Every finding on record at Stonebridge Maryland Heights

Based on observation, interview and record review, the facility failed to ensure one resident was provided with adequate supervision and staff oversight when the resident wandered outside and was brought back to their secured housing unit after approximately five to ten minutes of being outside unsupervised (Resident #1). The resident knocked on the door of a different housing unit and was brought back to their unit by a Certified Nursing Assistant (CNA). The sample was 9. The census was 136. The Administrator was notified on 3/26/26 of the past non-compliance. The facility in-serviced nursing staff on alarms and monitoring exits when alarms by the doors are making noise. They were in-serviced on identifying residents at risk of elopement and those who having exit seeking behavior. They were also given mock elopement drills to ensure the facility policy is followed when an alarm goes off or a resident is found to be missing. The deficiency was corrected on 3/25/26. Review of the facility's Elopement Policy, undated, showed:Policy Statement: Staff shall investigate and report all cases of missing resident and the appropriate staff will be notified. The resident will be located in a timely manner that does not disrupt or impede regular routines in all areas of the facility.Policy Interpretation and Implementation:-Reporting Practices: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing.-Resident Leaving the Premises;2. If an employee observes a resident leaving the premises, he/she should:-Attempt to prevent the departure in a courteous manner;-Get help from other staff members in the immediate vicinity, if necessary; and-Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises.-Procedure for Locating a Missing Resident: 3. Should a staff member become concerned with the possibility that a resident may be missing, complete the following steps:-Conduct a thorough search of the entire unit. Do not panic; be certain to check all rooms, restrooms, closets, etc.;-If unable to locate resident, notify the Nursing Home charge nurse;-The nursing home charge nurse will announce overhead, All units check your exits;-On duty staff will then thoroughly search areas within their scheduled assignment; including vacant rooms, restrooms, closets, etc.;-Staff will report a head count for their assigned area to the nursing home charge nurse. Head count for facility will be completed; Staff will inform the charge nurse of any residents who have signed out of the facility;-If the resident is located, the charge nurse will announce overhead, All exitsare clear;-If the search is unsuccessful, the nursing home charge nurse will notify the Administrator and Director Of Nursing (DON) immediately. If they are unavailable, then the on-call nurse will be notified;-The charge nurse will then assign staff to search the outside and surrounding grounds;-The Administrator or DON will make a decision to notify the police department with a physical description of the resident;-The Missouri Department of Health and Senior Services will be contacted within two hours if the resident is not located.4.Nursing Service Duties Upon Return of Resident Who Was Observed Leaving the Facility: When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall:-Examine the resident for injuries;-Notify the Attending Physician;-Notify the resident's legal representative (sponsor) of the incident; -Complete and file an Incident Report. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/25/26, showed the following:-Severe cognitive impairment;- Wandering - Presence & Frequency: Has the resident wandered? - Behavior of this type occurred 1 to 3 days;- Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected; - Wander/elopement alarm: Not used;-Diagnoses include Alzheimer's disease, Non-Alzheimer's Dementia, insomnia. Review of the resident's care plan, initiated 3/1/26, showed:-Focus: Elopement risk/wanderer;-Goal: Will not leave facility unattended through the review date;-Interventions: Monitor when resident is pacing to ensure he/she is not attempting to exit seek, Every 15 minute checks due to attempting to get out of the building, Wander guard on right ankle every shift, 1:1 from 7pm-7am due to attempting to try to exit building. Review of the resident's elopement evaluation, dated, 3/18/26, included:Complete for residents who ambulate independently with or without the use of an assistive device or wheelchair.Does the Resident have a history of elopement or an attempted elopement while at home? No;Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes;Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Yes;Does the Resident wander? Yes;Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.)? Yes; Does the Resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings)? Yes;Is the Resident's wandering behavior likely to affect the safety or well-being of self / others? No;Is the Resident's wandering behavior likely to affect the privacy of others? No;Has the Resident been recently admitted or re-admitted (within past 30 days) and is not accepting the situation? No Review of the resident's elopement evaluation, dated, 3/20/26, included: Complete for residents who ambulate independently with or without the use of an assistive device or wheelchair.Does the Resident have a history of elopement or an attempted elopement while at home? Yes;Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes;Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? No;Does the Resident wander? Yes;Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.)? No; Does the Resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings)? Yes;Is the Resident's wandering behavior likely to affect the safety or well-being of self / others? No;Is the Resident's wandering behavior likely to affect the privacy of others? Yes;Has the Resident been recently admitted or re-admitted (within past 30 days) and is not accepting the situation? No Review of the resident's medical record showed:-A progress note, dated 3/18/26 at 10:56 A.M., No exit seeking behaviors noted this shift. Res slept most of the night;-A progress note, dated 3/19/26 at 3:35 P.M., Resident remains on frequent monitoring due to continued exit seeking behaviors. Wander guard in place and functioning properly. Will continue to monitor;-A progress note, dated 3/20/26 at 12:34 A.M., Resident increased agitation unable to redirect see new order one time prn dose and psych eval request for psych services to evaluate and treatment as needed;-A progress note, dated 3/20/26 at 11:57 A.M., New order for Haldol (used to treat psychosis or agitation) injection 5mg/ml. Inject 1ml intramuscularly (deliver medication into the muscle) one time for agitation.-A progress note, dated 3/20/26 at 12:39 P.M., It was reported to this nurse that on 3/18 at around 6-6:30am, resident seen outside of the building. He/She was noticed by another aide who took safety of the resident and brought him/her back in the house where he/she lives. The nurse was also notified and immediately assessed the resident. Head to toe performed with no anomalies noted. Neuro checks were within normal limits with no changes from previous level of functioning. Performed a follow-up head to toes on the resident, no complaint of pain or distress. Due to poor memory, reasoning and understanding, he/she cannot give an account of what happened. Call placed to family member, made aware of what happened. Call placed to MD, aware of what took place as well. Updated interventions put in place;-A progress note, dated 3/20/26 at 5:54 P.M., Resident follow up following Elopement. Resident remained in tv area majority of shift beside meals which took place in dining area. Resident had no elopement attempt this shift. Resident will now be 1on1 during 7p-7a shift. Will continue to monitor;-A progress note, dated 3/21/26 at 9:01 P.M., Observation continues this shift, secondary to Elopement Precaution Monitoring. Resident in TV area, with assigned 1 on 1 staff;-A progress note, dated 3/22/26 at 7:40 P.M., Resident follow up following Elopement and frequent monitoring. Resident remained in tv area majority of shift beside meals which took place in dining area. Resident had no elopement attempt this shift;-A progress note, dated 3/22/26 at 11:31 P.M., Res up and awake at this time. Ambulating the unit, wandering aimlessly about. Denies pain/discomforts at this time. No distress noted. No exit seeking at this time;-A progress note, dated 3/23/26 at 1:12 P.M., Interviews with staff concludes that resident is up most nights moving around or he/she sits in the common area during hours of sleep. Spoke with his/her family member, and he/she stated the resident also did this at home and he/she is okay with him/her going on Melatonin as he/she would give it to him/her at home. Call made to MD and new order obtained for Melatonin 3mg po at HS. Family member aware of how much he/she's being started on;-A progress note, dated 3/23/26 at 6:12 P.M., Resident on frequent monitoring for exit-seeking behaviors. Noted attempting to wander toward exits, redirected as needed. No distress noted. Safety measures in place. Will continue to monitor;-A progress note, dated 3/23/26 at 6:14P.M., Resident continues to exit seek was able to redirect behaviors to other activities. Resident remains calm at this time. Will continue to monitor;-A progress note, dated 3/25/26 at 8:50 P.M., Frequent checks remain in place no exit seeking noted;-A progress note, dated 3/26/26 at 6:08 A.M., Observation precautions continued this shift, with 1;1 oversight adhered. Resident quietly resting during night shift. Review of the facility's investigation showed: Incident: Resident #1 lives in Cypress. He/She has diagnosis in part that includes Alzheimer's Disease and Unspecified Dementia. He/She has times where he/she wanders aimlessly, is on elopement precautions, and has a wander guard in place.It was reported to the DON on the morning of 03/20/2026 that on 03/19/2026, Resident #1 had been outside of his/her living unit in Cypress. An investigation was initiated and staff interviews were conducted. The following was revealed:- Upon interview, CNA B on duty 3/18/2026 into 3/19/2026 reported that he/she was in a resident's room giving care and heard the door alarm sounding on twice during this time. The first time Resident #1 and another resident, with a history of wandering, were observed by Resident #1 at the door when CNA B came out of the room. The CNA redirected both residents away from the door, assisted them to the sitting area, provided diversion, and returned to assisting the other residents. This was approximately 5:30 A.M. CNA B further stated that approximately 15 minutes later, at 5:45 am, the door alarm sounded again and this time only the other wandering resident was standing at the door, so he/she assumed that the resident had set the alarm off. CNA B assisted that resident from the door and turned off the key alarm to stop the sound. CNA B's rationale was, he/she did not look outside of the door since the other resident had been at the door earlier and had been redirected. Per CNA C on duty 3/18/2026-3/19/2026 in Magnolia House, he/she had observed Resident #1 outside of Magnolia, knocking on the door at approximately 6:00 A.M. on the morning of 3/19/2026. CNA C said the resident was fully dressed. The CNA had escorted the resident back to Cypress and informed the CNAs in Cypress and his/her charge nurse in Magnolia. CNA B states that he/she reported the incident to the charge nurse, Licensed Practical Nurse (LPN) D. Per CNA E, he/she witnessed CNA C walking with Resident #1 into Cypress around 6:00 A.M. LPN D reports that he/she received a call from the nurse working in Magnolia, LPN F that CNA C was bringing Resident #1 back to Cypress because the resident was seen knocking at the door at Magnolia. LPN D, the night shift charge nurse on duty for Cypress, said that when he/she received the call from LPN F, he/she was in [NAME] across from Cypress. LPN F then went into Cypress. Upon arrival, Resident #1 was sitting on the couch, fully dressed, watching TV. Conclusion of Findings:Resident #1 had been wandering throughout the night, had been redirected, and was placed on frequent checks. Despite these efforts he/she wandered from his/her building and down the courtyard to Magnolia. He/She knocked on the door and was observed at the door by staff and redirected back to his/her unit. The resident was fully clothed and was within the confines of the secured campus. After questioning staff and reviewing statements, it appears that the timeframe could be narrowed down to less than 15 minutes from the last sounding of the door alarm, the resident walking over to Magnolia, knocking on the door, waiting to be let in and then being escorted back to Aspen by staff. It further appears that at no time was he/she in harm's way by exposure to elements or dangers of being off site due to the gated, secured community. There were no failures in our electronic monitoring systems. All alarms functioned properly. Staff responded timely to each instance. Although it was reasonable to assume the resident standing at the door had set off the alarm, the most reasonable expectation would have been to check outdoor parameters as an added precaution. Summary of interventions to prevent recurrence: -The nurse performed a head-to-toe assessment on Resident #1 with no injuries or distress noted. Due to his/her cognition and lack of understanding, the resident is unable to give an account of the incident.-The resident's adult child and physician were notified.-He/She remains on 15-minute checks and has been placed on 1:1 for the night shift until further notice. -ln-Servicing immediately initiated on staff responding to door alarms. Specifically, to include checking outdoor parameters, reporting, when to notify the charge nurse, residents who wander and are at risk of elopement.-The exit doors were checked throughout the facility and the wander guard alarm at the exits of the Manors were assessed for proper functioning along with all wander guard alarm bracelets.-The door alarms will be checked daily x 7 days and then weekly.-The resident had a medication review and Melatonin (medication to help with sleep) has been ordered for bedtime due to him/her having increased restlessness at night.-An Elopement drill was performed in Cypress on 03/24/2026 and will continue twice weekly until compliance is assured. Re-education will be provided as needed-The nurse that failed to document and report the incident per facility policy and procedure in a timely manner has received re-education and disciplinary action. During an interview on 3/26/26 at 12:50 P.M., the DON said if the CNA had just walked outside when he/she heard the alarm, then he/she would have seen Resident #1. The resident had not been known to get out before. She would have expected them to go to the door that was sounding the alarm. The search started at the door. She would have expected them to check outside. If someone was really exit seeking, she expected staff to call and let them know. She would not have expected them to turn off the alarm and not check. It was never appropriate to ignore an alarm. CNA B did assume it was the other resident by the door that set the alarm off. The CNA should have walked outside to see if anyone had walked out. They in-serviced everyone and did mock elopement drills where they stood outside the doors to ensure they checked outside too. During an interview on 3/26/26 at 12:04 P.M., CNA B said that night shift, the resident kept sounding the alarm. He/She was exit seeking the entire shift. CNA B was providing care and heard the alarm. Around 5:45 A.M., CNA B heard the alarm and went to check and then turned the alarm off. Due to the behavior overnight, CNA B thought Resident #1 had just gotten to close again and sounded the alarm. He/She did not think the resident actually got out. CNA E was providing showers at the time of the incident. CNA B said the nurse was in the other building. CNA B said around 6:00 A.M., CNA C brought the resident back. The resident does wear a wander guard but did not believe it was a different alarm. The keypad went off. CNA B said he/she should have checked outside. They have done in-services and completed mock drills since the incident. CNA B said it was hard to hear alarms when in resident rooms providing care. During an interview on 3/26/26 at 3:56 P.M., CNA E said he/she worked the night of the incident. Around 4:00 A.M., Resident #1 started exit seeking and trying to press the door. CNA B redirected the resident twice. The resident was calm. CNA B sat the resident on the couch in the main area. Around 5:30 A.M., they started to do rounds to get everyone ready for the day. The CNA was in the shower room with a resident who screamed a lot so he/she did not hear any alarm between the shower and the resident. CNA E said he/she did not know the resident got out until CNA C brought the resident back and notified the nurse. CNA E is not sure who turned the alarm off. He/She does not believe the resident was outside for more than 5-10 minutes. Since the incident, they have done mock drills and in-servicing. CNA E believes this was the first time the resident has actually gotten out of the building. If CNA E had heard the alarm, he/she would have checked outside and then done a head count. During an interview on 3/26/26 at 12:43 P.M., LPN D said the night of the incident he/she was the nurse for Cypress and [NAME]. He/She was in [NAME] providing care when Resident #1 was returned. The last time he/she had last seen the resident at 12:00 A.M. and was told the resident had been trying to get out all night. When LPN D saw the resident, he/she was not trying to get outside. From LPN D's understanding both CNA's were in rooms providing care when the alarm went off. CNA B heard the alarm, turned it off, then did not check on Resident #1. LPN D believed the resident had gotten out recently about a month ago and they had the resident on 15 minute checks. The staff has been in-serviced on elopement and mock drills have been done. The nurse would have expected staff to make sure the resident they were providing care to was safe and then go check on the alarm. The alarm could be heard in resident rooms. There were two different alarms. One for the wander guard and then one when the door was opened. During an interview on 3/26/26 at 2:30 P.M., the Administrator and DON said they would expect staff to follow policy. It was not appropriate for staff to ignore any alarm. They would expect staff to respond, go outside and check, do a head count. If someone was missing, then call the supervisor. During an interview on 3/27/26 at 6:30 P.M., CNA C said he/she was in the front of his/her building when he/she saw Resident #1 stand at the door. The resident was dressed. CNA C recognized the resident and brought him/her back to Cypress then notified the charge nurse for both buildings. He/She was not sure why the staff did not hear the alarm. He/She was not sure if Resident #1 had gotten out before this incident. CNA C believes it was around 6:00 A.M. when the resident was outside. CNA C said if an alarm was going off, then they were supposed to check outside and then do a head count. 2964555

