe smoking practices which included oxygen should not be in use or in the area when smoking. She indicated she knew the residents should be supervised during smoking as per their care plans. Interview, on 10/17/13 at 12:15 PM, with State Registered Nursing Assistant (SRNA) #1 revealed, before the incident involving Resident #1, staff and residents smoked together. According to the SRNA, she had not received monitoring instructions for supervising residents during smoke breaks. She stated it was a common practice for her and other staff to leave the oxygen tank on Resident #1's wheelchair. SRNA #1 stated prior to the incident involving Resident #1, she had signed a paper indicating oxygen tanks were to be removed from wheelchairs and not taken into the designated resident smoking area. Interview, on 10/17/13 at 11:35 AM, with the Administrator revealed it was her responsibility to ensure care plan interventions were implemented to ensure safety of residents. She indicated it was her responsibility to monitor to ensure safety of residents. She stated she ensured safety of residents by daily rounding; however, was unable to provide documented evidence of the rounding. She stated Resident #1 and Unsampled Resident A were not appropriately supervised by staff as per their Comprehensive Care Plans while smoking on 10/14/13. The Administrator stated residents should not have cigarettes in their possession and staff should not give a lighter to any resident. She stated Resident #1's oxygen should have been off and the oxygen canister should have remained in the building away from combustibles. Further interview revealed the facility did not follow the Comprehensive Plan of Care to remove the oxygen. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 10/21/13 that alleged removal of the Immediate Jeopardy (IJ) effective 10/18/13. Review of the AOC revealed the facility implemented the following: 1) On 10/14/13, Resident #1 was transported to the Emergency Department for further evaluation and returned on the same date with topical medications for burns. 2) On 10/14/13, a head-to-toe assessment was performed on the residents in the area of the incident; Resident #1 and Unsampled Resident A. These residents were assessed by a licensed nurse. 3) One 10/14/13, the Medical Director was notified of the incident; and, all residents' responsible party were notified per letter of the "smoking rules". 4) On 10/14/13, a Quality Assurance (QA) Committee meeting was held with the Medical Director in attendance via phone. The incident was discussed and, education was planned, developed and implemented. 5) On 10/14/13, the Regional Nurse Consultant provided education to the Administrator and Director of Nursing (DON) to include safe smoking practice. 6) Beginning 10/14/13, all staff was educated with written competencies regarding the facility's "smoking rules". 7) On 10/14/13, education was provided one-on-one by the Administrator to the four (4) identified residents who smoked regarding the facility's "smoking rules". 8) On 10/14/13, a communications letter was sent to all responsible parties regarding the facility's "smoking rules". 9) On 10/14/13, all residents who smoked were reassessed for safety by the Activities Director who normally performed these assessments. 10) Beginning 10/14/13, the facility's Nurse Consultant and Department Managers were to monitor resident/staff smoke breaks for twenty-four (24) hours to ensure safe smoking practice was adhered to. 11) On 10/14/13, residents' Comprehensive Care Plans were revised and updated for all residents who smoked by the Activity Director. The care plans were revised and updated to include smoking with supervision and wearing a smoking apron when smoking. 12) On 10/14/13, a one time audit of entrances/exits was completed by the Administrator regarding "No Smoking" signs being posted. 13) On 10/14/13, fifteen (15) oxygen dependent residents were identified to ensure a "No Smoking Oxygen in Use" sign was posted at each resident's room door. 14) On 10/14/13, the designated resident smoking area was observed by Regional Nurse Consultant to assure a fire blanket and extinguisher were readily available. 15) Beginning 10/14/13, the Administrator and/or DON was to audit all exit/entrances for four (4) weeks to assure all have "No Smoking" signs. 16) Beginning 10/14/13, all new hires will be educated regarding smoking rules and safety. 17) On 10/14/13, the Medical Director was notified by Administration of the audit findings. 18) On 10/15/13, a fire drill was completed to assess staff response. 19) Beginning 10/15/13, the Manager or a Licensed Nurse was to monitor smoking breaks for seven (7) days to ensure the adherence of safe smoking practice. 20) On 10/17/13, all employees were educated on the staff smoking policy and resident smoking policy which was "established" on 10/17/13. 21) Beginning 10/21/13, audit findings and plans will be reviewed weekly and ongoing until resolved. 22) All new admits will have a smoking assessment completed upon admission, quarterly and, with any changes in smoking status. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Emergency Department records and interview on 10/16/13, with Resident #1 validated medical assessments and treatment completed by Emergency Department staff. 2) Review of the head-to-toe assessments dated 10/14/13, for the residents in the area of the incident, Resident #1 and Unsampled Resident A, indicated they were performed by licensed nursing staff. 3) Interview, on 10/16/13, with the Medical Director validated the immediate notification by facility staff of the incident. Resident #1 has a BIMS score of 15 and is his/her own responsible party and was educated on the facility's "smoking rules". In addition, the facility mailed a letter to his/her family related to the facility's "smoking rules". 4) Review of Quality Assurance (QA) meeting notes with sign in sheet dated 10/14/13 validated the incident was discussed and education was developed. Review of the educational program material revealed it was implemented. 5) Review of the list of content for the education revealed the Administrator and the DON were educated on 10/14/13, and this education included safe smoking practice. Interview with the Administrator and the DON on 10/24/13 validated the education. 6) Review of education sign-in sheets and post-test competencies revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they all had received education regarding safe smoking practice and smoking rules. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on safe smoking practice and smoking rules. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on safe smoking practice and smoking rules. 7) Interview, on 10/24/13, with three (3) of the four (4) residents who smoked, revealed all had been educated by the Administrator on safe smoking practice and the facility's smoking rules. 8) Review of the communications letter sent to all responsible parties revealed the letter addressed the facility's smoking rules. 9) Review of the updated resident smoking assessments completed on 10/14/13 revealed the four (4) smokers in the facility had been reassessed for safety by the Activity Director, who normally performed these smoking assessments. 10) Review of the audit reports dated 10/14/13 to 10/15/13, revealed smoking breaks were monitored by managers for twenty-four (24) hours. 11) Review of the Comprehensive Care Plans for all four (4) resident smokers validated revisions and updates were completed on 10/14/13. 12) Review of the audit of entrances/exits regarding posting of "No Smoking" signs revealed it was completed by the Administrator on 10/14/13. Surveyor observations revealed signs at entrances and exits on 10/22/13, 10/23/13 and 10/24/13. 13) Review of the audit identification of fifteen (15) oxygen dependent residents revealed they had been identified and observation of oxygen dependent resident doors revealed "No Smoking Oxygen In Use" signs posted on their doors. 14) Review of the audit report for the Regional Nurse's audit of fire blanket and fire extinguisher revealed they were in place and ready for use. Observation of the designated resident smoking area revealed a fire blanket and extinguisher in place and ready for use. 15) Review of the "No Smoking" sign at exit/entrances audit dated 10/14/13, revealed the audits had been initiated on that date. Further review of the audits revealed the Administrator and/or DON had performed audits of this 10/18/13 to 10/23/13. 16) Review of two (2) new hire employee records revealed they had been educated on safe smoking education and smoking rules as this information was in the new hire packet. 17) Interview with the Medical Director on 10/16/13, verified his notification of audit findings by the Administrator. 18) Review of the fire drill assessment completed 10/15/13 revealed a fire drill was conducted that date and all staff responded "appropriately". Interview on 10/24/13 with Licensed Practical Nurse (LPN) #5 at 10:45 AM, LPN #2 at 11:55 AM, State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM, Housekeeping Staff #1 at 11:40 AM, SRNA ##11 at 4:35 PM, and the Director of Nursing (DON) at 2:30 PM revealed a fire drill had been conducted the prior week. Interviews with these staff revealed they had been educated on proper response during a fire drill. 19) Review of the audit reports dated 10/15/13 to 10/21/13, revealed smoking breaks were monitored by managers and/or licensed staff for seven (7) days. 20) Review of education sign-in sheets for 10/17/13 revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they had all been educated on the staff smoking policy and resident smoking policy. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on the staff smoking policy and resident smoking policy. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on the staff smoking policy and resident smoking policy. 21) Review of first audit, dated 10/17/13 and interview with Administrator revealed audits were ongoing until resolved. 22) Review of a new admit resident revealed a smoking assessment was completed on admission.

Based on observation, interview and review of the facility's Plan of Correction (POC), it was determined the facility's Administration failed to ensure the facility had achieved substantial compliance per the facility's POC. The facility's Administration failed to identify a potential safety hazard in fourteen (14) of the facility's thirty-five (35) rooms. Observations revealed television cable wiring on the floor of residents' rooms numbered 1, 4, 9, 12, 13, 17, 24, 25, 27, 28, 29, 35, 37 and 38. (Refer to F323) The findings include: Review of the facility's Plan of Correction (POC), dated and signed by the Administrator on 11/15/13, and with a compliance date of 11/25/13, revealed a one time audit of all resident rooms was completed by the Regional Nurse Coordinator on 10/25/13 to identify any hazards and rooms were to be monitored daily to ensure all potential hazards were identified. Observations on 12/10/13 at 10:05 AM, and on 12/11/13 at 8:56 AM revealed resident rooms 1, 4, 9, 12, 13, 17, 24, 25, 27, 28, 29, 35, 37 and 38 had television cable wiring lying on the floor in the residents' rooms, which could have been a potential hazard to residents, staff and visitors. Continued observation, on 12/11/13 at 9:04 AM, revealed television cable wiring coiled three (3) times in the area of the feet of a resident in room [ROOM NUMBER]-B and the chair which he/she was sitting in up beside the bed. Interview, on 12/11/13 at 10:13 AM, with the Maintenance Director revealed the television cable wiring had been on the floor for a while in the residents' rooms. The Maintenance Director indicated this was a potential safety issue. Interview with the Regional Nurse Coordinator on 12/11/13 at 3:37 PM, revealed she had completed the one time audit of all resident rooms to identify any potential hazards. She indicated the television cable wiring was present during this audit; however, it was not identified as a safety issue. The Regional Nurse Coordinator stated staff had completed daily rounds of resident rooms, as per the Plan of Correction (POC); however, the television cable wiring had not been identified as a potential hazard for residents during the daily rounds. Interview with the Administrator on 12/11/13 at 10:46 AM; and, on 12/11/13 at 3:37 PM, revealed daily resident room safety rounds had been completed per the POC and she had participated in the rounds. She stated the television cable wiring lying on the floor in the resident rooms could be a safety issue; however, neither she nor staff had identified the television cable wiring on the floor as a potential hazard during the rounds.