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one resident (Resident #1), per facility policy when the resident experienced a hypoglycemic episode and became unresponsive. The resident experienced a second hypoglycemic episode on the following shift, required life saving measures, and was sent out to the hospital urgently. The sample size was 8. The facility census was 141.Review of the facility's Change in a Resident's Condition or Status policy, dated [DATE], showed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Review of facility's Diabetes Clinical Protocol policy, dated [DATE], showed:- Risk of hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. It may be necessary to accept somewhat higher blood sugars in order to minimize the risk of hypoglycemia;-The physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved;-As indicated, the physician will order appropriate labs test and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes;-The physician will order desired parameters for monitoring and reporting information related to blood sugar management;-The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management. For example, urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for two or more days and has fever, hypotension, lethargy or confusion.-The physician will help the staff clarify and respond to these episodes.Review of Resident #1 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed diagnoses included dementia and diabetes. Moderately impaired cognition. Review of resident's care plan, in use during the survey, showed:-Focus: Resident has diabetes.-Goal: Resident will have no complication is related to diabetes through the review date.-Interventions: Diabetes medication as ordered by doctor. Monitor/document for effectiveness. Fasting blood sugar as ordered by doctor. Review of the resident's electronic physician order sheet, showed:-An order dated [DATE], for Glucagon (an emergency medication kit used to raise blood sugar very quickly in someone with severe hypoglycemia) injection, inject 1 milligram (mg) subcutaneously (under the skin) as needed for hypoglycemia. May give 2nd dose if no response after 15 minutes;-An order dated [DATE], for Glimepiride (medication to treat diabetes, lowers the blood sugar by simulating the pancreas to release more insulin) 2 mg, one tablet a day;-An order dated [DATE], for Humalog (short acting insulin) pen, inject as per sliding scale: if 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 10 units; 351-400 = 12 units; 401-450 = 14 units; 451 - 500 = 16 units call MD if over 500, subcutaneously one time a day related to diabetes with unspecified complications;-An order dated [DATE], for insulin glargine (Lantus, long acting insulin), inject 20 unit subcutaneously one time a day for diabetes with unspecified complications. Review of resident's electronic Medication Administration Record (eMar) medication administration notes, showed:-On [DATE] at 7:26 A.M., Glucagon injection kit. Inject 1mg subcutaneously as needed for hypoglycemia. May give second dose if no response after 15 minutes: Resident's blood sugar is 40 (a blood sugar below 54 is considered severe hypoglycemia, a condition that requires immediate help from another person to treat and can lead to unconsciousness);-On [DATE] at 8:27 A.M., Glucagon injection kit. Inject 1mg subcutaneously as needed for hypoglycemia. May give second dose if no response after 15 minutes: Blood sugar was 67, 5 minutes after administration, orange juice given and blood sugar was 127 (normal range), 15 minutes afterward. Will continue to monitor. PRN (as needed) administration was effective. Review of resident's progress notes, showed on [DATE] at 3:20 A.M., the Registered Nurse (RN) C found the resident face down on the floor in his/her room, hardly breathing, foaming at the mouth and unresponsive. 911 was called and cardiopulmonary resuscitation (CPR) was started. When paramedics arrived, they took the resident's blood sugar and administered D10 (dextrose and water mixture given in the vein (IV) to correct hypoglycemia). Review of the resident's hospital medical record, dated [DATE], showed:-Blood sugar problem: Reading was 27, patient given D5 in route. Blood sugar was ten 88. Per EMS, the call was originally for cardiac arrest;-Resident brought in by EMS from skilled nursing facility after episode of unresponsiveness, found down;-Diagnosis: Hypoglycemia. During an interview on [DATE] at 10:18 A.M., a representative with the emergency medical services company who responded to the 911 call, said when they arrived on scene, the resident's blood sugar was low and they treated it. During an interview on [DATE] at 11:40 A.M., Licensed Practical Nurse (LPN) A said during his/her shift on [DATE] at around 7:30 A.M., he/she found the resident was not responding at all, so he/she checked the resident's blood sugar level. It was 40. He/She administered glucagon and re-checked it later and it was normal. The resident was fine the rest of the day, so he/she did not have to check it again after that. He/She made sure the resident got up and had breakfast because he/she knows glucagon only lasts for a little bit and the resident needed to eat so his/her blood sugar did not drop again. LPN A believed he/she had to call the physician to get the order for glucagon, but he/she could not say for sure. He/She believed he/she wrote the change of condition down on the shift change report. During an interview on [DATE] at 1:35 P.M., Physician Representative E said no one from the facility reached out to Physician B's office on [DATE] for any reason for this resident. The facility did not notify the physician's staff of the resident's change in condition until [DATE] at 3:51 A.M. During an interview on [DATE] at 1:50 P.M., the RN C said he/she was not made aware the resident had a prior blood sugar of 40 the morning of [DATE]. During an interview on [DATE] at 2:37 P.M., Family Member D said when Emergency Medical Services (EMS) arrived to the facility, they had to do CPR and resuscitated the resident. His/Her blood sugar was 27 at that time. During an interview on [DATE] at 11:04 A.M., Physician B said he/she would have expected the facility to call him in the morning of [DATE] when the resident experienced the low blood sugar level and became unresponsive. If he/she had been made aware he/she would have had the facility hold the Lantus for a day or two, along with holding all the resident's oral diabetes medication on [DATE]. He would have also increased the blood sugar check from once a day to twice a day for the next couple of days. During an interview on [DATE] at 2:20 P.M., the Director of Nursing said she would expect staff to follow the facility's policies and protocols. 2665394

Based on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation, for four out of six medication carts reviewed. This had the potential to affect all residents with orders for controlled substances. The census was 150.Review of the facility's Controlled Substances policy, revised 2016, showed:-Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (substances with a high potential for abuse and addiction but also have accepted medical use in treatments) and other controlled substances;-Policy Interpretation and Implementation:-Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises;-The Director of Nursing Services will identify staff members who are authorized to handle controlled substances;-Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents;-Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together;-They must document and report any discrepancies to the Director of Nursing Services;-The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings;-The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further action is indicated. Review of the facility's Administering Medications policy, revised 2012, showed:-Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed;-Policy Interpretation and Implementation:-Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so;-The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions;-Medications must be administered in accordance with the orders, including any required time frame;-Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the facility's Narcotic Reconciliation Revised 8/19/2025, showed:-The narcotic count must be done by both on-coming and off-going licensed nurse/Certified Medication Technician (CMT).-The on-coming employee will be handling the actual bubble cards to be counted;-The off-going employee will handle the actual narcotic book;-The number of cards will be counted and verified first. All items must be visibly checked (Check for refrigerated items);-All liquid narcotics MUST be poured into a 30 cc (cubic centimeters) medication cup to be measured for accuracy. After you get the correct number, pour it back into the original bottle;-The employee with the book will begin the count by calling out the name of the resident, drug and how many pills remain on the card; -It is always wise for the employee with the bubble cards to look at the sheet to ensure that the correct number is being called out;-Once the narcotics are all counted and verified, both employees must sign the reconciliation sheet under the appropriate date NO EXCEPTIONS!!!!!!!!!;-The off-going nurse will then hand the keys over to the on­coming employee.-If there is a discrepancy with the count, the Director of Nursing (DON) and management MUST BE CALLED IMMEDIATELY;-The on-coming employee does not have to accept the keys until further directives are given, and discrepancies are cleared;-Keys must stay with the nurse/CMT at all times, or under double locks, DO NOT PLACE KEYS IN THE DRAWERS; -Always report issues and concerns dealing with narcotics to management;-Failure to follow policy and procedure narcotics will result in termination and possible jail time and reporting to Missouri Board of Nursing. 1. Review of Aspen's narcotic book count sheets, dated August 2025, showed:-16 out of 37 shifts had no nurse or CMT signature on the shift change count;-37 out of 37 shifts failed to count the controlled substances cards and/or boxes. 2. Review of Magnolia's narcotic book count sheets, dated August 2025, showed:-Seven out of 37 shifts had no nurse or CMT signature on the shift change count;-29 out of 37 shifts failed to count the controlled medications cards and/or boxes. 3. Review of Cypress' narcotic book count sheets, dated August 2025, showed:-10 out of 37 shifts had no nurse or CMT signature on the shift change count;-35 out of 37 shifts failed to count controlled substance cards and/or boxes. 4. Review of Hawthorn's narcotic book count sheets, dated August 2025, showed:-Three out of 37 shifts had no nurse or CMT signature on the shift change count;-12 out of 37 shifts failed to count controlled substances cards and/or boxes. 5. During an interview on 8/19/25 at 7:15 A.M., Listened Practical Nurse (LPN) A said he/she was aware the facility was missing narcotics. He/She didn't really know anything about it. He/She knew narcotics should be counted shift to shift. All controlled medications should be kept in the locked medication cart. The nurses should keep the keys on them at all times. The CMT's were allowed to pass controlled substances in pill form but not in liquid form. Each building had a narcotic count sheet; staff were expected to count each card and document how many pills were on the card. Staff accounted for liquid controlled medication by looking at how much was left in the bottle. Sometimes the count might get missed because there was only one nurse for four buildings. CMTs were allowed to do the count. 6. During an interview on 8/19/25 at 8:25 A.M., The DON said she was alerted on 8/14/25, that three cards of controlled substances were missing from the [NAME] building. During the course of her investigation, she identified staff were not appropriately counting controlled substances shift to shift. Staff were leaving their keys in accessible areas and were just eyeballing the count for liquid controlled substances. She had not yet completed an audit of the other building and/or wings. 7. During an interview on 8/20/25 at 7:25 A.M., LPN B said, controlled substances should be counted shift to shift. The facility operated with 12 hours shifts. The oncoming nurse or CMT should count with the off going nurse or CMT. Each pill should be accounted for along with the number of cards in the locked medication cart. Controlled liquid medications were accounted for by looking at the bottle. Staff did not pour out liquid medications when they counted. There was supposed to be two licensed nurses between the four buildings. Most of the time there was one nurse and two CMTs. There were times only one nurse was available to pass medications for all four buildings. 8. During an interview on 8/20/25, Registered Nurse (RN) C said nurses should count controlled medications every shift. He/She didn't know who was responsible for making sure the counts were being done. He/She was aware medications came up missing from the [NAME] building. He/She was not involved with the investigation. 9. During an interview on 8/20/25 at 11:15 A.M. LPN C said he/she was aware controlled substances should be counted shift to shift. The count should include the number of pills on each card, the number of cards and the number of bottles. Liquid controlled substances were not poured out and measured during the count. He/She was aware of the missing narcotics. He/She did not know what happened to the medications. He/She was the only nurse working the evening shift the day the medications came up missing. LPN C had left the keys to the medication cart in the drawer behind the nurse's station. It was common practice to leave the keys for one building in the building when he/she was in another building. He/She understood that he/she should have never left the keys unattended. He/She counted the medications when he/she came on duty at 7:00 P.M. with the day shift nurse. LPN C could not remember if he/she counted all the cards thoroughly in each building. He/She had been in serviced to not leave the keys unattended and how to do a thorough controlled substance count. He/She had never poured out a liquid controlled substance to account for the exact amount of liquid in the bottle. Sometimes the count wasn't done because only one person was available for all four buildings. 10. During an interview on 8/20/25 at 11:30 A.M., LPN D said, licensed nurses and/or CMTs should count controlled substances when they came on duty and when they went off duty. He/She tried to make sure the controlled substances were counted each day he/she came in and left work. Each building had its own narcotic account book. Each resident had an individual count sheet and then there was a sheet to document how many cards and/or bottles of controlled substances were in each building. He/She had never poured a liquid controlled substance from the bottle into a measuring cup to assure the count was accurate. He/She was aware of the missing controlled substances from [NAME]. He/She worked the morning shift the day prior to the medications going missing. He/She counted the medications at the end of his/her shift. 11. During an interview on 8/20/25 at 2:30 P.M., the Administrator and DON said they were unaware staff were not always counting the controlled medications shift to shift. They were unaware staff routinely left the medication cart keys unattended in the nurse's station. They were unaware staff were not accounting for liquid medications by pouring it into a measuring cup to assure accuracy. Controlled medications should be counted shift to shift by the on-coming and off-going nurse or CMT. The documentation in the narcotics books should be complete and accurate.

Based on interview and record review, the facility failed to meet professional standards when staff failed to administer and document medications as ordered by the physician for six of seven sampled residents (Residents #6, #2, #4, #5, #3 and #1). The census was 150. Review of the facility's Administering Medications policy, revised 2012, showed:-Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed;-Policy Interpretation and Implementation: -Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so; -The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications must be administered in accordance with the orders, including any required time frame; -Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of Resident #6's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:-Cognitive impairment;-Diagnoses included cancer and Alzheimer's disease;-Dependent with activities of daily living (ADLs);-No prognosis of life expectancy of less than 6 months; -Received antianxiety medications daily;-Received hospice services. Review of the resident's care plan, revised on [DATE], showed the following:-Problem: Chemotherapy related to right neoplasm of the breast (cancer);-Intervention: Administer medications and treatments as ordered; Monitor/document for side effects and effectiveness;-Problem: Hospice services-end of life care;-Intervention: Give medications as ordered. Review of the resident's physician's orders dated for [DATE], showed an order, dated [DATE], for lorazepam (antianxiety) oral concentrate 2 milligram (mg) per milliliter (ml), give 0.25 ml by mouth every 4 hours related to malignant neoplasm of right breast.Review of the resident's [DATE] medication administration record (MAR), for lorazepam 0.25 ml every 4 hours showed:-[DATE], administered at 4:00 P.M. and 10:00 P.M.;-[DATE], no missed doses;-[DATE], not administered as ordered at 4:00 P.M. and 10:00 P.M.;-[DATE] not administered as ordered at 12:00 A.M. and 4:00 A.M.;-[DATE], no missed doses;-[DATE], not administered as ordered at 4:00 P.M. Review of the resident's individual controlled substance record for lorazepam 2 mg/ml, showed staff did not sign out the medications on:-[DATE], at 4:00 P.M. or at 10:00 P.M.;-[DATE], at 4:00 A.M. or at 10:00 P.M.;-[DATE], at 4:00 A.M, 8:00 A.M., 12:00 P.M. 4:00 P.M. or at 10:00 P.M.;-[DATE], at 12:00 A.M., 4:00 A.M., or at 10:00 P.M;-[DATE], at 4:00 A.M.;-[DATE], at 4:00 P.M. Observation of the resident's controlled medications on [DATE] at 9:30 A.M., showed the resident had one bottle of liquid lorazepam 2 mg/ml, delivered to the facility on [DATE] with 30 ml. The bottle contained 28 ml of unused liquid. Review of the resident's physician's orders dated [DATE], showed an order dated [DATE], for Morphine Sulfate concentrate solution (for moderate to severe pain), 100 mg per 5ml. Give 0.25 ml, by mouth every four hours related to Alzheimer's disease. Review of the resident's [DATE] MAR, showed morphine sulfate 0.25 ml every four hours left blank on:-[DATE] at 4:00 P.M. and 10:00 P.M.;-[DATE] at 12:00 A.M. and 4:00 A.M.;-[DATE] at 4:00 P.M. Review of the resident's individual controlled substance record for morphine sulfate 0.25 every four hours, showed no documentation staff signed out or administered the medication on:-[DATE] at 4:00 A.M. or 10:00 P.M.;-[DATE] at 4:00 A.M, 8:00 A.M., 12:00 P.M., 4:00P.M. or 10:00 P.M.;-[DATE] at 12:00 A.M., 4:00 A.M., or 10:00 P.M.;-[DATE] at 4:00 A.M., or 8:00 A.M.;-[DATE] at 4:00 P.M. Observation of the resident's controlled medications on [DATE] at 9:30 A.M., showed the resident had one bottle of liquid morphine sulfate solution 100 mg/5 ml, delivered to the facility on [DATE] with 30 ml. The bottle had 28 ml of unused liquid. Review of the resident's progress note dated [DATE], showed he/she expired at 6:20 P.M. 2. Review of Resident #2's admission MDS, dated 7/20125, showed the following:-Cognitive impairment;-No behaviors;-Partial/moderate assistance with ADLs;-Diagnoses of cancer and dementia;-On scheduled pain regimen;-Opioids daily;-Received hospice care. Review of the resident's care plan, dated [DATE], showed the following:-Problem: Hospice services-End of life care;-Intervention: Give medications as ordered for comfort and air hunger (a distressing sensation of suffocation or breathlessness) as needed. Review of the resident's physician's orders for [DATE], showed an order for hydrocodone-acetaminophen (hydro/apap, given for moderate to severe pain) 325 mg oral tablets, one tablet three times per day related to neoplasm related to pain. Review of the resident's [DATE] MAR, showed the following:-Hydro/apap 5/325 mg, one tablet three times per day at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 12:00 P.M. and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -Not available on [DATE] at 8:00 A.M., 12:00 P.M., and 6:00 P.M. Review of the resident's individual controlled substance record on [DATE], for [DATE] showed:-On [DATE], the pharmacy delivered 45 hydro/apap 5-325 mg to the facility (one card with 30 pills and one card with 15 pills);-No documentation the hydro/apap 5/325 mg was administered from [DATE] at 8:00 A.M., until [DATE] at 8:00 A.M.;-No documentation the medication was administered after [DATE] at 5:00 P.M;-The count sheet for 30 pills showed no pill had been administered indicating 30 pills should have remained on one individual card;-The count sheet for the 15 pills showed three doses accounted for, with 12 pills remaining. Observation on [DATE] at 9:35 A.M., showed the resident had no hydro/apap 5/325 mg tablets available in the controlled substance locked box. There were 42 unaccounted pills. Review of the resident's progress notes, dated from [DATE] through [DATE], showed no documentation of the resident's missing medications and/or whether the missing doses of medication had been administered to the resident from the facility's emergency medication stock (STAT kit). During an interview on [DATE] at 9:45 A.M., the resident said he/she had some pain in his/her big toe. He/She thinks he/she is getting his/her medications. He/She would not know if staff did not provide his/her medications as ordered. He/She is on hospice and has cancer. 3. Review of Resident #4's care plan, revised on [DATE], showed the following:-Problem: Uses psychotropic medications for his/her moods;-Interventions: Administer medications as ordered;-Care plan did not address hospice services and/or opioid use. Review of resident's significant change in status MDS, dated [DATE], showed the following:-Cognitive impairment;-Diagnosis included Alzheimer's disease;-Dependent with ADLs;-No prognosis of life expectancy of less than 6 months; -Received opioid medications daily;-Received hospice services. Review of the resident's physician's orders, dated, [DATE], showed an order for lorazepam oral concentrate 2 mg per ml, give 0.25 ml by mouth three times a day for clinical management related to anxiety. Review of the resident's [DATE] MAR, showed lorazepam give 0.25 ml three times a day: -[DATE] at 1:00 P.M., not administered;-[DATE], not administered at 1:00 P.M. and 5:00 P.M.;-[DATE], 5:00 P.M., not administered. Review of the resident's individual controlled substance record on [DATE], for lorazepam 2 mg/ml showed:-[DATE], no doses were documented as administered at 5:00 P.M.;-[DATE], no doses were documented as administered at 1:P.M. or 5:00 P.M.;-[DATE], no doses were documented as administered at 9:00 A.M., 1:00 P.M. or 5:00 P.M.; -8/7, 8/8, [DATE], no doses documented as administered at 9:00 A.M., 1:00 P.M. or 5:00 P.M.;-8/11, 8/12, 8/13, 8/14, [DATE], no doses documented as administered at 9:00 A.M., 1:00 P.M., or 5:00 P.M.;-[DATE], no doses were documented as administered at 12:00 A.M., 4:00 A.M., or 10:00 P.M;-[DATE], no doses documented as administered at 5:00 P.M. Observation on [DATE] at 9:30 A.M., showed, the resident had one bottle of liquid lorazepam 2 mg/ml, with a delivery date to the facility of [DATE] with 30 ml. The bottle contained 20 ml of unused liquid. Review of the resident's [DATE] physician's orders showed an order dated [DATE], for morphine sulfate concentrate solution 100 mg per 5ml. Give 0.25 ml by mouth every four hours for pain. Review of the residents [DATE] MAR, showed:-Morphine sulfate 0.25 ml every four hours left blank on:-[DATE], at 12:00 A.M., 4:00 A.M, 8:00 A.M., and 12:00 P.M.;-[DATE], at 4:00 A.M., and 8:00 P.M.;-[DATE], at 8:00 P.M.;-[DATE], at 12:00 P.M. and 8:00 P.M.;-[DATE], at 4:00 P.M. and 8:00 P.M.;-[DATE], at 12:00 A.M. and 4:00 A.M.;-[DATE], at 4:00 P.M. and 8:00 P.M. Review of the resident's individual controlled substance record on [DATE], for morphine sulfate 0.25 ml, showed no documentation the medication was administered on-[DATE], at 4:00 A.M., 4:00 P.M., or 8:00 P.M.;-[DATE], at 12:00 A.M., 4:00a A.M., 8:00 A.M. or 4:00 P.M.; -[DATE], at 8:00 A.M., 12:00 P.M., or 8:00 P.M.;-[DATE], at 8:00 A.M.;-[DATE], at 8:00 P.M.;-[DATE], at 12:00 A.M., 4:00 A.M., 4:00 P.M., or 8:00 P.M.;-[DATE], at 8:00 A.M., 12:00 P.M. or 4:00 P.M.; -[DATE], at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M, or 4:00 P.M.; -[DATE], at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00P.M., 4:00 P.M.;-[DATE], at 8:00 A.M., 12:00 P.M., 4:00 P.M., or 8:00 P.M.;-[DATE], at 8:00 A.M., 12:00 P.M., 4:00 P.M., or 8:00 P.M.;-[DATE], at 8:00 A.M., 12:00 P.M., 4:00 P.M., or 8:00 P.M.;-[DATE], at 4:00 P.M. or 8:00 P.M.;-[DATE], at 12:00 A.M., 4:00 A.M., or at 8:00 P.M.;-[DATE], at 4:00 P.M., or 8:00 P.M. Observation on [DATE] at 9:30 A.M., showed, the resident had one bottle of liquid morphine sulfate solution 100 mg/5 ml, delivered to the facility on [DATE] with 30 ml. The bottle contained 27.5 ml of unused liquid. Observation and interview on [DATE] at 8:30 A.M., showed the resident sat in the dining room. Staff assisted the resident with breakfast meal. The resident would make eye contact but only nodded his/her head when asked any questions. The resident smiled and said okay to every question asked. He/She was appropriately dressed and did not appear to be in any physical pain. 4. Review of Resident #5's annual MDS dated [DATE], showed the following:-Cognitive impairment;-Diagnoses included dementia, high blood pressure and depression;-Dependent with ADLs;-No prognosis of life expectancy of less than 6 months; -Received antianxiety medications daily;-Receives hospice services. Review of the resident's care plan, revised on [DATE], showed the following:-Problem: Hospice services-end of life care;-Intervention: Give lorazepam for anxiety and notify hospice if it does not provide relief from anxiety. Review of the resident's physician's orders for [DATE], showed an order for lorazepam concentrate 2mg/ml, give 0.5 ml (1mg) two times per day. Review of the resident's [DATE] MAR, showed lorazepam 0.50 ml (1 mg) was not documented as administered on:-[DATE] at 4:00 P.M.;-[DATE] at 4:00 P.M. Review of the resident's individual controlled substance record on [DATE] for lorazepam 2 mg/ml, give 0.50 ml twice a day, showed no documentation staff administered the medication on:-[DATE] at 8:00 A.M. or 4:00 P.M.;-[DATE] at 4:00 P.M.;-[DATE] at 4:00 P.M.;-[DATE] through [DATE], at 8:00 A.M., or 4:00 P.M.;-[DATE] at 4:00 P.M.;-[DATE] at 4:00 P.M.;-[DATE] at 4:00 P.M.;-[DATE] at 8:00 A.M. or 4:00 P.M.;-[DATE] at 4:00 P.M. Observation on [DATE] at 9:30 A.M., of the resident's liquid lorazepam 2 mg/ml, showed:-One bottle delivered to the facility on [DATE] with 30 ml. The bottle contained 28 ml of unused liquid;-One bottle delivered to the facility on [DATE] with 30 ml. The bottle was still sealed with 30 ml of fluid in the bottle. Observation and interview on [DATE], at 8:40 A.M., showed the resident ambulated aimlessly in the hall. He/She was alert but unable to answer questions in regard to pain and/or anxiety. 5. Review of Resident #3's care plan, revised on [DATE], showed the following:-Problem: Malignant neoplasm of the prostate;-Intervention: Treat pain per orders;-Problem: Hospice services-end of life care;-Intervention: Pain medications as ordered. Review of the resident's quarterly MDS dated [DATE], showed the following:-Cognitive impairment;-Diagnoses included cancer, high blood pressure and Alzheimer's disease;-Required substantial assistance with ADLs;-Life expectancy of less than 6 months; -Scheduled pain regimen;-No opioids administered daily;-Receives hospice services. Review resident's physician's orders for [DATE], showed an order dated [DATE] for oxycodone (used for moderate to severe pain) 5 mg three times daily. Review of the resident's [DATE] MAR, showed oxycodone 5 mg was not documented as administered on:-[DATE] at 6:00 A.M., 2:00 P.M. or 10:00 P.M.;-[DATE] at 10:00 P.M.;-[DATE] at 10:00 P.M.; -[DATE] at 10:00 P.M.;-[DATE] at 10:00 P.M. Review on [DATE] of the resident's individual controlled substance record dated [DATE] for oxycodone 5 mg three times a day, showed:-On [DATE], the pharmacy sent a card with 30 pills;-No documentation staff administered the medications on: -[DATE] at 6:00 A.M., 2:00 P.M. or 10:00 P.M.; -[DATE] at 2:00 P.M; -On [DATE] staff documented administering 0.5 (no dose specified) at 12:00 A.M. and 4:00 A.M., and one pill at 6:00 A.M. 14 pills remained on the card;-No additional documentation regarding the remaining 14 pills; -On [DATE], the pharmacy sent a card of 15 oxycodone 5 mg pills;-No documentation staff administered the medication as ordered on [DATE] at 2:00 P.M;-On [DATE], there were 9 remaining pills on the card Review of the resident's progress notes, dated [DATE] through [DATE], showed no documentation regarding the resident's missing medications and/or whether the missing doses of medication had been administered to the resident from the facility's STAT kit. Observation on [DATE] at 9:30 A.M., showed the resident had one card of oxycodone, dated [DATE], with nine remaining pills. Observation and interview on [DATE], at 8:40 A.M., showed the resident seated in the dining room area waiting for breakfast. He/She denied pain and/or could not remember if staff provided his/her mediations as ordered. 6. Review of Resident #1's quarterly MDS dated [DATE], showed the following:-Cognitive impairment;-Diagnoses included dementia, high blood pressure and depression;-Dependent with ADLs;-No behaviors;-No rejection of care. Review of the resident's care plan, revised on [DATE], showed the following:-Problem: Potential for pain related to altered skin integrity;-Intervention: Give medications as ordered for pain. Review of the resident's physician's orders for [DATE], showed an order for pregabalin capsules (used to treat nerve pain) 75 mg two times per day. Review of the resident's [DATE] MAR showed staff documented pregabalin capsules 75 mg administered twice daily. Review of the resident's individual controlled substance record for pregabalin capsules 75 mg showed:-On [DATE], the pharmacy delivered two cards of 30 capsules for a total of 60 capsules;-No documentation staff signed out the medications on: -[DATE] at 5:00 P.M.; -[DATE] at 5:00 P.M.; Observation on [DATE] at 9:30 A.M. of the resident's medication, showed the resident had one card of pregabalin with 22 capsules remaining. Observation and interview on [DATE], at 8:40 A.M., showed the resident sat in a chair in the TV room. He/She was alert but unable to answer questions. He/She denied pain and was not able to say if he/she received his/her medications from staff as ordered. 7. During interviews on [DATE] at 9:30 A.M. and [DATE] at 2:30 P.M., the Director of Nursing said she expected staff to give all medications as ordered. Staff should never sign a medication as administered if it had not been given. The individual controlled substance records were the true and accurate count of if/when controlled medication had been administered. 2591516