Based on interview, record review, and review of facility policy and the facility's Plan of Correction (POC) for the Standard Survey on 01/11/13, it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to ensure residents received adequate supervision and monitoring to ensure residents' safety and to ensure services provided by the facility were in accordance with each residents' Comprehensive Plan of Care. On 10/14/13, two residents (Resident #1 and Unsampled Resident A), were outside in the facility designated resident smoking area. Resident #1 was receiving oxygen therapy per nasal cannula via an oxygen tank located on the back of his/her motorized wheelchair. Two (2) staff members were also in the resident smoking area. Registered Nurse (RN) #1 allowed Unsampled Resident A to borrow his lighter, which the resident used to light his/her cigarette. Unsampled Resident A then handed the lighter to Resident #1 to light his/her cigarette. Resident #1 lit his/her cigarette and the oxygen combusted and flamed under the resident's nose at the nasal cannula area. Resident #1 was transferred to the hospital Emergency Department (ED) where he/she was diagnosed with [REDACTED]. The facility's failure to have an effective Quality Assessment and Assurance Program to identify and implement appropriate plans of action to correct identified quality deficiencies related to supervision and monitoring to ensure residents' safety was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified at 42 CFR 483.20 Resident Assessment, F-282; 42 CFR 483.25 Quality of Care, F-323; 42 CFR 483.75 Administration, F-490 and F-520, with Substandard Quality of Care in the area of 42 CFR 483.25 Quality of Care, F-323. The Immediate Jeopardy was identified on 10/17/13 and determined to exist on 10/14/13. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 10/21/13 alleging the Immediate Jeopardy was removed on 10/18/13. On 10/24/13, the State Survey Agency verified the Immediate Jeopardy was removed on 10/18/13, as alleged. However, non-compliance continued to exist at 42 CFR 483.20, Resident Assessment, F-282; 42 CFR 483.25, Quality of Care, F-323; 42 CFR 483.75 Administration, F-490 and F-520 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and, the facility's Quality Assurance monitors the systemic changes to ensure compliance. The findings include: 1. Based on interview and record review, it was determined the facility failed to ensure services were provided in accordance with resident's Comprehensive Plan of Care. This was a repeat deficiency for the facility which was cited during the standard Recertification Survey conducted 01/08/13 through 01/11/13. Review of the facility's Plan of Correction (POC), with a compliance date of 02/15/13, revealed the licensed nurses were re-educated related to following the plan of care. In addition, audits were to be performed by the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the Education Manager for at least ten (10) residents each week for six (6) weeks, then two (2) residents each week for two (2) months to ensure the plan of care was followed. Interview, record review and review of the facility's "Care Plan Policy", revealed, on 10/14/13, facility staff failed to implement Resident #1's and Unsampled Resident A's Comprehensive Plans of Care related to interventions to supervise the residents when smoking and to ensure Resident #1's oxygen was off when smoking. Interview with the Administrator, who was over the facility's Quality Assurance (QA) Committee, revealed the facility had not identified any recent issues with care plan implementation. She stated the interventions in the residents' Comprehensive Plans of Care should have been implemented to ensure their safety when smoking. (Refer to F-282) 2. Based on interview, record review and review of the facility's 'smoking rules", the facility failed to have an effective system to maintain an environment that was as free from accident hazards and to provide supervision and monitoring to each resident to prevent avoidable accidents. The facility failed to ensure policy and procedures were implemented to ensure residents' safety during resident and staff smoking breaks. Failure to provide adequate supervision was a repeat deficiency for the facility which was cited during the standard Recertification Survey conducted 01/08/13 through 01/11/13. Review of the facility's Plan of Correction (POC), with a compliance date of 02/15/13, revealed the licensed nurses were re-educated related to supervision of residents to prevent accidents and injuries. In addition, a one (1) time audit of fifteen (15) residents was performed to identify any resident not being supervised per their plan of care to prevent accidents and injuries; to ensure assistive devices were correct and to identify any resident that was not supervised. Additionally, a one (1) time audit of all accident and incident reports for the period of 01/01/13 through 02/08/13, was completed to identify any accident and incident that occurred due to not following the Comprehensive Plan of Care and/or due to an issue with resident supervision. The Administrator and Education Manager was to complete a daily walk through for four (4) weeks of all resident rooms to ensure residents were being supervised. Record review and interview revealed, on 10/14/13, two (2) facility staffs was outside during their employee break smoking in the designated resident area. Facility staff failed to provide supervision and monitoring of residents to prevent avoidable accidents, to ensure the facility's "smoking rules" were implemented to ensure residents' safety during smoking breaks. This was evidenced by Resident #1, who wore oxygen per nasal cannula per Physician Order, having access to a cigarette and lighter. Resident #1 lit the cigarette with the lighter and the oxygen combusted and flamed at the nasal cannula under the resident's nose. Resident #1 was transported to a hospital where he/she was diagnosed with [REDACTED]. (Refer to F-323). Interview, on 10/17/13 at 11:35 AM, with the Administrator, who headed the Quality Assurance (QA) Committee, revealed she still performed daily rounding to ensure residents were safe in the facility; however, did not document her audits. Per interview, she knew employees were smoking in resident designated areas, but had not noticed residents in smoking areas with oxygen in use. She stated staff should have been in the employee smoking area and not smoking in the designated resident smoking area. The Administrator stated Resident #1 and Unsampled Resident A were not appropriately supervised by staff while smoking on 10/14/13. The Administrator stated residents should not have cigarettes in their possession and staff should not ever give a lighter to any resident. She indicated she felt the root cause of the incident was that staff was smoking with the residents and this created a relaxed environment which resulted in decreased resident supervision. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 10/21/13 that alleged removal of the Immediate Jeopardy (IJ) effective 10/18/13. Review of the AOC revealed the facility implemented the following: 1) On 10/14/13, Resident #1 was transported to the Emergency Department for further evaluation and returned on the same date with topical medications for burns. 2) On 10/14/13, a head-to-toe assessment was performed on the residents in the area of the incident; Resident #1 and Unsampled Resident A. These residents were assessed by a licensed nurse. 3) One 10/14/13, the Medical Director was notified of the incident; and, all residents' responsible party were notified per letter of the "smoking rules". 4) On 10/14/13, a Quality Assurance (QA) Committee meeting was held with the Medical Director in attendance via phone. The incident was discussed and education was planned, developed and implemented. 5) On 10/14/13, the Regional Nurse Consultant provided education to the Administrator and Director of Nursing (DON) to include safe smoking practice. 6) Beginning 10/14/13, all staff was educated with written competencies regarding the facility's "smoking rules". 7) On 10/14/13, education was provided one-on-one by the Administrator to the four (4) identified residents who smoked regarding the facility's "smoking rules". 8) On 10/14/13, a communications letter was sent to all responsible parties regarding the facility's "smoking rules". 9) On 10/14/13, all residents that smoked were reassessed for safety by the Activities Director who normally performed these assessments. 10) Beginning 10/14/13, the facility's Nurse Consultant and Department Managers were to monitor resident/staff smoke breaks for twenty-four (24) hours to ensure safe smoking practice was adhered to. 11) On 10/14/13, residents' Comprehensive Care Plans were revised and updated for all residents who smoked by the Activity Director. The care plans were revised and updated to include smoking with supervision and wearing a smoking apron when smoking. 12) On 10/14/13, a one time audit of entrances/exits was completed by Administrator regarding "No Smoking" signs being posted. 13) On 10/14/13, fifteen (15) oxygen dependent residents were identified to ensure a "No Smoking Oxygen in Use" sign was posted at each resident room door. 14) On 10/14/13, the designated resident smoking area was observed by Regional Nurse Consultant to assure a fire blanket and extinguisher were readily available. 15) Beginning 10/14/13, the Administrator and/or DON was to audit all exit/entrances for four (4) weeks to assure all have "No Smoking" signs. 16) Beginning 10/14/13, all new hires will be educated regarding smoking rules and safety. 17) On 10/14/13, the Medical Director was notified by Administration of the audit findings. 18) On 10/15/13, a fire drill was completed to assess staff response. 19) Beginning 10/15/13, the Manager or a Licensed Nurse was to monitor smoking breaks for seven (7) days to ensure safe smoking practice was adhered to. 20) On 10/17/13, all employees were educated on the staff smoking policy and resident smoking policy which was "established" on 10/17/13. 21) Beginning 10/21/13, audit findings and plan will be reviewed weekly and ongoing until resolved. 22) All new admits will have a smoking assessment completed upon admission, quarterly and with any changes in smoking status. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Emergency Department records and interview on 10/16/13, with Resident #1 validated medical assessments and treatment completed by Emergency Department staff. 2) Review of the head-to-toe assessments dated 10/14/13, for the residents in the area of the incident, Resident #1 and Unsampled Resident A, indicated they were performed by licensed nursing staff. 3) Interview, on 10/16/13, with the Medical Director validated the immediate notification by facility staff of the incident. Resident has a BIMS score of 15 and is his/her own responsible party and was educated on the facility's "smoking rules". In addition, the facility mailed a letter to his/her family related to the facility's "smoking rules". 4) Review of Quality Assurance (QA) meeting notes with sign in sheet dated 10/14/13 validated the incident was discussed and education was developed. Review of educational program material revealed it was implemented. 5) Review of listed content of education revealed the Administrator and the DON were educated on 10/14/13, and this education included safe smoking practice. Interview with the Administrator and the DON on 10/24/13 validated the education. 6) Review of education sign-in sheets and post-test competencies revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they all had received education regarding safe smoking practice and smoking rules. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on safe smoking practice and smoking rules. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on safe smoking practice and smoking rules. 7) Interview, on 10/24/13, with three (3) of the four (4) residents who smoked, revealed all had been educated by the Administrator on safe smoking practice and the facility's smoking rules. 8) Review of the communications letter sent to all responsible parties revealed the letter addressed the facility's smoking rules. 9) Review of the updated resident smoking assessments completed on 10/14/13 revealed the four (4) smokers in the facility had been reassessed for safety by the Activity Director, who normally performed these smoking assessments. 10) Review of the audit reports dated 10/14/13 to 10/15/13, revealed smoking breaks were monitored by managers for twenty-four (24) hours. 11) Review of the Comprehensive Care Plans for all four (4) resident smokers validated revisions and updates were completed on 10/14/13. 12) Review of the audit of entrances/exits regarding posting of "No Smoking" signs revealed it was completed by the Administrator on 10/14/13. Surveyor observations revealed signs at entrances and exits on 10/22/13, 10/23/13 and 10/24/13. 13) Review of the audit identification of fifteen (15) oxygen dependent residents revealed they had been identified and observation of oxygen dependent resident door revealed "No Smoking Oxygen In Use" signs posted on their doors. 14) Review of the audit report for the Regional Nurse's audit of fire blanket and fire extinguisher revealed they were in place and ready for use. Observation of the designated resident smoking area revealed a fire blanket and extinguisher in place and ready for use. 15) Review of the "No Smoking" sign at exit/entrances audit dated 10/14/13, revealed the audits had been initiated on that date. Further review of the audits revealed the Administrator and/or DON had performed audits of this 10/18/13 to 10/23/13. 16) Review of two (2) new hire employee records revealed they had been educated on safe smoking education and smoking rules as this information was in the new hire packet. 17) Interview with the Medical Director on 10/16/13, verified his notification of audit findings by the Administrator. 18) Review of the fire drill assessment completed 10/15/13 revealed a fire drill was conducted that date and all staff responded "appropriately". Interview on 10/24/13 with Licensed Practical Nurse (LPN) #5 at 10:45 AM, LPN #2 at 11:55 AM, State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM, Housekeeping Staff #1 at 11:40 AM, SRNA ##11 at 4:35 PM, and the Director of Nursing (DON) at 2:30 PM revealed a fire drill had been conducted the prior week. Interviews with these staff revealed they had been educated on proper response during a fire drill. 19) Review of the audit reports dated 10/15/13 to 10/21/13, revealed smoking breaks were monitored by managers and/or licensed staff for seven (7) days. 20) Review of education sign-in sheets for 10/17/13 revealed the following: on 10/24/13, interview with Licensed Practical Nurse (LPN) #4 at 9:25 AM, LPN #5 at 10:45 AM, LPN #7 at 2:26 PM, LPN #2 at 2:29 PM, LPN #1 at 2:45 PM and LPN #6 at 2:55 PM, revealed they had all been educated on the staff smoking policy and resident smoking policy. On 10/24/13, interview with State Registered Nursing Assistant (SRNA) #8 at 9:50 AM, SRNA #9 at 11:30 AM, SRNA #10 at 4:30 PM and SRNA #11 at 4:35 PM, revealed they had all received education on the staff smoking policy and resident smoking policy. On 10/24/13, interview with Housekeeping Staff #9 at 11:40 AM, revealed she had received education on the staff smoking policy and resident smoking policy. 21) Review of first audit, dated 10/17/13 and interview with Administrator revealed audits were ongoing until resolved. 22) Review of a new admit resident revealed a smoking assessment was completed on admission.

Based on observation, interview and review of the facility's Plan of Correction (POC), it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies in regards to failure to ensure each residents' environment remained as free of accident hazards as was possible for fourteen (14) of the facility's thirty-five (35) resident rooms. Observation revealed television cable wiring on the floor in resident rooms number 1, 4, 9, 12, 13, 17, 24, 25, 27, 28, 29, 35, 37 and 38. (Refer to F323 and F490) The findings include: Review of the facility's POC with an alleged compliance date of 11/25/13, revealed the facility was to monitor all resident rooms daily for four (4) weeks beginning 11/04/13 to ensure all potential hazards were identified. Review of the POC revealed the daily rounds were to be completed by the Department Managers, Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator and/or Regional Nurse Coordinator. Further review of the POC revealed on 10/31/13, a Safety Committee meeting was conducted on 10/31/13 to review the POC and identify any potential hazards. Further review of the POC revealed the Safety Committee was to meet on a monthly basis. Observations on 12/10/13 at 10:05 AM, and on 12/11/13 at 8:56 AM revealed television cable wiring lying on the floor in fourteen (14) of the facility's thirty-five (35) resident rooms. Interview, on 12/11/13 at 10:13 AM, with the Maintenance Director and on 12/11/13 at 10:46 AM, with the Regional Nurse Coordinator revealed the television cable wiring was a potential safety issue. Interview with the Human Resource (HR) Director on 12/11/13 at 8:29 PM, revealed she was responsible for monitoring resident rooms for safety hazards. She stated during her monitoring she did see cable wiring on the floor. She indicated she had not identified this as a safety hazard. The HR Director stated she had not observed "anything that looked out of place" or "nothing that would be a hazard" during her safety inspections. Interview with the Assistant Director of Nursing (ADON) on 12/11/13 at 8:34 PM, revealed her responsibilities included monitoring of resident rooms for safety hazards. She stated she had seen the television cable wires lying on the resident's floor; but, had not identified the wires to be a potential safety hazard during her rounds. The ADON indicated at the time of the interview she could see the television cable cords could possibly be a safety hazard for residents. An additional interview, on 12/11/13 at 3:37 PM, with the Regional Nurse Coordinator revealed the "Caring Partners Daily Rounding Sheet" was utilized during the rounds; however, the television cable wiring on the floor of resident rooms had not been identified as a potential hazard. Interviews, on 12/11/13 at 10:46 AM, 3:37 PM and 6:27 PM, with the Administrator revealed daily rounds of resident rooms had been completed as per the POC. The Administrator stated she had performed rounds for resident room inspection and to monitor for potential hazards; however, during her rounds she had not identified the television cable wiring to be a potential hazard. The Administrator stated the television cable wiring could be considered a safety issue.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the Physician was notified related to changes in conditions/or need to alter treatment. In addition the facility failed to follow their policy entitled, "Notification of Resident Change in Condition" for one (1) of twelve (12) sampled residents (Resident #1). On 09/01/12 at approximately 7:30 PM, Resident #1, who had been assessed by the facility as being at risk for elopement and had a history of [REDACTED]. Approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who stated they found Resident #1 walking in the neighborhood behind the facility approximately 1000 feet from the facility's front door. The facility failed to notify Resident #1's Physician of the incident and the potential need to alter treatment for [REDACTED]. On 09/03/12 sometime between 12:02 PM and 12:05 PM Resident #1 eloped again from the facility unsupervised and was located on a sidewalk getting ready to take a step onto the roadway of the "housing projects" located behind the facility, approximately 475 feet from the facility's front door. Resident #1 was placed on one to one (1:1) staffing and later sent to a psychiatric hospital for further evaluation. Resident #1 was not in the facility during the survey. Based on the above findings it was determined the facility's failure to ensure the Physician was notified related to a significant changes in a resident's condition and/or a need to alter treatment was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 09/13/12 and determined to exist on 09/01/12. The facility was notified of the Immediate Jeopardy on 09/13/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 with the facility alleging removal of the Immediate Jeopardy on 09/14/12. Immediate Jeopardy was verified to be removed on 09/14/12 prior to exiting the facility on 09/20/12 with remaining non-compliance at 42 CFR 483.10 Resident Rights F-157 Notification of Change, with a scope and severity of an "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure appropriate notifications of residents' changes in conditions. The findings include: Review of the policy the facility utilized as a reference titled, "Notification of Resident Change in Condition", dated 07/01/12, revealed "Clinicians" would immediately inform the resident's Physician when there was a significant change in the resident's physical, mental, or psychosocial status. Resident #1 was admitted to the facility, on 06/06/12, with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) Assessment, dated 06/13/12, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of ten out of fifteen (10/15), indicating Resident #1 was moderately impaired with cognition. Review of Interdisciplinary Team (IDT) Notes, dated 06/13/12, revealed Resident #1 had exit seeking behaviors due to the desire to return home. Review of physician's orders [REDACTED]. Review of Nurses Notes (NN), dated 07/23/12, revealed Resident #1 continued to exit the facility's front door and sit on the rocking chair and was to be sent to a psychiatric facility for a psychiatric evaluation. Resident #1 returned to the facility on [DATE]. Review of NN, dated 08/28/12 revealed Resident #1 exited the building three (3) times to the facility's front porch unsupervised and was redirected by staff back into the building. There was no documented evidence the Physician was notified of the resident's increased exit seeking behavior. Review of NN, dated 09/01/12, revealed Resident #1 exited the facility's front door to a housing area behind the facility and was "escorted back to the facility"; however, there was no documented evidence the Physician was notified. Interview, with State Registered Nursing Assistant (SRNA) #7, on 09/13/12 at 9:30 AM, revealed he was assigned to provide direct care to Resident #1 on 09/01/12 and at approximately 7:30 PM he responded to the Wander Guard alarm sounding at the front door. SRNA #7 stated he observed Resident #1 to sit down in a rocking chair on the front porch with unidentified visitors. SRNA #7 indicated he left Resident #1 on the front porch unsupervised by staff and went back into the facility. He continued that approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who told SRNA #7 they found Resident #1 walking in the neighborhood behind the facility (approximately 1000 feet from the facility's front door). Additional interview revealed he took Resident #1 to RN #1 and reported the incident to her. Interview, on 09/13/12 at 7:30 AM, with Licensed Practical Nurse (LPN) #4 who provided care to Resident #1 on 09/01/12 revealed she had just returned from her break at approximately 8:00 PM and was told by Registered Nurse (RN) #1 that Resident #1 had "gotten out" to the "housing projects" behind the facility and was brought back to the facility by two (2) unknown males. Further interview revealed RN #1 had told her to document what she was just told in the NNs. Interview with RN #1, on 09/13/12 at 8:10 AM, revealed she could only recall that Resident #1 had opened the front door and was going towards the rocking chairs on 09/01/12. She stated she did not call Resident #1's Physician to notify him of the incident, but had called the Director of Nursing (DON) and informed her that Resident #1 had opened the front door and got out on the front porch. Interview with the DON, on 09/13/12 at 10:55 AM, revealed she received a phone call from RN #1 on 09/01/12 at approximately 8:00 PM that Resident #1 went out on the front porch unsupervised by staff and she had instructed RN #1 to place Resident #1 on visual checks every fifteen minutes (Q15 checks). Further interview revealed if she had been informed Resident #1 had eloped from the facility for approximately twenty (20) minutes and was brought back to the facility by two (2) unknown males, she would have called Resident #1's Physician to obtain orders to alter treatment, such as assigning one (1) staff person to Resident #1 for constant visual checks (1:1) and requesting a physician's orders [REDACTED]. Further review of the NN, dated 09/03/12, revealed Resident #1 exited the facility again without staff's knowledge and was located on the sidewalk getting ready to take a step into the roadway of the "housing projects" located behind the facility (approximately 475 feet from the facility's front door). Continued interview with the DON, on 09/13/12 at 11:05 AM, revealed if the Physician had been notified of the 09/01/12 incident then maybe Resident #1 would not have eloped again on 09/03/12. Interview with Resident #1's Physician, on 09/19/12 at 11:30 AM, revealed Resident #1 was a high risk for elopement with a history of elopement and the facility was responsible for ensuring Resident #1 was adequately supervised to prevent elopement. Continued interview revealed he was not notified Resident #1 had eloped from the facility on 09/01/12. Further interview revealed leaving Resident #1 on the front porch with some unknown visitors was not fair to the visitors because it put the responsibility on them when it should be the responsibility of staff. Additional interview revealed if he had been made aware of the elopement on 09/01/12 he would have instructed the facility to place Resident #1 on 1:1 staffing and ordered for Resident #1 be sent to a psychiatric hospital for evaluation and then there possibly wouldn't have been the elopement on 09/03/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: 1) All staff in all departments were inserviced by the Assistant Director of Nursing on 09/03/12 and by the Education Director on 09/13/12 related to the following: a. Definition of elopement, revised Elopement Management and Prevention Policies, Missing Resident Action Plan, Head Count Procedures and Care Plan Policy which were revised on 09/13/12; and approved by the QA committee consisting of Administrator, DON, Social Services Director, Activities Director, Maintenance Director, Referral Manager, Business Office Manager, Business Office Assistant and Regional Nurse. b. Alarm procedures/action which included who responds to the alarm, what to do when the alarm sounds, and level of supervision needed. c. All staff reeducated regarding the Elopement Risk Book on 09/13/12 by the Education Director/Department Manager. d. Notify the Charge Nurse immediately of missing or exit seeking resident and the Charge Nurse will immediately notify the Administrator, DON and Nurse Consultant. The Charge Nurse will update the plan of care and update staff verbally and in writing of the increased supervision on the twenty-four (24) hour shift report. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 2) All elopement care plans were reviewed and revised on 09/13/12 by the DON, Administrator, Social Services, and Charge Nurse. All residents were visualized by the DON and Education Nurse on 09/13/12 to identify mode of locomotion and staff interviews were conducted to better determine residents with elopement risk. 3) On 09/13/12, a Quality Assurance Meeting was held to discuss the steps to be taken to prevent further incidents to Resident #1 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 4) License staff will complete the accident/incident report immediately for an elopement attempt or actual elopement and the education was completed by the Department Manager and or the Education Director by 09/14/12. 5) On 09/13/12, the DON and Administrator conducted an elopement drill to evaluate the staff response to alarms sounding. 6) Department Manager monitoring of the facility twenty four/seven (24/7) for ten days beginning 09/13/12 to include at least one random staff interview each shift to determine any resident changes as related to wander risk, monitoring and witnessing wander guard checks for function and placement, visualizing all residents, ensure staff response to door alarms, check function of all doors every shift to ensure all systems are functioning, ensure staff can complete head count properly and timely, Department Manager to complete a daily elopement drill, care plan updates, twenty four (24) hour report sheet completed. Any decrease in Department Manager monitoring will be reviewed by the QA committee after ten days and then weekly for a decrease in monitoring, any issues identified and need for further education. 7) Twenty-four/seven 24/7 front door monitoring beginning at 12 noon on 09/13/12 until door is upgraded and function is verified on 2 shifts. 8) New employees are to be trained on the elopement system upon hire by the Education Director. The Elopement Risk Book will be reviewed during orientation of new staff. The revised elopement policies and procedures were included in the new hire orientation material beginning 09/13/12. 9) All activity care plans reviewed/revised 09/13/12 by the Life Enrichment Director, DON, Social Services, MDS Nurse and Regional Nurse Consultant to ensure activities where in place for all residents and identified residents' individual needs. On 09/20/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/14/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/13/12 based on the following: Review of facility inservice records and attendance logs, dated 09/13/12, revealed staff was educated related to the facility's revise policies and procedures for elopement to include Elopement Management and Prevention, Head Count, Missing Resident, Care Plan Policies and notifications to be made if a resident attempted to exited the building unsupervised. Further review of the inservice records revealed staff received education and training related to responding to the Wander Guard alarms and procedures to be followed which included the completion of the incident report. Record review revealed all resident's elopement care plans had been reviewed and revised on 09/13/12. Review of the facilities QA meeting minutes revealed a meeting was held on 09/13/12 to implement plans of correction to remove the immediate jeopardy. Review of the facility's monitoring log, dated 09/13/12 through 09/19/12, revealed staff had monitored the front door 24/7 until the front door was upgraded. Observation, on 09/18/12 at 3:10 PM, revealed the front door was secured when the Wander Guard was within four (4) feet and the door would not open for fifteen (15) seconds once the bar was pushed. Review of the facility's elopement drill records revealed the DON and Administrator conducted an elopement drill on 09/13/12 to evaluate the staff response to alarms sounding. Further review of the elopement drill records revealed an elopement drill had been conducted daily at varying times and shifts from 09/13/12 though 09/18/12. Observation, on 09/19/12 at 10:15 AM, revealed an elopement drill was conducted by the Administrator. Further observation revealed staff immediately responded to the alarm by a nurse at the nurse's station going to the front door, dietary staff going out the side door and housekeeping going out the back doors and checking the facility property, SRNA's, LPN's and activities doing a head count and checking behind doors and all areas of the facility until the Maintenance Director (who was placed behind a door in a bathroom as a resident) was located. Interview with the Dietary Manager on 09/19/12 at 1:30 PM, Maintenance Director at at 2:15 PM, Assistant Director of Nursing at 3:45 PM and on 09/20/12 at 11:00 AM with the Director of Nursing and the Administrator revealed they had been assigned rotating shifts to include visualizing all residents, ensure staff response to door alarms, care plans were updated, twenty four (24) hour report sheet completed and notifications made. Observation, on 09/18/12 from 4:00 PM until 4:30 PM, revealed there were Elopement Risk Books on both the nursing units including the East and West Nurse's Station, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including RN #4 on 09/19/12 at 12:55 PM, SRNA #8 at 1:00 PM, LPN #3 at 1:05 PM, LPN #6 at 1:15 PM, Dietary Manager at 1:30 PM, SRNA #9 at 1:45 PM, Housekeeper #2 at 2:00 PM, RN #1 at 2:25 PM, LPN #7 at 2:35 PM, LPN #8 at 2:45 PM, LPN #1 at 2:55 PM, SRNA #10 at 3:00 PM, SRNA # 11 at 3:10 PM, and Physical Therapy aide at 3:20 PM, revealed they had received inservice education and were aware of what an elopement was, the Elopement Risk Book and the elopement policy and procedure to include providing staff supervision as well appropriate notifications to be made if a resident attempted to leave the facility unsupervised, including notifying the physician. They were also aware of the procedure in responding to the door alarm to include searching inside and outside the facility. Record review revealed the Activities Director, Social Worker, DON and Regional Nurse Consultant reviewed and revised the activity assessments and activities care plans for all elopement risk residents by 09/13/12. Interview with the DON, Regional Nurse Consultant and Activities Director, on 09/20/12 at 9:20 AM, revealed they met as a group on 09/13/12 and reviewed and revised care plans and activities assessments of residents at risk for elopement to ensure those residents received routine time out side to meet their needs. Further interview revealed all residents care plans and activity assessments were being reviewed and revised. Further interview with the Administrator revealed the current Activities Director would become an Activities Assistant when the Dietary Manager completed the training course approved by the state. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed she had assisted with the changes in the new elopement policies and the policies would be reviewed with each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Review of the facility's revised orientation packet revealed orientation included review of the facility's revised elopement polices and procedures. Interview with the Administrator, DON and Regional Nurse and review of the new Elopement Management and Prevention Policies, on 09/20/12 at 11:00 AM, revealed the policies were updated 09/13/12 to include staff supervision of residents at elopement risk, reviewing and revising individualized care plan interventions to prevent elopement (such as enhanced recreational activities), responding to wander guard alarms, completing incident reports, and notifications to be made when a resident attempts to leave the facility unsupervised, to include notifying the physician. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC). .