Based on observation, interview, and record review, the facility failed to provide counseling due to no payor source for two of six residents (Resident (R) 65 and R113) sampled for mental and psychosocial health out of a total sample of 33 residents. R65 was not provided counseling when suicidal ideations were expressed and R113 was not provided supportive services following the unexpected death of her husband who was her roommate in the facility due to being Medicaid pending. The failure to provide counseling resulted in psychosocial harm to both R65 and R113. Findings include: 1.Review of the Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R65 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness/paralysis) following cerebral infarction (stroke) affecting the left dominant side, depression, and anxiety disorder. Review of the significant change Minimum Data Set (MDS), located under the RAI tab in the EMR, with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R65 was cognitively intact. Review of the Care Plan, located under the RAI tab in the EMR, updated [DATE], revealed that R65 was prescribed an antidepressant every day. The goal was noted as to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Approaches were listed as Monitor/document/report to MD [physician] prn [as needed] ongoing s/sx [signs/symptoms] of depression unaltered by antidepressant meds [medications]: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Review of the Clinical Physician Orders, located under the Orders tab in the EMR revealed R65 was prescribed Zoloft 200 mg (milligrams), on [DATE], for depression; and Bupropion HCl ER(XL) tablet extended release 24 Hour 150 mg, on [DATE], for depression. Review of the Nursing Notes located under the Progress Notes tab in the EMR revealed R65 was transferred to the hospital on [DATE] for statements of wanting to die; on [DATE] for suicidal post home visit; and on [DATE] for suicide ideals, after calling the suicide hotline for help. During an observation and interview on [DATE] at 10:31 AM, R65 stated, The worst thing is I don't have any insurance, I get told we can't offer that [counseling] and we're working on it, because I'm Medicaid pending. I have depression, they don't understand, they just say oh well, you have meds. When asked did the Social Service staff provide services, R65 stated, the facility Social Worker [SW] doesn't talk with me, doesn't know what to do about it, she's not equipped. Review of the Psychiatric Notes located under the Miscellaneous tab in the EMR revealed an initial psychiatric encounter on [DATE] which noted a medication reconciliation and follow up for medication management. The [DATE] note read seen for medication management. On [DATE], R65 was seen for follow up medication management, reports I don't want to be here, no changes to medications, staff to call 911 in case of emergency if patient is in imminent danger to self or others. No further psychiatric notes were located addressing the [DATE], [DATE], or [DATE] hospital visits. Further review of the Care Plan for antidepressant use revealed no new interventions added after R65's verbalizations of suicidal thoughts. During an interview on [DATE] at 3:47 PM, the Social Service Designee (SSDE) stated, [R65] gets upset a lot, once Medicaid kicks in she can have a counselor. We'll find someone that she can go see. When asked what medically related social services were being provided to R65 while in a pending financial situation, the SSDE said, I talk to her every day, but I'm not a counselor. When asked if she monitored the specified signs/symptoms identified on R65's care plan and if there was documentation to show the monitoring and/or interventions provided, the SSDE stated, I guess not. During an interview on [DATE] at 4:20 PM, the Administrator stated, We provide whatever they need, it doesn't matter what the payment source is. The Administrator did not state why medically related social services had not been provided to R65 while she awaited her Medicaid status. When asked for a policy to address provision of services during a pending financial status, the Administrator stated, We don't have a policy for that. 28306 2.Review of R113's undated Face Sheet located under the Profile tab in the EMR revealed R113 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation and glaucoma. Review of R113's quarterly MDS located under the MDS tab in the EMR with an ARD of [DATE] revealed R133 was coded as having a BIMS score of 15 out of 15 indicating that R113 was cognitively intact. During an interview on [DATE] at 2:35 PM, R113 stated, My husband got sick after he ate nachos and some dip with beans in it last Wednesday night. He started coughing and got sick. They gave him something for nausea and he went to sleep. I heard him sound kind of funny and I called the staff. The nurse came in and told me he was barely breathing and called 911. 911 came and started CPR [Cardiopulmonary Resuscitation] and he did not make it. He was my life. And now he is gone. I do not want to live anymore. I pray that I will die in my sleep each night. R113 was asked if anyone had come into to talk to her about the grieving process or have the Psychiatrist and or Psychologist talk to her since her husband had passed. The resident stated, No. Asked if the MD (Medical Doctor) or the NP (Nurse Practitioner) had come to see her since her husband had passed and she stated, No one has come in. The social worker came in briefly and talked to me about clothes for my husband to be laid in and if I wanted to have him cremated or not. Other than that, no one has talked to me . While speaking with R113, the resident was crying, appeared anxious and visibly upset and stated, I was this close to him, and I couldn't do anything to help him. Review of R113's Care Plan located under the Care Plan tab in the EMR revealed no documentation of a care plan for grieving the loss of R113's husband. During an interview on [DATE] at 9:40 AM, the Assistant Director of Nursing (ADON)1 stated, I go in and make rounds and ask her [R113] if she [R113] is doing ok, is there anything I can do for her, then she will become tearful. I have asked her [R113] if she wants me to reach out to psych [Psychiatrist] to get her an antidepressant. [R113] told me that she was already on antidepressant and did not want another one. I really don't chart that part. ADON1 was asked why she does not chart it, and ADON1 stated, It slipped my mind, I get busy with my managerial duties but if the resident has unusual behaviors, then I will document that. During an interview on [DATE] at 1:30 PM, the surveyor shared with the Social Services Designee (SSDE) of R113 stating on [DATE] that she (R113) does not want to live without her husband, and she prays nightly that she wants to die in her sleep. The SSDE stated, I am not a counselor, I just go in and ask her how she is doing and visit with her. Asked if R113 had been referred to counseling, psychiatrist, or psychologist services for the grieving of the loss of R113's husband and the SSDE stated, She [R113] hasn't been referred yet. Her [R113's] Medicaid is not approved yet and I do not know if they have heard anything yet or not. I can't schedule a consultation until the Medicaid is approved. During an interview on [DATE] at 2:22 PM, the Social Services Director (SSD) was asked how she monitors the SSDE's job performance. The SSD stated, I usually check to make sure her documentation is what she is doing. The SSD was notified of R113 losing her husband that was her (R113's) roommate in the facility. R113 has verbalized that she does not want to live anymore, and she (R113) prays nightly that she wants to die in her sleep. The SSD stated, I didn't know that. During an interview on [DATE] at 5:00 PM, the Administrator was notified of R113 stating she does not want to live anymore, and she (R113) prays nightly that she wants to die in her sleep. The Administrator was asked if a consultation to either counseling services or to the psychiatrist/psychologist could be made for R113 even though the resident does not have Medicaid approved yet. The Administrator stated, Most certainly we can make these consults [consultations] if the resident is in need of them. We do not have to wait until her [R113's] Medicaid is approved to do that. The Administrator was notified of no consultations had been made thus far since R113's husband passed away on [DATE] or R113 not having a care plan addressing grief and the loss of R113's husband on [DATE].

Based on observations, interviews, and facility policy review, the facility failed to ensure food stored in the main kitchen was labeled, dated, and disposed upon expiration. These failures had the potential to increase the prevalence and spread of foodborne illnesses for 140 of the 142 facility residents. Findings include: Review of the facility policy dated September 2022 titled Food Safety Requirements indicated the facility should label, date, and monitor refrigerated food so it is used by its use-by-date. Open foods should be covered or in tight sealed containers. During an observation of the kitchen on 01/27/25 at 10:00 AM the following opened items were observed and verified by the Dietary Manager (DM) in the kitchen reach-in refrigerator: One container of unidentified white sauce with no label or date or discard date. One quart of Thick and Easy orange juice with no date. Instructions on the bottle indicated the product was to be used within 10 days of opening. Opened package of hot dogs with no date. The package was opened and left uncovered. An opened gallon of milk with no open or use by date One bag of thawed Harvest blend mixed vegetable with no date. One bag of Oriental blend mixed vegetables with no date. A bag of six hard boiled eggs with no date. A whole ham in plastic bag with no date. A plastic bag of sliced ham with no date. A gallon jar of sweet pickle relish with no open date or use by date. A plastic bag of lunch meat with no date. Twenty-three cartons of milk with an expiration date of 01/23/25. An observation of the kitchen walk-in refrigerator revealed 32 cartons of milk with an expiration date of 01/26/25. During an interview with the DM on 01/27/25 at 10:33 AM she stated that the weekend staff should have been responsible for labeling and making sure there were no outdated items in the refrigerators. The DM stated she expects all dietary staff to be aware of the food storage policy and follow it.

Based on interview, record review, and policy review, the facility failed to monitor the use of antibiotics for three of three residents (Resident (R)86, R81, and R102) reviewed for antibiotic stewardship of a total sample of 33 residents. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised 11/2024, revealed . Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program . During an interview on 01/29/25 at 3:55 PM, the Infection Preventionist (IP) was asked to provide the facility's documentation of the antibiotic stewardship program from 01/01/24 through 12/31/24. The IP provided documentation dated 07/01/24 through 12/31/24. The IP confirmed that when she began as the IP, she was provided the facility's Infection Control Log and confirmed the log did not contain the required start and end date of the administered antibiotics, or the met/not met criteria for administration. The IP confirmed antibiotic usage should be tracked with use and outcome criteria applied. She also stated she was aware that numerous residents did not meet the criteria for antibiotic usage and that she had discussed the issue with the facility medical director. She could not provide documentation of her report of discussion with the medical director. During an interview on 01/29/25 at 4:40 PM, the Corporate Nurse stated she could not provide documentation that supported adherence to their antibiotic stewardship policy for Resident (R)81, R86, and R102. Infection surveillance checklists (MGeers Criteria) were provided for R86, R81, and R102 but were incomplete.

Based on observation, interview, and review of the Dietary Manager's (DM) job description, the facility failed to provide palatable meals for four of four residents (Residents (R) 56, R9, R54, and R107) who complained their meals were not appetizing out of a total sample of 33 residents. This failure increased the risk of residents not being satisfied with their meals. Findings include: During an interview on [DATE] at 11:48 AM R56 stated that the food was horrible. R56 stated that she keeps food in her room so she can have something to eat when the meal tastes bad. The meal observation on [DATE] at 5:10 PM revealed patty melt, French fries, vegetable soup, chicken dumpling soup and a mixed fruit cup was served to residents. During an observation on [DATE] at 5:55 PM, R9 was observed licking the bread. R9 stated that she could not eat the sandwich because the bread was tough and soggy. R9 was observed to drink the soup and leave the table without finishing the meal. During an observation on [DATE] at 6:10 PM, R54 was observed throwing his sandwich off his plate. R54 was observed to eat a few French fries and leave the table. When asked why he did not eat his meal he responded that the meal tasted bad so why bother to eat it? During an interview on [DATE] at 6:15 PM, R107 stated the meal could not be eaten. R107 stated the bread, and the meat was tough, and the bread was soggy. R107 stated that even the alternate which was grilled cheese was not worth ordering because it was the same soggy bread with cheese. A test tray was requested on [DATE] at 1:03 PM. The menu listed the lunch as baked ham, scalloped potatoes, candied carrots, pie of the day, dinner roll with margarine. The Dietary Manager (DM) verified the temperature of the items on the plate. The temperature of the ham was 80 degrees Fahrenheit (F), the temperature of the potatoes was 85 degrees F, and the temperature of the carrots was 81 degrees F. There was no dinner roll and no pie with the meal. Upon sampling the food items the ham was dry and could not be chewed easily, the carrots had no seasoning and no glaze, and the potatoes were dry. The DM could not explain why there was no seasoning, or any margarine provided with the meal. The DM stated that they have condiments in the kitchen and did not know why the meal tray did not have any condiments. A review of the DM Job Description dated [DATE] indicated that the DM was responsible to inspect the meals to ensure the meals meet the standards for appearance, and palatability. MO00244432 MO00245053 MO00246536

Based on observations, interview, and facility policy review, the facility failed to ensure menus were followed and food preferences were honored for four residents (Resident (R)5, R65, R56, and R107) reviewed out of a total sample of 33 residents. The failure placed 140 of the 142 residents in the facility at risk of nutritional problems and dissatisfaction with their meals. Findings include: Review of the facility policy dated October 2017 titled Menus indicated the menus would be followed and provide a variety of foods and be approved by the Registered Dietitian (RD). Review of the facility policy dated October 2017 titled Food and Nutrition Services Staffing indicates the facility must take into consideration the preferences of each individual. Review of the week one menu provided to the survey team indicated that on 01/27/25 the lunch meal would be spaghetti with meat sauce, Italian tossed salad, brownie, and breadstick. An observation of the meal at 11:55 AM revealed the resident received peas and carrots in place of the salad, a slice of white bread in place of the bread stick and oranges in place of the brownie. Review of the week one dinner menu for 01/27/25 indicated that the residents would receive Beef and Bean Burrito with cheese sauce, Fiesta corn salad and fruit salad. An observation of the dinner meal at 5:45 PM revealed the residents received chicken tenders, peas and carrots, French fries, and animal crackers. 1. Review of the Face Sheet, located under the Profile tab in the electronic medical record (EMR) revealed R5 was initially admitted on [DATE] with diagnoses that included anxiety disorder, chronic pain, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R5 was cognitively intact. During an observation and interview on 01/27/25 at 1:08 PM, R5 had just received her lunch. R5 stated, I eat all my meals in my room. I'm more comfortable here. Observation of R5's diet card noted the resident disliked pork and was to receive juice with each meal. R5 stated, I don't dislike pork, I really enjoy pork, I just don't like pork breakfast sausages or patties. I've tried to get that changed but can't. I gave up. What I really want them to put on is coffee with breakfast. I ask every day, and they tell me they didn't send any up. Seems like it's been going on for [AGE] years. My kids bring me coffee sometimes in the evening when they visit so I make it last for a few days. R5's breakfast trays were observed on the following dates: 01/28/25 at 9:59 AM, no coffee served 01/29/25 at 10:11 AM, no coffee served, received two pork breakfast patties that R5 did not eat 01/30/25 at 10:02 AM, coffee was provided after asking the Certified Nursing Assistant (CNA2) During an interview on 01/28/25 at 10:05 AM, CNA5 stated, They don't usually send [R5] coffee. I can't always go get it. During an interview on 01/29/25 at 10:29 AM, R5 stated she did not get coffee again and was drinking leftover coffee her family brought her two days ago. 2. Review of the Face Sheet, located under the Profile tab in the EMR revealed R65 was admitted on [DATE] with diagnoses that included myocardial infarction type 2, hemiparesis and hemiplegia following cerebral infarction affecting the left dominant side, and diabetes mellitus. Review of the significant change MDS, located under the RAI tab in the EMR, with and ARD of 11/05/24 revealed a BIMS of 15 out of 15 which indicated R65 was cognitively intact. During an interview on 01/28/25 at 9:59 AM, R65 stated there was no coffee served to her. During an observation and interview on 01/28/25 at 10:31 AM, R65 stated, The food is terrible, tastes terrible, it's not food for a young person, they serve hot dogs a lot on white bread, no ketchup or mustard, just dry, always serve the same thing. 3. During an interview on 01/28/25 at 10:12 AM, R56 stated that it was impossible to get coffee when requested. She stated they only have one pot in the dining room, and it runs out all the time and there is not anyone to make more. R56 stated she now keeps coffee in her room because that is the only way to get any. During a continued interview on 01/28/25 at 10:12 AM, R56 stated that the meals never match the menus and there is never an alternative to choose from. R56 stated that they were served chicken strips at dinner which was not even close to the menu posted. R56 stated that they received peas and carrots twice in one day and they are often served leftover food. 4. During an interview on 01/28/25 at 10:49 AM, R107 stated that they are given a flat piece of bread for a hot dog bun. R107 stated that they also never get condiments like mustard, ketchup, and relish. R107 stated he has never received butter or jelly with his meals and when he asks, he is told they do not have them. R107 stated that it makes him feel like a child and becomes very frustrating. During an interview on 01/29/25 at 1:40 PM, the Dietary Manager (DM) stated that staff are not supposed to change the menu without telling the residents. The DM had no explanation as to why the correct menu was not served. During an interview on 01/29/25 at 1:55 PM, the RD stated that staff should not be changing the menu. The RD stated that staff should be planning the menu far enough ahead so that they would know they can make the menu and get any approval for appropriate substitutions. MO00244432 MO00245053 MO00246536

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of five errors occurred out of 33 opportunities for error due to residents not receiving their medications that were ordered and one medication not being the ordered strength, for one resident (Resident (R)50) of five residents observed for medication administration. The facility medication error rate was 15.15%. This failure had the potential to affect the accurate dosing of medication administered to the residents. Findings include: During medication administration observation on 01/29/25 at 8:37AM, Certified Medical Technician (CMT)3, administered/applied a four percent lidocaine patch to R50's right knee. Review of R50's Physician Orders dated May 31, 2024, in the electronic medical record (EMR) under the Orders tab indicated the physician's order was for a five percent lidocaine patch to R50's right knee. Further review of the Physician's Orders reveled physician orders for Fexofenadine HCl Tablet 60 MG BID (twice a day), Spironolactone 25mg QD (every day), Artificial Tears 1.4% 1 drop both eyes TID (three times a day), and Gabapentin 100mg TID (three times a day), all were due during the morning medication administration, but not given. These medications were initialed and signed off as given. Review of R50's Progress Notes dated 01/29/25 in the (EMR) under the Progress Notes tab, revealed no notes indicating a change in the strength of the lidocaine patch or the omission of above medications. Interview on 01/29/25 at 3:00 PM, CMT3 was asked about the five percent lidocaine patch, she stated the insurance won't pay for the five percent lidocaine patches, so they use the four percent patches. When CMT3 was asked about the medications Fexofenadine HCl Tablet 60 MG BID, Spironolactone 25mg QD, Artificial Tears 1.4% 1 drop both eyes TID, and Gabapentin 100mg TID, not being given, she stated I guess it slipped my mind, until later. I did let the Director of Nurses [DON] know about my error. Interview on 01/29/25 at 4:15 PM, the DON was asked about CMT3 using four percent lidocaine patches instead of five percent lidocaine patches, she stated Well I heard about that this morning, I'm not sure why the correct patches weren't ordered, probably just a simple mistake. She was asked about the medications CMT3 did not give during the morning medication pass, she stated I also heard about that this morning, CMT3 overlooked those medications, but was too nervous to say anything once she realized her mistake. Review of the facility policy Administering Medications undated, stated, The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document appropriately in the clinical chart .

Based on interviews and record review, the facility failed to provide an ongoing program of resident preferred activities three residents (Resident (R)27, R93, and R137) reviewed for activities in sample size of 33 residents. This failure placed R27, R93 and R137 at risk for increased feelings of isolation, depression, helplessness, and boredom. Findings include: 1. Review of R27's Resident Face Sheet located in the Resident tab, in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnosis to include but not limited to unspecified psychosis, anxiety disorder, chronic obstructive pulmonary disorder, restless legs syndrome, schizoaffective disorder, and insomnia. Review of R27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/24 and located in the Resident Assessment Instrument (RAI) tab of the EMR, revealed she scored 14 of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact. The MDS did not indicate preferences for daily activities. Review of R27's Care Plan dated 10/15/23 and located in the RAI tab of the EMR, revealed her activity preferences were watching television and some music with request to be offered and assisted to activities. Activity attendance logs of participation were requested but were not provided during the survey. During an interview with R27 on 01/29/25 at 10:47 AM, she stated they don't have activities here. All they do is color, they bring me a page to color, but I don't like to color. She stated no one came to visit her in her room to talk about activities and personal interests. 2. Review of R93's Resident Face Sheetlocated in the Resident tab, of the EMR revealed she was admitted to the facility on [DATE] with diagnosis to include but not limited to unspecified dementia, peripheral vascular disease, and osteoarthritis. Review of R93's annual MDS with an (ARD) of 01/01/25 and located in the Resident Assessment Instrument (RAI) tab of the EMR, revealed she scored 13 of 15 on the BIMS which indicated she was cognitively intact. The MDS did not indicate a staff assessment of her daily activity preferences. Review of R93's Care Plan dated 10/06/23 and located in the RAI tab of the EMR, revealed her activity preferences were attending group activities of her choice that included bingo, trivia, movies, nail/hair care, socials, talking with peers, and independent catholic studies. The care plan indicated staff would invite and encourage her to attend her favorite activities. Activity attendance logs of participation were requested but were not provided during the survey. During an interview with R93 on 01/29/25 at 11:23 AM, she stated they don't have activities here because no one invites me to anything. R93 stated she enjoyed the activities when she was first admitted to the facility, but it had been a long time since she had talked to anyone about things to do around here. 3. Review of R137's Resident Face Sheet located in the Resident tab, of the EMR revealed she was admitted to the facility on [DATE] with diagnosis to include but not limited to unspecified dementia, depression, and anxiety disorder. Review of R137's quarterly MDS with an ARD of 11/24/24 and located in the Resident Assessment Instrument (RAI) tab of the EMR, revealed she scored 11 of 15 on the Brief Interview for Mental Status (BIMS) which suggested she was cognitively intact. The MDS did not indicate a staff assessment of her daily activity preferences. Review of R137's Care Plan dated 09/09/24 and located in the RAI tab of the EMR, revealed her activity preferences were attending two group activities of her choice The care plan also indicated staff would invite and encourage her to attend her favorite activities and would talk with her to record her prior level of activity involvement and interests. Activity attendance logs of participation were requested but were not provided during the survey. During an interview with R137 on 01/29/25 at 11:49 AM, she stated she did not know of any activities in the facility. She said more than anything, she would love to go outside for some fresh air. During an interview with the Administrator on 01/29/25 at 10:32 AM, she stated her activity director resigned on 01/13/25 and she had not yet found another qualified activity director for the facility. She said the Certified Nursing Assistants (CNA) were helping out the activity assistant (AA) with the activity program, but she could not provide a current activity calendar or documentation of resident attendance and participation logs for the six months prior to the survey.