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to have an effective system to ensure the comprehensive plan of care was reviewed and revised for one (1) of twelve (12) sampled residents (Resident #1). The facility developed the elopement plan of care, dated 06/13/12, due to the resident's exit seeking behaviors to include interventions of placing a Wander Guard on the resident and to encourage movement and exercise. On 06/25/12, the care plan was revised and indicated redirection was not effective. A new intervention was added to encourage resident to go outside with the smokers during designated smoke breaks (even though Resident #1 was not a smoker) and to give time out doors. However, the facility failed to revise the plan of care to include timetables and objectives in measurable outcomes to ensure Resident #1 received routine supervised time outside to prevent elopement. On 09/01/12 at approximately 7:30 PM, Resident #1 was left unsupervised by staff on the facility's front porch. Approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who stated they found Resident #1 walking in the neighborhood behind the facility approximately 1000 feet from the facility's front door. The facility failed to revise Resident #1's elopement plan of care to include new interventions to prevent further elopement. On 09/03/12 between 12:02 PM and 12:05 PM Resident #1 eloped from the facility again unsupervised and was located on a sidewalk getting ready to take a step onto the roadway of the "housing projects" located behind the facility, approximately 475 feet from the facility's front door. Resident #1 was placed on one to one (1:1) staffing and sent to a psychiatric hospital for evaluation. Resident #1 was not in the facility during the survey. Based on the above findings it was determined the facility's failure to revise the plan of care to include timetables and objectives in measurable outcomes to include new interventions to prevent further elopement was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 09/13/12 and determined to exist on 09/01/12. The facility was notified of the Immediate Jeopardy on 09/13/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 with the facility alleging removal of the Immediate Jeopardy on 09/14/12. Immediate Jeopardy was verified to be removed on 09/14/12 prior to exiting the facility on 09/20/12 with remaining non-compliance at 42 CFR 483.20 Resident Assessment F-280, with a scope and severity of an "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure care plans are revised. The findings include: Review of the policy the facility utilized as a reference titled, "Care Plans-Comprehensive", dated December 2010, revealed each resident's comprehensive care plan was designed to incorporate risk factors associated with identified problems, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals, timetables and objectives in measurable outcomes, identify the professional services that were responsible for each element of care. Further review of the policy revealed the IDT is responsible to ensure the care plan is revised when there is a significant change in the resident's condition and when the desired outcome is not met. Record review revealed the facility admitted Resident #1 on 06/06/12 with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, dated 06/13/12, revealed the facility assessed Resident #1 as cognitively impaired with a score of 10/15 on the Brief Interview for Mental Status Exam. Review of physician's orders [REDACTED]. An Elopement Plan of Care was initiated on 06/13/12 to include the intervention of placing the Wander Guard on the resident and to encourage movement and exercise. Record review revealed during a care plan conference, dated 06/25/12, it was noted by the Power of Attorney (POA) that Resident #1 often took walks in the woods and liked sitting outside at home. On 06/25/12, the care plan was revised and a new intervention was added to encourage the resident to go outside with the smokers during designated smoke breaks (even though Resident #1 was not a smoker) and to give time out doors. Further review of the plan of care revealed there was no evidence the facility revised the plan of care to include timetables, measurable objectives, or what professional services were responsible to ensure Resident #1 received supervised time out doors. Review of the Nurses Notes (NN), dated 08/28/12, revealed Resident #1 exited the building three (3) times and was redirected back into the building. The plan of care was revised on that date to include supervised sitting out doors with family and staff. However, the facility failed to ensure the care plan was revised to include timetables, measurable objectives, or exactly what professional services were responsible to ensure Resident #1 received supervised time out doors. Review of NN, dated 09/01/12, revealed Resident #1 exited the facility's front door and two (2) unknown males in housing area behind the facility escorted Resident #1 back to the facility. Interview with State Registered Nursing Assistant (SRNA) #7, on 09/13/12 at 9:30 AM, revealed at approximately 7:30 PM he responded to the Wander Guard alarm sounding at the front door. SRNA #7 indicated he observed Resident #1 to sit down in a rocking chair on the front porch with unidentified visitors. SRNA #7 stated he knew Resident # 1 should not be outside on his/her own due to his/her elopement risk, but that he/she would be allowed to be outside with staff or family members per the plan of care. He indicated he left Resident #1 on the front porch with some visitors that were "someone's family members". Additional interview revealed approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who told SRNA #7 they found Resident #1 walking in the neighborhood behind the facility (approximately 1000 feet from the facility's front door). During an interview with Licensed Practical Nurse (LPN) #4, on 09/13/12 at 7:30 AM, she stated she had just returned from her break at approximately 8:00 PM and was told by Registered Nurse (RN) #1 that Resident #1 had "gotten out" to the "housing projects" behind the facility and was brought back to the facility by two (2) unknown males. She indicated RN #1 had told her to document what she was just told in NNs, but was never told by RN #1 to revise the care plan to include interventions of increased supervision. Additionally she stated she did not know it was her responsibility to revise the plan of care and thought it was the the MDS Coordinator's function. Interview with RN #1, on 09/13/12 at 8:10 AM, revealed she called the DON on 09/01/12 at approximately 8:00 PM and informed her that Resident #1 had opened the front door and went out on the front porch. She indicated she did not recall the incident with Resident #1 going to the "housing projects". She stated the DON had instructed her to place Resident #1 on every fifteen minute visual checks, but as far as revising the plan of care she "just didn't think about it". Interview with the MDS Coordinator, on 09/14/12 at 10:00 AM, revealed he developed the Comprehensive Plan of Care after the MDS was completed and revised the plan of care after Quarterly MDSs were completed. He indicated each discipline was responsible for developing and revising their own care plans related to their own discipline, such as Activities. Further interview revealed if there was a need to revise or add an intervention to any nursing plan of care it was the responsibility of the nurse who was assigned to provide care to that resident at the time of the incident. Interview with the DON, on 09/13/12 at 10:55 AM, revealed she received a phone call from RN #1 on 09/01/12 at approximately 8:00 PM that Resident #1 went out on the front porch unsupervised by staff and she had instructed RN #1 to place Resident #1 on visual checks every fifteen minutes (Q15 checks). Further interview revealed she did not know Resident #1 had eloped from the facility without staff knowledge, was gone for approximately twenty (20) minutes, and was brought back to the facility by two (2) unknown males. Additionally she stated had she known, she would have called Resident #1's Physician to obtain orders to alter treatment, such as assigning one (1) staff person to Resident #1 for constant visual checks (1:1) and requesting a physician's orders [REDACTED]. Interview with LPN #3, on 09/12/12 at 3:15 PM, revealed Resident #1 exited the facility through the front door at least two (2) times the morning of 09/03/12. However, the resident's level of supervision was not increased. Review of NN, dated 09/03/12, revealed Resident #1 exited the facility without staff's knowledge and was located on the sidewalk getting ready to take a step into the roadway of the "housing projects" located behind the facility (approximately 475 feet from the facility's front door). Further record review revealed Resident #1 was placed on 1:1 until he/she was sent to a psychiatric hospital for evaluation. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: 1) All staff in all departments were inserviced by the Assistant Director of Nursing on 09/03/12 and by the Education Director on 09/13/12 related to the following: a. Definition of elopement, revised Elopement Management and Prevention Policies, Missing Resident Action Plan, Head Count Procedures and Care Plan Policy which were revised on 09/13/12; and approved by the QA committee consisting of Administrator, DON, Social Services Director, Activities Director, Maintenance Director, Referral Manager, Business Office Manager, Business Office Assistant and Regional Nurse. b. Alarm procedures/action which included who responds to the alarm, what to do when the alarm sounds, and level of supervision needed. c. All staff reeducated regarding the Elopement Risk Book on 09/13/12 by the Education Director/Department Manager. d. Notify the Charge Nurse immediately of missing or exit seeking resident and the Charge Nurse will immediately notify the Administrator, DON and Nurse Consultant. The Charge Nurse will update the plan of care and update staff verbally and in writing of the increased supervision on the twenty-four (24) hour shift report. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 2) All elopement care plans were reviewed and revised on 09/13/12 by the DON, Administrator, Social Services, and Charge Nurse. All residents were visualized by the DON and Education Nurse on 09/13/12 to identify mode of locomotion and staff interviews were conducted to better determine residents with elopement risk. 3) On 09/13/12, a Quality Assurance Meeting was held to discuss the steps to be taken to prevent further incidents to Resident #1 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 4) License staff will complete the accident/incident report immediately for an elopement attempt or actual elopement and the education was completed by the Department Manager and or the Education Director by 09/14/12. 5) On 09/13/12, the DON and Administrator conducted an elopement drill to evaluate the staff response to alarms sounding. 6) Department Manager monitoring of the facility twenty four/seven (24/7) for ten days beginning 09/13/12 to include at least one random staff interview each shift to determine any resident changes as related to wander risk, monitoring and witnessing wander guard checks for function and placement, visualizing all residents, ensure staff response to door alarms, check function of all doors every shift to ensure all systems are functioning, ensure staff can complete head count properly and timely, Department Manager to complete a daily elopement drill, care plan updates, twenty four (24) hour report sheet completed. Any decrease in Department Manager monitoring will be reviewed by the QA committee after ten days and then weekly for a decrease in monitoring, any issues identified and need for further education. 7) Twenty-four/seven 24/7 front door monitoring beginning at 12 noon on 09/13/12 until door is upgraded and function is verified on 2 shifts. 8) New employees are to be trained on the elopement system upon hire by the Education Director. The Elopement Risk Book will be reviewed during orientation of new staff. The revised elopement policies and procedures were included in the new hire orientation material beginning 09/13/12. 9) All activity care plans reviewed/revised 09/13/12 by the Life Enrichment Director, DON, Social Services, MDS Nurse and Regional Nurse Consultant to ensure activities where in place for all residents and identified residents' individual needs. On 09/20/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/14/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/13/12 based on the following: Review of facility inservice records and attendance logs, dated 09/13/12, revealed staff was educated related to the facility's revise policies and procedures for elopement to include Elopement Management and Prevention, Head Count, Missing Resident, Care Plan Policies and notifications to be made if a resident attempted to exited the building unsupervised. Further review of the inservice records revealed staff received education and training related to responding to the Wander Guard alarms and procedures to be followed which included the completion of the incident report. Record review revealed all resident's elopement care plans had been reviewed and revised on 09/13/12. Review of the facilities QA meeting minutes revealed a meeting was held on 09/13/12 to implement plans of correction to remove the immediate jeopardy. Review of the facility's monitoring log, dated 09/13/12 through 09/19/12, revealed staff had monitored the front door 24/7 until the front door was upgraded. Observation, on 09/18/12 at 3:10 PM, revealed the front door was secured when the Wander Guard was within four (4) feet and the door would not open for fifteen (15) seconds once the bar was pushed. Review of the facility's elopement drill records revealed the DON and Administrator conducted an elopement drill on 09/13/12 to evaluate the staff response to alarms sounding. Further review of the elopement drill records revealed an elopement drill had been conducted daily at varying times and shifts from 09/13/12 though 09/18/12. Observation, on 09/19/12 at 10:15 AM, revealed an elopement drill was conducted by the Administrator. Further observation revealed staff immediately responded to the alarm by a nurse at the nurse's station going to the front door, dietary staff going out the side door and housekeeping going out the back doors and checking the facility property, SRNA's, LPN's and activities doing a head count and checking behind doors and all areas of the facility until the Maintenance Director (who was placed behind a door in a bathroom as a resident) was located. Interview with the Dietary Manager on 09/19/12 at 1:30 PM, Maintenance Director at at 2:15 PM, Assistant Director of Nursing at 3:45 PM and on 09/20/12 at 11:00 AM with the Director of Nursing and the Administrator revealed they had been assigned rotating shifts to include visualizing all residents, ensure staff response to door alarms, care plans were updated, twenty four (24) hour report sheet completed and notifications made. Observation, on 09/18/12 from 04:00 PM until 4:30 PM, revealed there were Elopement Risk Books on both the nursing units including the East and West Nurse's Station, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including RN #4 on 09/19/12 at 12:55 PM, SRNA #8 at 1:00 PM, LPN #3 at 1:05 PM, LPN #6 at 1:15 PM, Dietary Manager at 1:30 PM, SRNA #9 at 1:45 PM, Housekeeper #2 at 2:00 PM, RN #1 at 2:25 PM, LPN #7 at 2:35 PM, LPN #8 at 2:45 PM, LPN #1 at 2:55 PM, SRNA #10 at 3:00 PM, SRNA # 11 at 3:10 PM, and Physical Therapy aide at 3:20 PM, revealed they had received inservice education and were aware of what an elopement was, the Elopement Risk Book and the elopement policy and procedure to include providing staff supervision as well appropriate notifications to be made if a resident attempted to leave the facility unsupervised, including notifying the physician. They were also aware of the procedure in responding to the door alarm to include searching inside and outside the facility. Record review revealed the Activities Director, Social Worker, DON and Regional Nurse Consultant reviewed and revised the activity assessments and activities care plans for all elopement risk residents by 09/13/12. Interview with the DON, Regional Nurse Consultant and Activities Director, on 09/20/12 at 9:20 AM, revealed they met as a group on 09/13/12 and reviewed and revised care plans and activities assessments of residents at risk for elopement to ensure those residents received routine time out side to meet their needs. Further interview revealed all residents care plans and activity assessments were being reviewed and revised. Further interview with the Administrator revealed the current Activities Director would become an Activities Assistant when the Dietary Manager completed the training course approved by the state. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed she had assisted with the changes in the new elopement policies and the policies would be reviewed with each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Review of the facility's revised orientation packet revealed orientation included review of the facility's revised elopement polices and procedures. Interview with the Administrator, DON and Regional Nurse and review of the new Elopement Management and Prevention Policies, on 09/20/12 at 11:00 AM, revealed the policies were updated 09/13/12 to include staff supervision of residents at elopement risk, reviewing and revising individualized care plan interventions to prevent elopement (such as enhanced recreational activities), responding to wander guard alarms, completing incident reports, and notifications to be made when a resident attempts to leave the facility unsupervised, to include notifying the physician. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on observation, interview, record review and review of facility's policies, it was determined the facility failed to have an effective system in place to provide adequate supervision and monitoring to prevent accidents for one (1) of twelve (12) sampled residents (Resident #1). The facility failed to ensure policy and procedures were implement for monitoring residents to ensure safety. In addition, the facility failed to ensure staff was trained and knowledgeable on how to adequately monitor and supervise residents at risk for elopement. The facility assessed Resident #1 as being at risk for elopement and with a history of leaving the building unsupervised. On 09/01/12, Resident #1 was left unsupervised by staff on the facility's front porch at 7:30 PM. Approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who stated they found Resident #1 walking in the neighborhood behind the facility approximately 1000 feet from the facility's front door. The facility failed to notify the Director of Nursing (DON) of the incident per facility policy and failed to notify Resident #1's Physician of the incident in order to assess the need to alter treatment for [REDACTED]. In addition, the facility failed to revise the plan of care to prevent further elopement. On 09/03/12, sometime between 12:02 PM and 12:05 PM Resident #1 eloped from the facility unsupervised and was located on a sidewalk getting ready to take a step on to the roadway of the "housing projects" located behind the facility, approximately 475 feet from the facility's front door. Resident #1 was placed on one to one (1:1) staffing and later sent to a psychiatric hospital for further evaluation. Resident #1 was not in the facility during the survey. Based on the above findings it was determined the facility's failure to ensure adequate supervision and monitoring was provided to prevent elopement was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy (IJ) was identified on 09/13/12 and determined to exist on 09/01/12. The facility was notified of the Immediate Jeopardy on 09/13/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 with the facility alleging removal of the Immediate Jeopardy on 09/14/12. Immediate Jeopardy was verified to be removed on 09/14/12 prior to exiting the facility on 09/20/12 with remaining non-compliance at 42 CFR 483. 25 Quality of Care F-323 Accidents and Supervision with a scope and severity of an "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure appropriate measures are put into place to provide adequate supervision to prevent accidents. The findings include: Review of the policy the facility utilized as a reference titled, "Wandering, Unsafe Resident", revised December 2001, revealed staff would identify residents at risk for harm because of unsafe wandering, including elopement. Further review of the policy revealed interventions to maintain safety would be included in the resident's care plan, nursing would document circumstances related to unsafe actions, staff would initiate a detailed monitoring plan, and notify the Administrator and Director of Nursing (DON) immediately and institute appropriate measures when a resident was discovered missing from the facility. Review of the policy the facility utilized as a reference titled, "Elopements", revised December 2008, revealed staff should promptly report any resident who tried to leave the premises to the DON. Further review of the policy revealed when a departing resident returned to the facility the DON or Charge Nurse should examine the resident for injuries, notify the Physician, complete and incident/accident report, and document relevant information in the resident's medical record. Review of the medical record revealed the facility admitted Resident #1 on 06/06/12, with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) Assessment, dated 06/13/12, revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of ten (10) out of fifteen (10/15), indicating Resident #1 was moderately impaired in cognition. Review of Interdisciplinary Team (IDT) Notes, dated 06/13/12, revealed Resident #1 had exit seeking behaviors due to the desire to return home. Review of physician's orders [REDACTED]. Review of Resident #1's Comprehensive Plan of Care related to elopement, dated 06/13/12, revealed Resident #1 expressed the desire to leave, desire to return home and was independently mobile. Interventions for the elopement plan of care included to initiate "Wander Alert System", place resident information in the elopement risk book and encourage movement and exercise. Review of an Activities Plan of Care, dated 06/13/12, noted that sitting on the porch was one of Resident #1's favorite activities and interventions included to encourage participation of activities of interest during stay. Interview with the Activities Director, on 09/12/12 at 3:45 PM, revealed Resident #1 had frequently expressed the desire to go home and had a history of [REDACTED]. She indicated whichever staff responded to the alarm would go outside and sit with him/her on the porch, but if staff didn't have time to sit with him/her, they would re-direct him/her back into the facility. Additional interview revealed she would take Resident #1 outside including going for walks on the facility property if she had "spare time". She stated she had developed the activity plan of care and indicated she had not specified when Resident #1 should go outside. Review of Resident #1's medical record revealed a care plan conference was held on 06/25/12 with Resident #1's Power of Attorney (POA) and at that time the POA told the facility that Resident #1 often took walks in the woods and liked sitting outside at home. On 06/25/12, the care plan was revised and a new intervention was added to encourage the resident to go outside with the smokers during designated smoke breaks (even though Resident #1 was not a smoker) and to give time out doors. Nurses Notes, dated 07/23/12, revealed Resident #1 continued to exit the facility's front door and sit on the rocking chair. Review of physician's orders [REDACTED]. Resident #1 returned to the facility on [DATE] with new care plan interventions which included Resident #1 was to have Physical Therapy (PT). Review of PT notes revealed Resident #1 received PT from 07/30/12 through 08/24/12. Interview with Physical Therapy Assistant #1, on 09/12/12 at 2:30 PM, revealed Resident #1 would be taken outside for walks when the weather was nice as part of his/her therapy. Review of NN, dated 08/28/12, revealed three (3) days after PT was discontinued, Resident #1 exited the building three (3) times to the facility's front porch unsupervised and was redirected by staff back into the building. Review of the elopement plan of care revealed it was revised on 08/28/12 with an intervention to accompany resident outside and supervise sitting outdoors with family and staff. Review of NN, dated 09/01/12, revealed Resident #1 exited the facility's front door and two (2) unknown males in housing area behind the facility escorted Resident #1 back to the facility. Interview with State Registered Nursing Assistant (SRNA) #7, on 09/13/12 at 9:30 AM, revealed at approximately 7:30 PM he responded to the Wander Guard alarm sounding at the front door. SRNA #7 indicated he observed Resident #1 to sit down in a rocking chair on the front porch with unidentified visitors. SRNA #7 stated he knew Resident # 1 should not be outside on his/her own due to his/her elopement risk, but that he/she would be allowed to be outside with staff or family members per the plan of care. He indicated he left Resident #1 on the front porch with some visitors that were "someone's family members". Additional interview revealed approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who told SRNA #7 they found Resident #1 walking in the neighborhood behind the facility (approximately 1000 feet from the facility's front door). During an interview with Licensed Practical Nurse (LPN) #4, on 09/13/12 at 7:30 AM, she stated she had returned from her break at approximately 8:00 PM and was informed by Registered Nurse (RN) #1 that Resident #1 had "gotten out" to the "housing projects" behind the facility and was brought back to the facility by two (2) unknown males. She indicated RN #1 instructed her to document the incident in NNs. Interview with RN #1, on 09/13/12 at 8:10 AM, revealed she called the DON on 09/01/12 at approximately 8:00 PM and informed her that Resident #1 had opened the front door and went out on the front porch. She indicated she did not recall the incident with Resident #1 going to the "housing projects". She stated the DON had instructed her to place Resident #1 on every fifteen (15) minute visual checks, but as far as revising the plan of care she "just didn't think about it". Interview with the DON, on 09/13/12 at 10:55 AM, revealed she received a phone call from RN #1 on 09/01/12 at approximately 8:00 PM that Resident #1 went out on the front porch unsupervised by staff and she had instructed RN #1 to place Resident #1 on visual checks every fifteen minutes (Q15 checks). Further interview revealed if she had been informed Resident #1 had eloped from the facility for approximately twenty (20) minutes and was brought back to the facility by two (2) unknown males, she would have informed staff to conduct a head to toe skin assessment of Resident #1, have staff complete an Accident/Incident report for further investigation, and notified Resident #1's Physician per the facility's wander and elopement policies. Review of NN, dated 09/03/12 with a clarification NN dated 09/04/12, revealed Resident #1 had been visualized at 11:55 AM by staff during the every fifteen (15) minute checks. Further review of NN revealed staff had heard the alarm sounding, went to the exit door and did not visualize any residents. Continued review of NN revealed the alarm was silenced and at 12:10 PM a housekeeper informed a nurse that Resident #1 was outside ambulating to the apartments behind the facility. Additional review of NN revealed the Assistant Director of Nursing (ADON) left the facility and escorted Resident #1 back to the facility. The NN revealed the Physician and POA were notified, Resident #1 was placed on 1:1 staffing, and was later transferred to a psychiatric hospital for evaluation. Interview with LPN #3, on 09/12/12 at 3:15 PM, revealed Resident #1 exited the front door and got out onto the porch at least twice on the morning of 09/03/12. She stated that morning Resident #1 seemed more anxious and stated to her that he/she wanted to go out and find a "woman" to live with. She indicated one time when she responded to the alarm sounding at the front door, Resident #1 stated he/she was just outside "checking the weather." She stated she was on lunch break when Resident #1 eloped from the facility and that RN #1 was assigned to do the every fifteen (15) minute checks at that time. LPN #3 stated Resident #1 was already on every fifteen (15) minute checks and she didn't think about calling the DON or placing Resident #1 on 1:1 prior to Resident #1 exiting the facility and getting off the property around lunch time. She stated she was not aware of Resident #1's elopement that had occurred two (2) days earlier, on 09/01/12. During an interview with RN #1, on 09/10/12 at 2:10 PM, she stated she was aware Resident #1 had more attempts to exit the building by constantly opening the front door and sometimes getting out on the front porch before staff could get to him/her because he/she was "very fast". Additional interview revealed Resident #1 had expressed to her that he/she was looking for a woman. Further interview revealed she had last seen Resident #1 at approximately 11:55 AM sitting in the lobby by the front door. She stated she heard the alarm sounding at approximately 12:05 PM while she was in another resident's room providing a treatment. She indicated that by the time she finished giving her treated and came out into the hall, she was informed by staff that Resident #1 had eloped and was found by the ADON in the "housing projects" behind the building. RN #1 stated she was not aware that Resident #1 had eloped from the facility on 09/01/12 and was only aware he/she had exited the front door and was on the front porch. Observations, on 09/12/12 between from 10:30 AM until 10:55 AM, with the Maintenance Director revealed there were four (4) exit doors from the facility. Further observation revealed if a Wander Guard was within four (4) feet of each of the four doors, an alarm would sound for that door. Continued observation revealed while the alarm was sounding an individual could push on the bar