Based on record review, staff interviews, review of Centers for Medicare and Medicaid Services (CMS) website, and policy review, the facility failed to issue the appropriate notice for termination of Medicare part A benefits for three (Resident (R)92, R1, and R49) residents reviewed for beneficiary notification out of a total sample of 33 residents. These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the residents'/representative's wishes. Findings include: Review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 accessed at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf on 06/04/24 revealed, The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Unless otherwise instructed to do so according to the specific guidance provided in these instructions, the notifier must not decide for the beneficiary which of the 3 checkboxes to select . If the beneficiary cannot or will not make a choice, the notice should be annotated, for example: beneficiary refused to choose an option. Review of the facility's policy Advanced Beneficiary Notices dated December 2018 and provided by the facility stated, . A liability notice shall be issued to Medicare beneficiaries and will explain: i. An item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary . A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending . 1. Review of R92's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R92 was readmitted to the facility on [DATE] with the diagnosis of heart failure, diabetes mellitus, and hypertension. Review of R92's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/25/24 coded R92 was having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that R92 was cognitively intact. Review of R92's Notice of Medicare Non-Coverage (NOMNC), dated 09/11/24 and provided on paper, revealed R92's last covered day (LCD) of Medicare Part A services was 09/13/24. The Skilled Services in which would not be covered after 09/13/24 did not specifically tell the resident which therapy would be discontinued. Review of R92's Advanced Beneficiary Notice of Noncoverage (ABN) dated 09/11/24 and provided on paper, revealed the notice was signed by the resident; however, no option was checked to indicate whether R92 wanted skilled services to be continued with responsibility for payment, skilled services to be discontinued, or skilled services to continue with an appeal to Medicare for further coverage. On this form was also noted to be left blank were the areas of Reason Why Medicare Will Not Pay and the Estimated Cost of the skilled service if the resident wishes to pay out of pocket for this service to continue. 2. Review of R1's updated Face Sheet located under the Profile tab in the EMR, revealed R1 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus, and congestive heart failure. Review of R1's quarterly MDS located under the MDS tab in the EMR with an ARD of 12/01/24 revealed R1 was coded as having a BIMS score of 14 out of 15 indicating R1 was cognitively intact. Review of R1's NOMNC, dated 01/10/25 and provided on paper, revealed R1's LCD of Medicare Part A services was 01/13/25. The Skilled Services in which they would not be covered after 01/10/25 did not specifically tell the residents which therapy would be discontinued. Review of R1's ABN dated 0/10/25 and provided on paper, revealed the notice was signed by the resident; however, no option was checked to indicate whether R92 wanted skilled services to be continued with responsibility for payment, skilled services to be discontinued, or skilled services to continue with an appeal to Medicare for further coverage. On this form was also noted to be left blank were the areas of Reason Why Medicare Will Not Pay and the Estimated Cost of the skilled service if the resident wishes to pay out of pocket for this service to continue. 3. Review of R49's undated Face Sheet located under the Profile tab in the EMR revealed R49 was readmitted to the facility on [DATE] with the diagnosis of heart failure, and renal failure. Review of R49's quarterly MDS located under the MDS tab in the EMR with an ARD of 01/05/25 revealed R49 was coded as having a BIMS score of seven out of 15 indicating R49 was moderately cognitively impaired. Review of 49's NOMNC, dated 11/08/24 and provided on paper, revealed R49's LCD of Medicare Part A services was 11/10/24. The Skilled Services in which would not be covered after 01/10/25 did not specifically tell the resident/representative which therapy would be discontinued. Review of R49's ABN dated 11/08/24 and provided on paper, revealed the notice was verbally consented by the resident representative; however, no option was checked to indicate whether R49 wanted skilled services to be continued with responsibility for payment, skilled services to be discontinued, or skilled services to continue with an appeal to Medicare for further coverage. On this form was also noted to be left blank were the areas of Reason Why Medicare Will Not Pay and the Estimated Cost of the skilled service if the resident wishes to pay out of pocket for this service to continue. During an interview on 01/30/25 at 3:00 PM, the Social Services Designee (SSDE) stated, I just put skilled serves and don't write out which therapy will be discontinued. On the other form [referring to the ABN form], I do not know the estimated cost of the skilled service, so I leave that blank. I really do not know where to get this information from. These options, I don't mark for the residents, so if they leave them blank, I won't do anything with them. During an interview on 01/30/25 at 5:00 PM, the Administrator was notified of the ABN forms not being filled out correctly and of the NOMNC not telling the residents and/or representative which specific skilled service is being discontinued. The Administrator stated, The social services [SSDE] is to make sure all areas of the forms are filled out completely and correctly even if they need to ask the resident to fill out which option they choose.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 12 residents who expired and had money in their accounts (Residents #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311 and #312). The financial sample was 12. The census was 146. Review of the facility's Resident Trust Fund Account Policy and Procedures, revised [DATE], showed the following: -Policy: It is the policy of the facility to manage personal funds of our residents, upon request and written authorization of the resident or legal representative. Funds will be managed in accordance with Federal and State Regulations; -Procedure: Upon discharge of a resident with a balance in the Resident Trust Fund, the facility will provide a final accounting within thirty days. If the facility is the Representative Payee for the resident, the facility will refund the balance to Social Security. If we are not Representative Payee, this accounting will be provided to the resident or the legal representative along with a check for the remaining balance in the fund. Upon the death of a resident with a balance in the Resident Trust Fund, the facility will complete the appropriate forms and submit to: Department of Social Services. This form shall be submitted within 60 days from the date of the resident's death. No funds shall be paid out of the resident's trust fund account, except for qualified funeral expenses, until notification is received from the Department of Social Services instructing the facility as to how the funds are to be distributed. 1. Review of Resident #301's medical record, showed the following: -Expired on [DATE]; -Ending balance of $655.30; -TPL was completed on [DATE]. 2. Review of Resident #302's medical record, showed the following: -Expired on [DATE]; -Ending balance of $205.32; -TPL was completed on [DATE]. 3. Review of Resident #303's medical record, showed the following: -Expired on [DATE]; -Ending balance of $1473.88; -TPL was completed on [DATE]. 4. Review of Resident #304's medical record, showed the following: -Expired on [DATE]; -Ending balance of $268.78; -TPL was completed on [DATE]. 5. Review of Resident #305's medical record, showed the following: -Expired on [DATE]; -Ending balance of $315.75; -TPL was completed on [DATE]. 6. Review of Resident #306's medical record, showed the following: -Expired on [DATE]; -Ending balance of $0.88; -TPL was completed on [DATE]. 7. Review of Resident #307's medical record, showed the following: -Expired on [DATE]; -Ending balance of $117.13; -TPL was completed on [DATE]. 8. Review of Resident #308's medical record, showed the following: -Expired on [DATE]; -Ending balance of $2018.08; -TPL was completed on [DATE]. 9. Review of Resident #309's medical record, showed the following: -Expired on [DATE]; -Ending balance of $153.54; -TPL was completed on [DATE]. 10. Review of Resident #310's medical record, showed the following: -Expired on [DATE]; -Ending balance of $50.41; -TPL was completed on [DATE]. 11. Review of Resident #311's medical record, showed the following: -Expired on [DATE]; -Ending balance of $62.67; -TPL completed on [DATE]. 12. Review of Resident #312's medical record, showed the following: -Expired on [DATE]; -Ending balance of $37.23; -TPL completed on [DATE]. 13. During an interview on [DATE] at 11:44 A.M., the Business Office Manager (BOM) said based on the state regulation form, he/she thought she had 60 days to complete the TPL. She did not realize the timeframe was 30 days. 14. During an interview on [DATE] at 11:46 A.M., the Administrator said she knew the TPL needed to be completed within 30 days. The BOM told her it was changed to 60 days, so she assumed it was now 60 days.

Based on interview and record review, the facility failed to ensure six of seven (Residents (R)121, R5, R65, R107, R7, and R136) reviewed for care planning of 33 sampled residents was afforded the right to participate in their care planning process. This failure placed the resident at risk of not being aware of the goals and outcomes of their care. Findings include: 1. Review of R121's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R121 was admitted to the facility on [DATE] with the diagnoses of anemia, orthostatic hypotension, and generalized weakness. Review of R121's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R121 was cognitively intact. Review of R121's Care Plan Sign in Sheet provided by the facility revealed the only documentation of a care plan meeting being held in 2024 was dated 06/25/24. During an interview on 01/28/25 at 9:03 AM, R121 stated, I don't understand what you are asking. I don't know what a care plan meeting is. During an interview on 01/29/25 at 3:30 PM, Minimum Data Set Coordinator (MDSC)1 stated, I could not find any more care plan meetings in 2024 for [R121]. That was all that she had. During an interview on 01/30/25 at 4:30 PM, the Administrator stated, I cannot confirm there were any more care plan meetings held for [R121] other than what is documented. The care plan meetings are to be held once a quarter and documented in PCC [Point Click Care]. 11599 2. Review of the Face Sheet located under the Profile tab (EMR) revealed R5 was initially admitted on [DATE] with diagnoses that included anxiety disorder, chronic pain, and cerebral infarction. Review of the quarterly MDS, located under the RAI tab in the EMR, with an ARD of 12/11/24 revealed a BIMS score of 13 out of 15 which indicated R5 was cognitively intact. During an interview on 01/27/25 at 1:08 PM, R5 was asked if she was invited to and attended care plan conferences. R5 stated, I used to, but only when I first came, I've been here for five years. They don't invite me anymore, but I would really like to go. They're important. During an interview on 01/29/25 at 4:14 PM, the MDS Coordinator (MDSC)1, responsible for care plan conference invitations, stated, I'll have to check who was invited when. MDSC1 was unable to provide any documentation that R5 had been invited or attended her care plan conferences. No explanation was given why R5 was not invited. 3. Review of the Face Sheet, located under the Profile tab in the EMR, revealed R65 was admitted on [DATE] with diagnoses that included myocardial infarction type 2, hemiparesis and hemiplegia following cerebral infarction affecting the left dominant side, and diabetes mellitus. Review of the significant change MDS, located under the RAI tab in the EMR, with and ARD of 11/05/24 revealed a BIMS of 15 out of 15 which indicated R65 was cognitively intact. During an interview on 01/28/25 at 10:31 AM, R65 was asked if she was invited to and attended care plan conferences. R65 stated, No, I've never been invited to a care conference. During an interview on 01/29/25 at 4:14 PM, the MDSC1 responsible for care plan conference invitations stated, I know for sure that (R65) has not been invited to care conferences. No explanation was given why R65 had not been invited. 39411 4. Review of R107's Admission Record, located under the Profile tab of the EMR revealed R107 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, epilepsy, depression, and hypertension. Review of R107's quarterly MDS with an ARD of 12/31/24 and located under the MDS tab of the EMR, revealed R107 scored 12 out of 15 on the BIMS, which indicated R107 was moderately cognitively impaired. Review of R107's Care Plan Sign in Sheet, dated 12/31/24 provided by the SSD revealed a signature that R107 had attended the care plan meeting for that quarter. There was no other evidence provided indicating R107 had been invited to attend any other care plan meeting. During an interview on 01/28/25 at 11:00 AM, R107 stated he had not been invited to or attended any care plan meetings for a long time and would go if he was invited. 5. Review of R7's Care Plan Sign in Sheet, dated 01/20/25 provided by the SSD revealed a signature sheet. There were no signatures of any family members of R7. There was no other evidence provided indicating R7's family had been invited to attend any other care plan meeting. During an interview on 01/28/25 at 1:02 PM Family Member (FM)1 stated her mother (R7) had been in the facility since 12/13/23 and she had never been invited to a care plan meeting. FM1 stated she is in the facility every day to feed her mother and make sure she is comfortable so she could have easily been invited. FM1 stated she would have attended the care plan meeting because she is very concerned about her mother's care. 6. Review of R136's Care Plan Sign in Sheet, dated 12/06/24 provided by the SSD revealed a signature sheet. There were no signatures of any family members of R136. There was no other evidence provided indicating R136's family had been invited to attend any other care plan meeting. During an interview on 01/28/25 at 1:02 PM, FM2 stated his family member (R136) had been in the facility since 08/23/24 and he had never been invited to a care planning meeting. FM2 stated he is in the facility every day to check on his family member and make sure she is comfortable so he could have been invited. FM2 stated he would have attended the care plan meeting because he likes to be involved in her care. In an interview on 01/30/25 at 2:32 PM, MDSC1 confirmed R7, R107, and R136 had not been sent notifications or been invited to care plan meetings.

Based on observation, interview, and policy review, the facility failed to provide knives with meals for two residents (Resident (R) 56 and R107) and staff was observed to stand while feeding (R) 22. These failures to promote dignity in dining had the potential to affect the 38 residents in the dining room. Findings include: Review of the facility policy dated January 2009 tilted Dining Room Audits indicated the Food Service Department should ensure the residents needs are met, and that dining is a pleasant experience.residents at each table should be served together and table should be in a homelike setting. During an interview on 01/28/25 at 12:27 PM, R56 stated that they never give knives at meals, and it made her feel like a child. During an interview on 01/28/25 at 12:30 PM, R107 stated that they never get knives with their meals. R107 stated that he is a grown man and feels like they should get a knife even if they do not use it. During a meal observation on 01/28/25 at 5:10 PM, residents were observed to get a spoon and fork and no knife with their meals. Staff were observed to serve meals randomly to tables while other residents sat without meals at the same table. Staff were observed to call out names to deliver meals. Residents raised their hand when they heard their name to get their meal served. During an interview on 01/29/25 at 1:03 PM the Dietary Manager (DM) stated she did not know why residents were not getting knives and they should be provided. The DM stated that they have knives so there is no reason the residents cannot have them. During an interview on 01/29/25 at 1:55 PM the Registered Dietitian (RD) stated that all residents should receive full service ware with their meals. 11599 3. Review of the Face Sheet located under the Profile tab in the EMR revealed R22 was initially admitted on [DATE] with diagnoses including cerebral palsy and seizure disorder. Review of the annual MDS, located under the RAI tab in the EMR with an ARD of 12/22/24 revealed R22 required assistance with eating. During an observation of the assisted dining room on 01/29/25 at 8:22 AM, Licensed Practical Nurse (LPN)2 was observed standing to feed R22. When asked if she should be standing or sitting, LPN2 stated, I always do, doesn't matter who it is. Whenever I'm helping, I stand. I didn't know I can't [sic] stand. LPN2 continued to stand to feed R22. During an interview on 01/29/25 at 8:24 AM, the Director of Nurses (DON) and two other staff members were observed standing at the half-wall looking toward the dining room, located next to the assisted dining room. On 01/29/25 at 8:25 AM, the DON was asked what her expectations were when a resident required to be fed by staff. The DON stated, They have to prepare the tray, make sure the meal is what they are to have, and sit to feed. The DON, by observation, confirmed that LPN2 was standing to feed R22. During an interview on 01/30/25 at 7:29 PM, the Administrator stated, Oh, she doesn't always feed residents, she was just helping out. She knows, she knows [not to stand]. No policy was provided as of 01/30/25 for dining assistance.

Based on staff interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of 35 sampled residents (Resident (R)121). This failure reflected R121 was receiving care or treatments that was inaccurate. Findings include: Review of R121's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R121 was admitted to the facility on [DATE] with the diagnoses of anemia, orthostatic hypotension, and generalized weakness. Review of R121's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R121 was cognitively intact. R121 was also coded as receiving dialysis while a resident in the facility. Review of R121's Physician Orders located under the 'Orders tab in the EMR revealed no orders for dialysis. During an interview on 01/27/25 at 4:43PM, R121 stated, I have never been on dialysis. During an interview on 01/29/25 at 7:33 AM, Minimum Data Set Coordinator (MDSC)1 stated, No, [R121] is not on dialysis, I get her [R121], and another resident mixed up. I made a mistake. During an interview on 01/29/25 at 9:00 AM, the Director of Nursing (DON) confirmed R121 was not receiving dialysis.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at the bedside for one of one resident (Resident (R)68) reviewed for self-administration out of a total sample of 33 residents. This failure had the potential for the medication errors to be made. Findings include: Review of R68's Face Sheet located under the Resident Info tab in the electronic medical record (EMR) revealed R68 was readmitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, and morbid obesity. Review of R68's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 and located under the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that R68 was cognitively intact. Review of R68's Physician Orders located under the Orders tab in the EMR revealed an order dated 09/16/24 for Advair Diskus inhalation aerosol powder breath activated 250-50 mcg (micrograms)-4.5 mcg/actuation HFA one puff twice a day. There was no order for the medication to be kept at the bedside of R68. During an observation on 01/27/25 at 11:30 AM, R68 had an inhaler (Advair) lying on a shelf, next to the resident's recliner. R68 stated he used the inhaler if he became short of breath. Observation on 01/28/25 at 9:24 AM the inhaler was at bedside. On 01/29/25 at 10:45 AM, the resident had an inhaler on the shelf next to the recliner. On 01/30/25 at 10:20 AM a request was made to the Administrator for a self-administration assessment. The Administrator stated she could not locate the document. On 01/30/25 at 11:17 AM R68 stated, a nurse came and snatched my inhaler from the shelf a few minutes ago without an explanation. During an interview with Licensed Practical Nurse (LPN)1 on 01/30/25 at 11:45 AM, LPN1 confirmed that R68 did not to have a self-administration assessment and there was no order for medications to be left at the bedside. LPN1 stated, I found the inhaler this morning after the Administrator called, I took it and placed it back in the medication cart. I have called the doctor and will be doing a self-administration assessment on [R68] later today. During an interview on 01/30/25 at 3:30 PM, the Director of Nursing (DON) confirmed that R68 had not been assessed for self-administration of the inhaler found by the bedside of R68 on 01/27/25. Review of the facility policy Self-Administration of Medications undated, stated, As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident .

Based on record review, staff interview, and facility document review, the facility failed to monitor targeted behaviors for one of six residents (Resident (R)133) reviewed for psychotropic medication out of a total sample of 33 residents. This failure had the potential for R133 to receive medications unnecessarily. Findings include: Review of R133's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R133 was admitted to the facility on [DATE] with the diagnosis of vascular dementia, and hallucinations. Review of R133's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/19/24 revealed R133 had been coded as receiving an antipsychotic and antidepressant medications while in the facility. Review of R133's Physician Orders located under the Orders tab in the EMR revealed an order dated 10/23/24 for Seroquel (an antipsychotic) 75 mg (Milligram) by mouth two times a day for unspecified dementia with psychotic disturbance, and an order dated 09/25/24 for Sertraline (antidepressant) 25 mg by mouth one time a day for depression. Review of R133's Care Plan located under the Care Plan tab in the EMR revealed on 12/23/24 R133 was care planned for the use of a psychotropic medication, Seroquel for vascular dementia. The interventions were: 1 Administer medications as orders. Monitor/document for side effects and effectiveness. 2 Discuss with MD [medical doctor] and family for ongoing need for the use of the medication. 3 I have behaviors of: I pick at my skin and will scratch it, I get agitated and will start yelling or hitting at staff, I have periods of hallucinations, and refusing care . Review of R133's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated December 2024 and January 2025, revealed no targeted behaviors documented for R133. During an interview on 01/30/25 at 10:29 AM, Licensed Practical Nurse (LPN)1 reviewed the EMR and stated, I don't see any behaviors documented in her [R133] chart. During an interview on 01/30/25 at 10:49 AM, Minimum Data Set Coordinator (MDSC)2 reviewed R133's EMR then stated, I don't see any behaviors documented. Review of the facility's policy Behavioral Assessment, Intervention and Monitoring provided by the facility, dated November 2016, stated, .When medications are prescribed for behavioral symptoms, documentation will include .Specific target behavioral and expected outcomes .Monitoring for efficacy and adverse consequences . Review of the facility's policy Antipsychotic Medication Use, provided by the facility and dated December 2016 stated, .The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications .

Based on record review and staff interview, the facility failed to ensure the Pre-Admission Screen and Resident Review (PASARR) Level I screen was completed prior to admission for one of four residents (Resident(R) 112) reviewed for PASARR out of a total sample of 33 residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of R112's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Parkinson's disease without dyskinesia, with fluctuations. Review of R112's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/06/25 and located in the MDS tab of the EMR, revealed she scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe impairment. R112 was admitted from another nursing home but the facility had no Level I PASRR upon admission to their facility. Review of the Orders tab of R112's EMR revealed the resident is not taking psychotropic medications. He is taking Carbidopa Levodopa, used to treat Parkinson's disease Review of R112's Care Plan, dated 01/10/23 and located in the Care Plan tab of the EMR revealed, [R112] has a dx of Unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The approaches included: administer medications as ordered . Allow me time to answer questions and to verbalize feelings perceptions, and fears. Assist/encourage/support me to set realistic goals. Consult with: Pastoral care, social services, Psychiatric consult. Monitor/document resident's usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leaves to fate, or luck There were no planned specialized services for mental health. Review of R112s EMR revealed there was no evidence of PASARR level one screen and determination prior to admission. During an interview on 01/30/24 at 03:29 PM, the Social Services Director (SSD) stated she was under the impression the PASRR level one screen had to be completed by the hospital before the resident was admitted . But if it were not done, the facility would have 72 hours to complete it. During an interview on 01/30/24 at 03:40 PM, Assistant Director of Nurses (ADON) she stated the PASRR level one screen had to be completed by the hospital before the resident was admitted . But if it wasn't done, I don't have the slightest idea who does it. During an interview on 01/30/24 at 03:55 PM, the Administrator stated the resident had a C form done but since resident did not need a Level 2 it was deleted. The PASRR level one screen should have been completed by the hospital before the resident was admitted . But if it were not done, the admission person would do it and social services would follow up.

Based on observation, interview, and record review, the facility failed to provide range of motion treatment to one of one residents (Resident (R) 65) reviewed for range of motion out of a total sample of 33 residents creating the potential for decline. Findings include: Review of the Face Sheet, located under the Profile tab in the electronic medical record (EMR) revealed R65 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness/paralysis) following cerebral infarction (stroke) affecting the left dominant side, depression, and anxiety disorder. Review of the significant change Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR with an Assessment Reference Date (ARD) of 11/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R65 was cognitively intact. Neither the admission MDS with an ARD of 09/05/24 nor the significant change MDS with an ARD of 11/05/24 noted that R65 received any physical therapy, occupational therapy, or range of motion on the assessment. Review of the Care Plan, located under the RAI tab in the EMR, updated 11/12/24, revealed Resident requires assist per staff with ADLs [activities of daily living] and mobility with ability to actively participate post CVA [cerebral vascular accident]. Mobility status will improve as evidenced by increased independence and mobility participation this review period. Allow resident time to complete tasks. Transfer assist per staff x [times] 1 with gait belt. and I have Hemiplegia/Hemiparesis Stroke affecting left dominant side. I will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis (specify) through review date. Reposition/Ambulate as tolerated and at least every 2 hours. During an observation and interview on 01/28/25 at 10:31 AM, R65 stated, The worst thing is I don't have any insurance, I get told we can't offer that and we're working on it. I would like therapy, but they won't give it to me because I'm Medicaid pending. I want to get stronger so I can move back with my husband. I'm too young to be here. R65 said her financial status has been pending since she was admitted . During an interview on 01/29/25 at 11:20 AM, the Business Office Manager (BOM) stated, It can take a very long time for Medicaid. During an interview on 01/29/25 at 4:01 PM, the Restorative Aide (RA) stated, (R65) does not receive restorative treatment. If a resident is Medicaid pending, the facility can pay for an evaluation by the therapist and then we can have a plan to follow. R65 had no such evaluation or restorative plan. The RA said, She would have range of motion with the nursing assistants and there's an exercise class in the morning. During an interview on 01/30/25 at 4:20 PM, the Administrator stated, We provide whatever they need, it doesn't matter what the payment source is. The Administrator did not state why services had not been provided to R65 while she awaited her Medicaid status. When asked for a policy to address provision of services during a pending financial status, the Administrator stated, We don't have a policy for that.