to open the door and the door would open after a fifteen second delay for three (3) of the four (4) exit doors which included the door on the side of the building next to the kitchen and the two doors in the back of the facility. However, observation of the front door revealed there was not a fifteen second delay when an individual pushed the bar to get out, allowing an individual to immediately open the door. Observation, on 09/13/12 at 1:55 PM, of a reenactment of what LPN #2 did around noon on 09/03/12 and interview with LPN #2 revealed she heard the front door alarm sounding at 12:00 PM as she was beginning her medication pass. Further observation and interview revealed she pushed her medication cart against the wall, locked the medication cart, walked through the front lobby where no one else was and opened the front door which took thirty (30) seconds. She then went through the front door and half way down the front side walk, looked to the left and to the right which took an additional fifteen (15) seconds. Additional interview revealed as she was coming back into the facility and was going to initiate a head count to see if all residents were accounted for, she was informed by an SRNA that the ADON went out to get Resident #1 from the "housing projects" behind the building. Interview with Housekeeper #1, on 09/12/12 at 11:50 AM, revealed she had clocked out at the time machine, located next to the front lobby, at 12:02 PM . She stated she had not heard an alarm sounding prior to clocking out. Further interview revealed she walked to the back of the building, went out the back door and as she was getting in her daughter's car her daughter described Resident #1 and asked her if he/she was a resident because she had seen him/her walk down the side road of the facility towards the housing area behind the facility. Additional interview revealed she went back to the back door and began "pounding" on the door until she got the attention of an SRNA who called to the ADON that Resident #1 was up the grassy incline in between two houses. An interview with the ADON on 09/14/12 at 1:25 PM, revealed she went outside and got Resident #1 on 09/03/12 after SRNA #4 had called out down the hall that Housekeeper #1 had knocked on the back door reporting Resident #1 was out. The ADON went on to reveal a head count was conducted to ensure no other residents were unaccounted for, Resident #1 was assessed, and he/she was placed on 1:1 supervision until he/she could be sent out for a psychiatric evaluation. The ADON revealed she was unaware Resident #1 had eloped from the facility on 09/01/12 and was unaware he/she was on fifteen (15) minute checks. Interview with Resident #1's Physician, on 09/19/12 at 11:30 AM, revealed Resident #1 was a high risk for elopement with a history of elopement and the facility was responsible for ensuring Resident #1 was adequately supervised to prevent elopement. Continued interview revealed he was not notified Resident #1 had eloped from the facility on 09/01/12. Further interview revealed leaving Resident #1 on the front porch with some unknown visitors was not fair to the visitors because it put the responsibility on them when it should be the responsibility of facility staff. Additional interview revealed if he had been made aware of the elopement on 09/01/12 he would have instructed the facility to place Resident #1 on 1:1 staffing and ordered for Resident #1 be sent to a psychiatric hospital for evaluation and then there possibly wouldn't have been the elopement on 09/03/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: 1) All staff in all departments were inserviced by the Assistant Director of Nursing on 09/03/12 and by the Education Director on 09/13/12 related to the following: a. Definition of elopement, revised Elopement Management and Prevention Policies, Missing Resident Action Plan, Head Count Procedures and Care Plan Policy which were revised on 09/13/12; and approved by the QA committee consisting of Administrator, DON, Social Services Director, Activities Director, Maintenance Director, Referral Manager, Business Office Manager, Business Office Assistant and Regional Nurse. b. Alarm procedures/action which included who responds to the alarm, what to do when the alarm sounds, and level of supervision needed. c. All staff reeducated regarding the Elopement Risk Book on 09/13/12 by the Education Director/Department Manager. d. Notify the Charge Nurse immediately of missing or exit seeking resident and the Charge Nurse will immediately notify the Administrator, DON and Nurse Consultant. The Charge Nurse will update the plan of care and update staff verbally and in writing of the increased supervision on the twenty-four (24) hour shift report. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 2) All elopement care plans were reviewed and revised on 09/13/12 by the DON, Administrator, Social Services, and Charge Nurse. All residents were visualized by the DON and Education Nurse on 09/13/12 to identify mode of locomotion and staff interviews were conducted to better determine residents with elopement risk. 3) On 09/13/12, a Quality Assurance Meeting was held to discuss the steps to be taken to prevent further incidents to Resident #1 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 4) License staff will complete the accident/incident report immediately for an elopement attempt or actual elopement and the education was completed by the Department Manager and or the Education Director by 09/14/12. 5) On 09/13/12, the DON and Administrator conducted an elopement drill to evaluate the staff response to alarms sounding. 6) Department Manager monitoring of the facility twenty four/seven (24/7) for ten days beginning 09/13/12 to include at least one random staff interview each shift to determine any resident changes as related to wander risk, monitoring and witnessing wander guard checks for function and placement, visualizing all residents, ensure staff response to door alarms, check function of all doors every shift to ensure all systems are functioning, ensure staff can complete head count properly and timely, Department Manager to complete a daily elopement drill, care plan updates, twenty four (24) hour report sheet completed. Any decrease in Department Manager monitoring will be reviewed by the QA committee after ten days and then weekly for a decrease in monitoring, any issues identified and need for further education. 7) Twenty-four/seven 24/7 front door monitoring beginning at 12 noon on 09/13/12 until door is upgraded and function is verified on 2 shifts. 8) New employees are to be trained on the elopement system upon hire by the Education Director. The Elopement Risk Book will be reviewed during orientation of new staff. The revised elopement policies and procedures were included in the new hire orientation material beginning 09/13/12. 9) All activity care plans reviewed/revised 09/13/12 by the Life Enrichment Director, DON, Social Services, MDS Nurse and Regional Nurse Consultant to ensure activities where in place for all residents and identified residents' individual needs. On 09/20/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/14/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/13/12 based on the following: Review of facility inservice records and attendance logs, dated 09/13/12, revealed staff was educated related to the facility's revise policies and procedures for elopement to include Elopement Management and Prevention, Head Count, Missing Resident, Care Plan Policies and notifications to be made if a resident attempted to exited the building unsupervised. Further review of the inservice records revealed staff received education and training related to responding to the Wander Guard alarms and procedures to be followed which included the completion of the incident report. Record review revealed all resident's elopement care plans had been reviewed and revised on 09/13/12. Review of the facilities QA meeting minutes revealed a meeting was held on 09/13/12 to implement plans of correction to remove the immediate jeopardy. Review of the facility's monitoring log, dated 09/13/12 through 09/19/12, revealed staff had monitored the front door 24/7 until the front door was upgraded. Observation, on 09/18/12 at 3:10 PM, revealed the front door was secured when the Wander Guard was within four (4) feet and the door would not open for fifteen (15) seconds once the bar was pushed. Review of the facility's elopement drill records revealed the DON and Administrator conducted an elopement drill on 09/13/12 to evaluate the staff response to alarms sounding. Further review of the elopement drill records revealed an elopement drill had been conducted daily at varying times and shifts from 09/13/12 though 09/18/12. Observation, on 09/19/12 at 10:15 AM, revealed an elopement drill was conducted by the Administrator. Further observation revealed staff immediately responded to the alarm by a nurse at the nurse's station going to the front door, dietary staff going out the side door and housekeeping going out the back doors and checking the facility property, SRNA's, LPN's and activities doing a head count and checking behind doors and all areas of the facility until the Maintenance Director (who was placed behind a door in a bathroom as a resident) was located. Interview with the Dietary Manager on 09/19/12 at 1:30 PM, Maintenance Director at at 2:15 PM, Assistant Director of Nursing at 3:45 PM and on 09/20/12 at 11:00 AM with the Director of Nursing and the Administrator revealed they had been assigned rotating shifts to include visualizing all residents, ensure staff response to door alarms, care plans were updated, twenty four (24) hour report sheet completed and notifications made. Observation, on 09/18/12 from 04:00 PM until 4:30 PM, revealed there were Elopement Risk Books on both the nursing units including the East and West Nurse's Station, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including RN #4 on 09/19/12 at 12:55 PM, SRNA #8 at 1:00 PM, LPN #3 at 1:05 PM, LPN #6 at 1:15 PM, Dietary Manager at 1:30 PM, SRNA #9 at 1:45 PM, Housekeeper #2 at 2:00 PM, RN #1 at 2:25 PM, LPN #7 at 2:35 PM, LPN #8 at 2:45 PM, LPN #1 at 2:55 PM, SRNA #10 at 3:00 PM, SRNA # 11 at 3:10 PM, and Physical Therapy aide at 3:20 PM, revealed they had received inservice education and were aware of what an elopement was, the Elopement Risk Book and the elopement policy and procedure to include providing staff supervision as well appropriate notifications to be made if a resident attempted to leave the facility unsupervised, including notifying the physician. They were also aware of the procedure in responding to the door alarm to include searching inside and outside the facility. Record review revealed the Activities Director, Social Worker, DON and Regional Nurse Consultant reviewed and revised the activity assessments and activities care plans for all elopement risk residents by 09/13/12. Interview with the DON, Regional Nurse Consultant and Activities Director, on 09/20/12 at 9:20 AM, revealed they met as a group on 09/13/12 and reviewed and revised care plans and activities assessments of residents at risk for elopement to ensure those residents received routine time out side to meet their needs. Further interview revealed all residents care plans and activity assessments were being reviewed and revised. Further interview with the Administrator revealed the current Activities Director would become an Activities Assistant when the Dietary Manager completed the training course approved by the state. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed she had assisted with the changes in the new elopement policies and the policies would be reviewed with each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Review of the facility's revised orientation packet revealed orientation included review of the facility's revised elopement polices and procedures. Interview with the Administrator, DON and Regional Nurse and review of the new Elopement Management and Prevention Policies, on 09/20/12 at 11:00 AM, revealed the policies were updated 09/13/12 to include staff supervision of residents at elopement risk, reviewing and revising individualized care plan interventions to prevent elopement (such as enhanced recreational activities), responding to wander guard alarms, completing incident reports, and notifications to be made when a resident attempts to leave the facility unsupervised, to include notifying the physician. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on interview, record review and review of the facility's policy, it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to have an effective system to ensure supervision to prevent accidents related to residents who were identified at risk for elopement/wandering. The facility's Administration failed to have an effective system to ensure the Physician was notified related to residents who eloped from the facility in order to alter treatment to prevent further elopement; failed to have an effective system to ensure staff was knowledgeable of residents who had eloped from the facility and what measures were put into place to prevent elopement, including activities; failed to have an effective system to ensure staff was trained to adequately respond to the facility's Wander Guard alert system to protect residents who were assessed to be an elopement risk; and, failed to have an effective system to ensure the Comprehensive Plans of Care were revised to include effective interventions and ensure continuous supervision and monitoring to prevent elopement. (Refer to F-157, F-248, F-280 and F-323). On 09/01/12 at approximately 7:30 PM, Resident #1 was left unsupervised by staff on the facility's front porch. Approximately twenty (20) minutes later, Resident #1 was brought back to the facility by two (2) unknown males who stated they found Resident #1 walking in the neighborhood behind the facility approximately 1000 feet from the facility's front door. The facility failed to notify Resident #1's Physician, failed to revise the plan of care, and failed to provide adequate supervision to prevent further elopement. On 09/03/12 sometime between 12:02 PM and 12:05 PM Resident #1 eloped from the facility unsupervised and was located on a sidewalk getting ready to take a step into the roadway of the "housing projects" located behind the facility, approximately 475 feet from the facility's front door. Resident #1 was placed on one to one (1:1) staffing and later sent to a psychiatric hospital for further evaluation. Resident #1 was not in the facility during the survey. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 09/13/12 and determined to exist on 09/01/12. The findings include: Review of the policy the facility utilized as a reference titled "Wandering, Unsafe Resident", revised December 2001, revealed staff would identify residents at risk for harm because of unsafe wandering, including elopement. Further review of the policy revealed interventions to maintain safety would be included in the resident's care plan, nursing would document circumstances related to unsafe actions, staff would initiate a detailed monitoring plan, and notify the Administrator and Director of Nursing immediately and institute appropriate measures when a resident was discovered missing from the facility. Review of the policy the facility utilized as a reference titled "Elopements", revised December 2008, revealed Staff should promptly report any resident who tries to leave the premises to the DON. Further review of the policy revealed when a departing resident returns to the facility the DON or charge nurse should examine the resident for injuries, notify the Physician, complete and Incident/accident report, and document relevant information in the resident' medical record. Resident #1 was assessed by the facility to be moderately cognitively impaired, an elopement risk, and a wander guard device was applied on 06/13/12. On 09/01/12, Resident #1 eloped from the facility without staff knowledge and was gone for approximately twenty minutes. The Director of Nursing (DON) was only notified that Resident #1 had exited the building unsupervised to the front porch and had instructed staff to place Resident #1 on every fifteen (15) minute visual checks. The facility failed to notify the Physician of the incident, failed to revise the plan of care to put new interventions in place to prevent elopement, and failed to ensure all staff were knowledgeable of the incident and of the every fifteen (15) minute checks to prevent further elopement. The facility failed to conduct an investigation related to the elopement to implement adequate interventions to prevent Resident #1 from eloping from the facility again. Although Resident #1 was on every fifteen (15) minute visual checks, Resident #1 eloped from the facility again on 09/03/12 sometime between 12:02 PM and 12:05 PM. Interviews with staff revealed not all staff was aware Resident #1 was on every fifteen (15) minute checks or knowledgeable related to fully responding to the Wander Alarm system sounding. Staff interviews revealed inconsistencies regarding how to accurately monitor, supervise, and respond to residents at risk for or who had a history of [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #7, on 09/13/12 at 9:30 AM, revealed although he was aware Resident #1 was an elopement risk he left Resident #1 on the front porch with some visitors that were "someone's family members" and was not aware that Resident #1 should be continuously monitored and supervised by the facility to prevent elopement. Interview with SRNA #1, on 09/11/12 at 1:10 PM, revealed although she was aware Resident #1 was at risk for elopement and had eloped on 09/01/12, she was unaware he was on every fifteen minute visual checks on 09/01/12 because the nurses "handle that". Interview with SRNA #3, on 09/11/12 at 1:45 PM, revealed she was unaware Resident # 1 had eloped from the facility on 09/01/12 and was unaware he was on every fifteen minute visual checks. Interview with Licensed Practical Nurse (LPN) #4, on 09/13/12 at 7:30 AM, revealed she had been employed at the facility for approximately two months and was unaware of any facility policy related to elopements or that the nurse responsible for providing care to a resident was responsible for ensuring the care plan was revised. Additional interview revealed whomever was close to the door that alarmed should respond immediately and do a quick sweep of the building and was not aware of any head count policy. Interview with Registered Nurse (RN) #1, on 09/13/12 at 8:10 AM, revealed she had been employed at the facility for approximately seven months and was unaware who was responsible for ensuring the care plan was revised to ensure all staff were knowledgeable of new measures. She indicated nurses were responsible for ensuring the fifteen minute checks were completed. An interview with the Assistant Director of Nursing (ADON) on 09/14/12 at 1:25 PM, revealed she was the charge nurse on 09/03/12 and at that time was unaware Resident #1 had eloped from the facility on 09/01/12 and was unaware he/she was on fifteen (15) minute checks. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed prior to the identification of the Immediate Jeopardy, new employees were walked through the building and shown all the doors, given the codes to the doors, shown the elopement books in each department, shown what a Wander Guard was and the need to respond to the alarm and given the different emergency codes, such as "Code Wayne Pink" for elopement. Further interview revealed there was no facility specific policies and procedures discussed related elopement or responding to the alarm to ensure continuous supervision of residents at risk for elopement. Interview with the Administrator, the Director of Nursing and the Corporate Nurse, on 09/13/12 at 10:55 AM and 09/19/12 at 1:15 PM, revealed the facility had changed ownership effective 07/01/12 and the company that owned the facility prior to 07/01/12 took all the facility specific policies. Further interview revealed the new company sent policies and procedures that were not specific to include detailed measures to ensure residents at risk for elopement received continuous supervision and monitoring and care plans were revised to prevent further elopement. Additional interview revealed they had started developing individualized policies and procedures but had not developed any facility specific elopement policies and procedures to ensure continuous monitoring and supervision of residents who were identified to be at risk for elopement. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: 1) All staff in all departments were inserviced by the Assistant Director of Nursing on 09/03/12 and by the Education Director on 09/13/12 related to the following: a. Definition of elopement, revised Elopement Management and Prevention Policies, Missing Resident Action Plan, Head Count Procedures and Care Plan Policy which were revised on 09/13/12; and approved by the QA committee consisting of Administrator, DON, Social Services Director, Activities Director, Maintenance Director, Referral Manager, Business Office Manager, Business Office Assistant and Regional Nurse. b. Alarm procedures/action which included who responds to the alarm, what to do when the alarm sounds, and level of supervision needed. c. All staff reeducated regarding the Elopement Risk Book on 09/13/12 by the Education Director/Department Manager. d. Notify the Charge Nurse immediately of missing or exit seeking resident and the Charge Nurse will immediately notify the Administrator, DON and Nurse Consultant. The Charge Nurse will update the plan of care and update staff verbally and in writing of the increased supervision on the twenty-four (24) hour shift report. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 2) All elopement care plans were reviewed and revised on 09/13/12 by the DON, Administrator, Social Services, and Charge Nurse. All residents were visualized by the DON and Education Nurse on 09/13/12 to identify mode of locomotion and staff interviews were conducted to better determine residents with elopement risk. 3) On 09/13/12, a Quality Assurance Meeting was held to discuss the steps to be taken to prevent further incidents to Resident #1 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 4) License staff will complete the accident/incident report immediately for an elopement attempt or actual elopement and the education was completed by the Department Manager and or the Education Director by 09/14/12. 5) On 09/13/12, the DON and Administrator conducted an elopement drill to evaluate the staff response to alarms sounding. 6) Department Manager monitoring of the facility twenty four/seven (24/7) for ten days beginning 09/13/12 to include at least one random staff interview each shift to determine any resident changes as related to wander risk, monitoring and witnessing wander guard checks for function and placement, visualizing all residents, ensure staff response to door alarms, check function of all doors every shift to ensure all systems are functioning, ensure staff can complete head count properly and timely, Department Manager to complete a daily elopement drill, care plan updates, twenty four (24) hour report sheet completed. Any decrease in Department Manager monitoring will be reviewed by the QA committee after ten days and then weekly for a decrease in monitoring, any issues identified and need for further education. 7) Twenty-four/seven 24/7 front door monitoring beginning at 12 noon on 09/13/12 until door is upgraded and function is verified on 2 shifts. 8) New employees are to be trained on the elopement system upon hire by the Education Director. The Elopement Risk Book will be reviewed during orientation of new staff. The revised elopement policies and procedures were included in the new hire orientation material beginning 09/13/12. 9) All activity care plans reviewed/revised 09/13/12 by the Life Enrichment Director, DON, Social Services, MDS Nurse and Regional Nurse Consultant to ensure activities where in place for all residents and identified residents' individual needs. On 09/20/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/14/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/13/12 based on the following: Review of facility inservice records and attendance logs, dated 09/13/12, revealed staff was educated related to the facility's revise policies and procedures for elopement to include Elopement Management and Prevention, Head Count, Missing Resident, Care Plan Policies and notifications to be made if a resident attempted to exited the building unsupervised. Further review of the inservice records revealed staff received education and training related to responding to the Wander Guard alarms and procedures to be followed which included the completion of the incident report. Record review revealed all resident's elopement care plans had been reviewed and revised on 09/13/12. Review of the facilities QA meeting minutes revealed a meeting was held on 09/13/12 to implement plans of correction to remove the immediate jeopardy. Review of the facility's monitoring log, dated 09/13/12 through 09/19/12, revealed staff had monitored the front door 24/7 until the front door was upgraded. Observation, on 09/18/12 at 3:10 PM, revealed the front door was secured when the Wander Guard was within four (4) feet and the door would not open for fifteen (15) seconds once the bar was pushed. Review of the facility's elopement drill records revealed the DON and Administrator conducted an elopement drill on 09/13/12 to evaluate the staff response to alarms sounding. Further review of the elopement drill records revealed an elopement drill had been conducted daily at varying times and shifts from 09/13/12 though 09/18/12. Observation, on 09/19/12 at 10:15 AM, revealed an elopement drill was conducted by the Administrator. Further observation revealed staff immediately responded to the alarm by a nurse at the nurse's station going to the front door, dietary staff going out the side door and housekeeping going out the back doors and checking the facility property, SRNA's, LPN's and activities doing a head count and checking behind doors and all areas of the facility until the Maintenance Director (who was placed behind a door in a bathroom as a resident) was located. Interview with the Dietary Manager on 09/19/12 at 1:30 PM, Maintenance Director at at 2:15 PM, Assistant Director of Nursing at 3:45 PM and on 09/20/12 at 11:00 AM with the Director of Nursing and the Administrator revealed they had been assigned rotating shifts to include visualizing all residents, ensure staff response to door alarms, care plans were updated, twenty four (24) hour report sheet completed and notifications made. Observation, on 09/18/12 from 04:00 PM until 4:30 PM, revealed there were Elopement Risk Books on both the nursing units including the East and West Nurse's Station, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including RN #4 on 09/19/12 at 12:55 PM, SRNA #8 at 1:00 PM, LPN #3 at 1:05 PM, LPN #6 at 1:15 PM, Dietary Manager at 1:30 PM, SRNA #9 at 1:45 PM, Housekeeper #2 at 2:00 PM, RN #1 at 2:25 PM, LPN #7 at 2:35 PM, LPN #8 at 2:45 PM, LPN #1 at 2:55 PM, SRNA #10 at 3:00 PM, SRNA # 11 at 3:10 PM, and Physical Therapy aide at 3:20 PM, revealed they had received inservice education and were aware of what an elopement was, the Elopement Risk Book and the elopement policy and procedure to include providing staff supervision as well appropriate notifications to be made if a resident attempted to leave the facility unsupervised, including notifying the physician. They were also aware of the procedure in responding to the door alarm to include searching inside and outside the facility. Record review revealed the Activities Director, Social Worker, DON and Regional Nurse Consultant reviewed and revised the activity assessments and activities care plans for all elopement risk residents by 09/13/12. Interview with the DON, Regional Nurse Consultant and Activities Director, on 09/20/12 at 9:20 AM, revealed they met as a group on 09/13/12 and reviewed and revised care plans and activities assessments of residents at risk for elopement to ensure those residents received routine time out side to meet their needs. Further interview revealed all residents care plans and activity assessments were being reviewed and revised. Further interview with the Administrator revealed the current Activities Director would become an Activities Assistant when the Dietary Manager completed the training course approved by the state. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed she had assisted with the changes in the new elopement policies and the policies would be reviewed with each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Review of the facility's revised orientation packet revealed orientation included review of the facility's revised elopement polices and procedures. Interview with the Administrator, DON and Regional Nurse and review of the new Elopement Management and Prevention Policies, on 09/20/12 at 11:00 AM, revealed the policies were updated 09/13/12 to include staff supervision of residents at elopement risk, reviewing and revising individualized care plan interventions to prevent elopement (such as enhanced recreational activities), responding to wander guard alarms, completing incident reports, and notifications to be made when a resident attempts to leave the facility unsupervised, to include notifying the physician. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on interview and record review, it was determined the facility failed to ensure the governing body established and implemented policies regarding the management and operation of the facility. The governing body failed to provide adequate oversight to ensure policy and procedures were implemented to ensure adequate supervision and monitoring to prevent accidents for a resident with a known risk for elopement and a history of leaving the building unsupervised. The facility also failed to ensure policy and procedures were implemented to revise the resident's care plan to address the resident's increased exit seeking behavior, and to ensure physician notification of a resident's condition change and potential need to alter treatment. In addition, the facility failed to ensure staff was trained and knowledgeable on how to adequately monitor and supervise residents at risk for elopement. On 09/01/12, the facility failed to provide continuous supervision of Resident #1, who had been exhibiting exit seeking behaviors, when SRNA #7 left Resident #1 on the front porch unsupervised by staff. Approximately twenty minutes later, Resident #1 was brought back to the facility by two (2) unknown males who told SRNA #7 they found Resident #1 walking in the neighborhood behind the facility. On 09/03/12, Resident #1 eloped from the facility again sometime between 12:02 PM and 12:05 PM. Resident #1 was located on the sidewalk getting ready to take a step onto the roadway of the "housing projects" located behind the facility, approximately 475 feet from the facility's front door. Interviews with staff revealed not all staff was knowledgeable of how to respond to the Wander Guard alarm system sounding. Staff interviews revealed inconsistencies regarding how to accurately supervise and monitor residents at risk for or who had a history of [REDACTED]. Immediate Jeopardy was identified at 42 CFR 483.10 Residents Rights F-157; 42 CFR 483.20 Resident Assessment F-280; 42 CFR 483.25 Quality of Care F-323; and 42 CFR 483.75 Administration F-490. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F-323. The facility's failure to ensure the governing body established and implemented policies regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 09/13/12 and determined to exist on 09/01/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 with the facility alleging removal of the Immediate Jeopardy on 09/14/12. Immediate Jeopardy was verified to be removed on 09/14/12 prior to exiting the facility on 09/20/12 with remaining non-compliance at 42 CFR 483.75 Administration F-493, with a scope and severity of a "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure the governing body implements policies regarding the management and operation of the facility. The findings include: (Refer to F157, F280, F323 and F490) The facility had assessed Resident #1 to enjoy having time out doors but also as having exit seeking behaviors and applied a Wander Guard device on 06/13/12. The facility failed to ensure the plan of care was revised to include interventions to ensure Resident #1 received supervised time out doors to help decrease the resident's exit seeking behaviors. On 07/23/12, Resident #1 continually exited out the front door and was sent to psychiatric hospital due to behaviors and returned to the facility on [DATE]. On 08/28/12 Resident #1 exited the building three (3) times to the facility's front porch unsupervised and was redirected by staff back into the building. The resident's plan of care was revised to include supervised sitting out doors with family and staff. However, the facility failed to ensure the care plan detailed who was responsible to ensure continuous supervision of Resident #1 to prevent elopement and failed to ensure staff was knowledgeable related to the level of supervision required. On 09/01/12, Resident #1 was left outside without staff supervision and eloped from the facility without staff knowledge. Although the Director of Nursing (DON) was notified that Resident #1 had exited the building unsupervised to the front porch and had instructed staff to place Resident #1 on every fifteen (15) minute visual checks, the facility failed to notify the Physician of the incident, failed to revise the plan of care to put new interventions in place to prevent elopement, and failed to ensure all staff were knowledgeable of the incident and the every fifteen (15) minute checks to prevent further elopement. The facility also failed to conduct an investigation related to the elopement to identify and implement adequate interventions to prevent Resident #1 from eloping from the facility again. On 09/03/12, Resident #1 eloped from the facility without staff knowledge. Policy review and interview with the Administrator, the Director of Nursing, and the Corporate Nurse on 09/13/12 at 10:55 AM and on 09/19/12 at 1:15 PM, revealed the facility had changed ownership effective 07/01/12 and the governing body sent policies and procedures that were not specific and they had been instructed to develop policies specific to the facility. Further interview revealed they had started developing some facility specific policies and procedures but had not developed any facility specific elopement policies and procedures to ensure continuous monitoring and supervision of residents who were identified to be at risk for elopement. An interview with The Facility Consultant, on 09/19/12 at 1:25 PM, revealed it varied how often she was at the facility, but she tried to come at least weekly. Further interview revealed she became an employee of the new governing body effective 07/01/12 and was to assist with developing facility specific policies and procedures. She indicated they had developed policies and procedures related to pressure sores and medications, but had not developed facility specific policies and procedures related to elopement, including staff responding to the Wander Guard and ensuring residents received adequate supervision to prevent elopement. During an interview with the Interim Regional Vice President, on 09/20/12 at 10:15 AM, he indicated he was out of Texas and had been to Kentucky several times prior to and since the company took over as governing body on 07/01/12. He stated there had been orientation and trainings held in Lexington and/or at the facility in Springfield on 06/01/12, 06/15/12 though 06/16/12, 07/09/12 through 07/11/12 and 08/28/12 through 08/30/12. Additional interview revealed it was the governing body's philosophy to follow state and federal regulations and that the facility was given a manual of generic policies to use as a reference point in developing facility specific policies and procedures. Continued interview revealed as issues came up or as problems were identified through the Quality Assurance meetings at the facility, policies would be developed. While the Governing Body visited the facility on a routine basis, there was no documented evidence these professionals identified, through their reviews and audits, these quality problems nor was there evidence of action taken to correct the systems failures at the time the survey was initiated. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/17/12 that alleged removal of the IJ effective 09/14/12, based on the following: 1) All staff in all departments were inserviced by the Assistant Director of Nursing on 09/03/12 and by the Education Director on 09/13/12 related to the following: a. Definition of elopement, revised Elopement Management and Prevention Policies, Missing Resident Action Plan, Head Count Procedures and Care Plan Policy which were revised on 09/13/12; and approved by the QA committee consisting of Administrator, DON, Social Services Director, Activities Director, Maintenance Director, Referral Manager, Business Office Manager, Business Office Assistant and Regional Nurse. b. Alarm procedures/action which included who responds to the alarm, what to do when the alarm sounds, and level of supervision needed. c. All staff reeducated regarding the Elopement Risk Book on 09/13/12 by the Education Director/Department Manager. d. Notify the Charge Nurse immediately of missing or exit seeking resident and the Charge Nurse will immediately notify the Administrator, DON and Nurse Consultant. The Charge Nurse will update the plan of care and update staff verbally and in writing of the increased supervision on the twenty-four (24) hour shift report. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 2) All elopement care plans were reviewed and revised on 09/13/12 by the DON, Administrator, Social Services, and Charge Nurse. All residents were visualized by the DON and Education Nurse on 09/13/12 to identify mode of locomotion and staff interviews were conducted to better determine residents with elopement risk. 3) On 09/13/12, a Quality Assurance Meeting was held to discuss the steps to be taken to prevent further incidents to Resident #1 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 4) License staff will complete the accident/incident report immediately for an elopement attempt or actual elopement and the education was completed by the Department Manager and or the Education Director by 09/14/12. 5) On 09/13/12, the DON and Administrator conducted an elopement drill to evaluate the staff response to alarms sounding. 6) Department Manager monitoring of the facility twenty four/seven (24/7) for ten days beginning 09/13/12 to include at least one random staff interview each shift to determine any resident changes as related to wander risk, monitoring and witnessing wander guard checks for function and placement, visualizing all residents, ensure staff response to door alarms, check function of all doors every shift to ensure all systems are functioning, ensure staff can complete head count properly and timely, Department Manager to complete a daily elopement drill, care plan updates, twenty four (24) hour report sheet completed. Any decrease in Department Manager monitoring will be reviewed by the QA committee after ten days and then weekly for a decrease in monitoring, any issues identified and need for further education. 7) Twenty-four/seven 24/7 front door monitoring beginning at 12 noon on 09/13/12 until door is upgraded and function is verified on 2 shifts. 8) New employees are to be trained on the elopement system upon hire by the Education Director. The Elopement Risk Book will be reviewed during orientation of new staff. The revised elopement policies and procedures were included in the new hire orientation material beginning 09/13/12. 9) All activity care plans reviewed/revised 09/13/12 by the Life Enrichment Director, DON, Social Services, MDS Nurse and Regional Nurse Consultant to ensure activities where in place for all residents and identified residents' individual needs. On 09/20/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/14/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/13/12 based on the following: Review of facility inservice records and attendance logs, dated 09/13/12, revealed staff was educated related to the facility's revise policies and procedures for elopement to include Elopement Management and Prevention, Head Count, Missing Resident, Care Plan Policies and notifications to be made if a resident attempted to exited the building unsupervised. Further review of the inservice records revealed staff received education and training related to responding to the Wander Guard alarms and procedures to be followed which included the completion of the incident report. Record review revealed all resident's elopement care plans had been reviewed and revised on 09/13/12. Review of the facilities QA meeting minutes revealed a meeting was held on 09/13/12 to implement plans of correction to remove the immediate jeopardy. Review of the facility's monitoring log, dated 09/13/12 through 09/19/12, revealed staff had monitored the front door 24/7 until the front door was upgraded. Observation, on 09/18/12 at 3:10 PM, revealed the front door was secured when the Wander Guard was within four (4) feet and the door would not open for fifteen (15) seconds once the bar was pushed. Review of the facility's elopement drill records revealed the DON and Administrator conducted an elopement drill on 09/13/12 to evaluate the staff response to alarms sounding. Further review of the elopement drill records revealed an elopement drill had been conducted daily at varying times and shifts from 09/13/12 though 09/18/12. Observation, on 09/19/12 at 10:15 AM, revealed an elopement drill was conducted by the Administrator. Further observation revealed staff immediately responded to the alarm by a nurse at the nurse's station going to the front door, dietary staff going out the side door and housekeeping going out the back doors and checking the facility property, SRNA's, LPN's and activities doing a head count and checking behind doors and all areas of the facility until the Maintenance Director (who was placed behind a door in a bathroom as a resident) was located. Interview with the Dietary Manager on 09/19/12 at 1:30 PM, Maintenance Director at at 2:15 PM, Assistant Director of Nursing at 3:45 PM and on 09/20/12 at 11:00 AM with the Director of Nursing and the Administrator revealed they had been assigned rotating shifts to include visualizing all residents, ensure staff response to door alarms, care plans were updated, twenty four (24) hour report sheet completed and notifications made. Observation, on 09/18/12 from 04:00 PM until 4:30 PM, revealed there were Elopement Risk Books on both the nursing units including the East and West Nurse's Station, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including RN #4 on 09/19/12 at 12:55 PM, SRNA #8 at 1:00 PM, LPN #3 at 1:05 PM, LPN #6 at 1:15 PM, Dietary Manager at 1:30 PM, SRNA #9 at 1:45 PM, Housekeeper #2 at 2:00 PM, RN #1 at 2:25 PM, LPN #7 at 2:35 PM, LPN #8 at 2:45 PM, LPN #1 at 2:55 PM, SRNA #10 at 3:00 PM, SRNA # 11 at 3:10 PM, and Physical Therapy aide at 3:20 PM, revealed they had received inservice education and were aware of what an elopement was, the Elopement Risk Book and the elopement policy and procedure to include providing staff supervision as well appropriate notifications to be made if a resident attempted to leave the facility unsupervised, including notifying the physician. They were also aware of the procedure in responding to the door alarm to include searching inside and outside the facility. Record review revealed the Activities Director, Social Worker, DON and Regional Nurse Consultant reviewed and revised the activity assessments and activities care plans for all elopement risk residents by 09/13/12. Interview with the DON, Regional Nurse Consultant and Activities Director, on 09/20/12 at 9:20 AM, revealed they met as a group on 09/13/12 and reviewed and revised care plans and activities assessments of residents at risk for elopement to ensure those residents received routine time out side to meet their needs. Further interview revealed all residents care plans and activity assessments were being reviewed and revised. Further interview with the Administrator revealed the current Activities Director would become an Activities Assistant when the Dietary Manager completed the training course approved by the state. Interview, on 09/19/12 at 3:25 PM, with the Education Director, revealed she had assisted with the changes in the new elopement policies and the policies would be reviewed with each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Review of the facility's revised orientation packet revealed orientation included review of the facility's revised elopement polices and procedures. Interview with the Administrator, DON and Regional Nurse and review of the new Elopement Management and Prevention Policies, on 09/20/12 at 11:00 AM, revealed the policies were updated 09/13/12 to include staff supervision of residents at elopement risk, reviewing and revising individualized care plan interventions to prevent elopement (such as enhanced recreational activities), responding to wander guard alarms, completing incident reports, and notifications to be made when a resident attempts to leave the facility unsupervised, to include notifying the physician. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).