Based on interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident #4). Resident #4 had a diagnosis of dementia and a history of exit seeking and attempting to leave the premises without necessary supervision. On 4/9/23, Resident #4 left the facility unsupervised when Floor Technician A opened the locked door and let the resident out of the secured unit because he/she thought the resident was a visitor. Floor Technician A did not follow facility policy and notify staff on the unit or the Director of Nursing (DON) the resident had left and did not do a thorough search for the resident. Facility staff failed to adequately monitor the whereabouts of the resident. On the morning of 4/10/23, a policy officer notified staff a stranger had discovered the resident walking along a highway. The census was 147. The Administrator was informed on 5/12/23, of the immediate jeopardy (IJ) past non-compliance, which occurred on 4/9/23. From 4/10/23 through 4/17/23, the facility provided in-services for all staff regarding the facility's elopements policy as well as proper nursing rounds procedures. One staff person's employment was terminated. The IJ was corrected on 4/17/23, prior to DHSS' onsite investigation which began on 4/19/23. Review of the facility's policy titled Elopements, revised January 2017, showed direction for staff to promptly report any resident who tried to leave the premises or is suspected of being missing to the charge nurse or DON. If an employee observed a resident leaving the premises, then he/she should attempt to prevent the departure in a courteous manner. The employee should get help from other staff members in the immediate vicinity, if necessary, and instruct another staff member to inform the charge nurse or DON that a resident left the premises. The procedure for a missing resident included the nursing home charge nurse or designee announcing overhead or via walkie talkie three times code white and the resident's name. If the resident was located, then the charge nurse was to announce, code white all clear. Review of the resident's undated face sheet, showed an admitted [DATE], and identified the resident's power of attorney. Review of the resident's progress notes, dated 2/21/23, showed the following: -2/22/23 at 8:22 A.M., the resident was alert and oriented with periods of confusion; -2/23/22 at 12:42 A.M., practitioner history and physical note: the resident was admitted from the hospital after being diagnosed with encephalopathy (disease, damage, or malfunction of the brain). The resident had dementia with mood lability (rapid, often exaggerated changes in mood during which strong emotions or feelings occur). Abnormal behavior according to the psychiatry record; he/she keeps trying to get up and go to the bathroom very frequently. The resident was alert and oriented times two and did not know where he/she was, but knew the month and year. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/23, showed the following: -Moderate cognitive impairment; -Wandering not exhibited; -No mobility devices documented; -Required supervision of bathing; -Required set up assistance for eating; -Diagnoses included cancer, encephalopathy, muscle weakness, dizziness and giddiness, pulmonary embolism (a blockage of the main artery of the lung or one of its branches by a substance that has traveled from elsewhere in the body), disorder of bone density (inadequate amount of minerals) and structure, high blood pressure and renal insufficiency (poor kidney function). Review of the resident's care plan, updated 3/2/23, showed the resident required assistance of staff with activities of daily living (ADLs) and mobility due to weakness/easily fatigued. He/She had impaired cognitive function/dementia/impaired thought processes related to disease process and encephalopathy. Review of the resident's progress notes, showed: -On 3/17/23 at 5:43 A.M., the resident was forgetful; -On 4/10/23 at 4:25 A.M., the resident returned to the facility at approximately 12:45 A.M. accompanied by a Police Officer, who said the resident had ben escorted to the Police Station by a civilian. The facility charge nurse assessed the resident, whose vital signs were as follows: -Blood Pressure 112/56 (normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg); -Heart Rate 76 (normal range: 60-100 beats per minute); -Temperature 98.1 (97.8 - 99.1 degrees Fahrenheit); -Oxygen Saturation 97% (normal range: 95%-100%); -Respirations 17 (normal range: 12-18 breaths per minute); -The charge nurse did not note any skin issues. The resident was alert, cooperative, and did not have labored breathing. The nurse notified the resident's physician and received orders to increase Olanzapine (an antipsychotic medication that can treat several mental health conditions) to 5 milligrams in the evening and obtain a psychiatric evaluation. Review of the Police Department Event Report, dated 4/10/23, showed at 12:45 A.M., a male arrived in the Police Department lobby with an elderly individual (the resident) whom he found walking on Highway 270. The elderly individual was extremely confused, unable to advise where he/she lived, had no identification or phone and said those belongings were lost or stolen. A Police Officer returned the individual to the facility. Review of Mapquest (mapping service website) directions showed the entrance ramp for Highway 270 (ten lanes of two-way traffic) was 4.2 miles from the facility. Review of the written statement of Floor Technician A, dated 4/10/23, showed he/she was performing his/her normal routine trash pulls on 4/9/23. When Floor Technician A was exiting the Aspen building, an individual was behind him/her. Floor Technician A did not know the individual was a resident, because he/she had never seen the resident before. The resident asked Floor Technician A to open the door. Floor Technician A opened it and then immediately alerted the front desk after seeing the resident walking towards the street. Review of the undated written statement/questionnaire filled out by Nurse B, showed on 4/9/23 Nurse B last saw the resident at 7:30 P.M. in his/her room with the lights off and the door barricaded. Review of the undated written statement/questionnaire filled out by Certified Nurse Aide (CNA) C, showed on 4/9/23 the resident ate dinner and started roaming around the unit with a bag and another resident, but was not near the door. CNA C last saw the resident from 7:00 P.M. to 7:30 P.M. in his/her room. Review of the facility investigation summary, signed 4/11/23, showed: -On Sunday, April 9, 2023, between 7:30 P.M. and 8:00 P.M., the resident left the Aspen building after Floor Technician A released the secured door and security gate to the Aspen building. The resident walked east. Floor Technician A said he/she did not realize the resident was not a visitor when he/she let the resident out of the building. Floor Technician A was previously educated on the population in the secured units and was aware he/she should have verified the resident's identity prior to opening the door; -During interviews with facility staff: -Nurse B said he/she observed the resident, in the resident's room at approximately 7:30 P.M., during routine medication pass at the start of Nurse B's shift. Nurse B did not notice anything unusual with the resident at the time, administered the resident's evening medications and continued with the medication pass; -CNA C said the resident was busy that day and would place a bag of his/her personal items near the front door. CNA C redirected the resident and returned the items to the resident's room. CNA C took his/her lunch break at around 7:30 P.M., when Nurse B came on duty. Prior to going on break, CNA C observed the resident in the resident's room. CNA C took a 30 minute lunch break in the Aspen private dining room. After lunch, CNA C went about his/her normal routine of providing care to residents as needed. During CNA C's rounds, the resident's door was closed. When CNA C opened it, the door bumped into a chair the resident placed behind the door at night to keep other residents and staff from coming into the room and disturbing him/her. According to CNA C, that was the resident's routine. Other staff who were familiar with the resident verified CNA C's assertion. On the evening of 4/9/23, CNA C assumed the resident was in bed; -The resident suffered from dementia, but had moments of lucidity and could express his/her needs. The resident was independent with ADLs, ambulated freely with a steady gait, ate and used the toilet independently. He/she required little to no personal care from staff; -During interviews, staff reported the facility was very busy that day (4/9/23). There were multiple visitors at the facility, due to the Easter holiday, entering and exiting all of the buildings in the community; -Shortly after midnight, a Police Officer contacted the facility, asked if the resident lived there and was told yes. The staff on duty completed a head count, in order to ensure all of the other residents were present; -At approximately 12:45 A.M., a Police Officer returned the resident to the main building at the facility and was escorted, along with the resident, to the Aspen building. The Officer said the resident had been brought to the Police Station by a citizen and identified via facility papers in the resident's belongings (a dietary department meal ticket); -Nurse B assessed the resident from head-to-toe and found no skin issues. The resident was in stable condition, pleasant and in no apparent distress; -Staff notified the resident's responsible party and physician of the incident. They placed him/her on 15 minute rounds; During an interview on 4/27/23 at 3:55 P.M., Floor Technician A said he/she had just completed elopement training a couple of weeks prior to the incident on 4/9/23. However, he/she was not trained to verify the identity of individuals leaving secured units. As a Floor Technician, he/she did not work inside one specific location. Floor Technician A had never before seen the resident, who appeared to be just another visitor. It was Easter and there were a lot of different families visiting. The resident, who was fully dressed and had a purse on his/her shoulder, blended in with a family who was leaving. The resident was walking with them and there were no other staff members around. None of the visitors were wearing the visitor badges the facility normally used. After Floor Technician A let the resident out of the Aspen unit with the family that was leaving, he/she noticed the resident was no longer walking with the family and was not walking towards a vehicle. Floor Technician A searched, but could not find any of the staff assigned to the Aspen building that day. Floor Technician A then ran down the hill to the main building and notified Receptionist D that the resident was walking around on the upper parking lot. Afterwards, Floor Technician A took a break. Receptionist D grabbed his/her keys, ran outside hopped into his/her car and pulled up on the resident. Receptionist D turned around, because he/she did not recognize the resident. Floor Technician A did not see Receptionist D or the staff assigned to the Aspen building again that day. Floor Technician A assumed that everything was okay. The next day, he/she was informed someone found the resident at a store out in the community. During an interview on 5/2/22 at 2:54 P.M., Receptionist D said on 4/9/23 visitors who entered the main building and signed in received visitor badges and green tickets to present at the manors. At around 7:30 P.M. or 8:00 P.M., Floor Technician A came down to the main building, stood in the door and said he/she had just let someone out. The resident was at the front door and said to Floor Technician A, Do you think you could open this? Receptionist D asked in what direction the resident had gone and then got into his/her car. Receptionist D drove to the right off of the lower parking lot, over the bridge to the stop sign without seeing the resident, before turning around and going back to the facility. He/She did not know the resident had gotten out of a secured unit. Receptionist D phoned Floor Technician A, who was back in the Aspen building. Receptionist D informed Floor Technician A he/she had not seen the resident and told Floor Technician A to let him/her know if anything came about. Floor Technician A said, okay. Receptionist D thought Floor Technician A told the Aspen nursing staff about the elopement. Receptionist D did not see any other staff, by the end of his/her shift at 11:00 P.M., and did not notify anyone at the facility about the elopement. He/She had previously attended elopement in-services at the facility and was aware he/she was expected to notify the charge nurse assigned to the unit from which a resident was suspected to have eloped. Receptionist D also knew he/she was expected to make a Code [NAME] announcement, for a missing resident, in order to alert all staff of the elopement. Anyone was allowed to make that announcement. Receptionist D realized he/she had dropped the ball by not following up with the staff working on the unit. The next day, the DON called and informed Receptionist D of where the resident had been found. Receptionist D felt a sense of relief, because something tragic could have happened to the resident. During an interview on 4/27/23 at 4:32 P.M., CNA C said the about one and a half months prior to the incident, the resident's dementia progressed and he/she began sundowning (phenomenon in which confusion becomes worse during the late afternoon, evening, and night). When that occurred, the resident would talk about leaving, constantly attempted to elope, saying you can't keep me here. When on a rampage the resident would attempt to kick the glass out of the window in his/her room. The resident tended to sundown around 3:30 P.M. or 4:00 P.M. Sometimes it started during the day and the outgoing staff would caution CNA C to watch the resident, because he/she was trying to get out. The resident was constantly trying to elope. CNA C worked from 3:00 P.M. to 11:00 P.M. Normally, visitors wore badges and handed staff in the cottages green tickets (indicating that they had signed in at the main building that day). On 4/9/23, there were so many visitors for Easter there was a blur of people leaving green tickets at the nurse's station. CNA C could not recall whether or not the visitors were all wearing badges. CNAs were expected to conduct rounds every two hours. That evening, CNA C put the resident to bed and went to lunch sometime between 7:00 P.M. and 7:30 P.M., thinking the resident was in his/her room. After lunch, CNA C sat at the nurse's station and entered notes/documented completed tasks in resident medical records. The door to the resident's room was closed. He/she did not open the resident's door during subsequent rounds, because he/she assumed that the resident was in bed. CNA C did not see the resident again on 4/9/23. During an interview on 4/27/23 at 4:13 P.M., Nurse B said his/her shift was from 7:00 P.M. until 7:00 A.M. On 4/9/23, he/she arrived to start his/her shift at around 7:30 P.M. or 7:45 P.M. and was assigned to two different cottages. Nurse B conducted rounds as often as he/she could and tried to peek into rooms, in order to make sure the residents were where they were supposed to be. However, that was difficult to do in two cottages. He/She relied on the CNAs on duty in the cottages to conduct direct rounds every two hours. Nurse B was a fairly new employee and unaware of the resident's exit seeking behavior. Nurse B saw the resident on 4/9/23 during medication pass around 7:30 P.M. He/She next saw the resident when a Police Officer returned the resident to the facility on [DATE]. During an interview on 5/12/23 at 9:46 A.M., Physician F said the resident had dementia. Staff previously reported the resident had begun sundowning and Physician F adjusted the resident's medications. The resident needed to reside on a secured unit due to his/her attempts to leave the facility. As a result of cognitive impairment, the resident did not have an adequate level of safety awareness to safely go out into the community unsupervised. During an interview on 5/19/23 at 8:00 A.M., the DON said the expectation for nursing staff conducting rounds was to go into each resident's room, look at each resident, ensure they are breathing and see if they needed anything. Conducting nursing rounds in that manner also served to confirm the whereabouts of each resident and what they were doing. She had only been employed at the facility since 2/20/23, but was pretty sure staff had previously been instructed to conduct nursing rounds in that manner. During an interview on 4/19/23 at 1:00 P.M., the Administrator said the resident's elopement on 4/9/23, was due to a Floor Technician letting the resident off of the secured unit without verifying the resident's identity. All staff had previously been trained to verify the identity of anyone, who was not a staff member, asking to be let off of a secured unit. The aide on duty in the Aspen building that evening had assumed the resident was still in his/her room. Staff had been instructed to conduct rounds at least every two hours by physically checking on residents. The expectation was that staff was to follow the procedure in the elopement policy. All staff had previously undergone training on that policy. MO00216737

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) received care consistent with professional standards to prevent and treat pressure ulcers (a localized injury to skin and/or underlying tissue as a result of pressure or friction). This resulted in a the resident's pressure ulcer to worsen and develop into a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). The sample was three. The census was 144. Review of the facility's Pressure Injury Surveillance policy, revised 8/29/22, showed: -Policy: A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsened pressure injuries in the facility; -The designated clinical leader serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports surveillance findings to the facility's quality assessment and assurance committee; -Registered nurses (RN) and licensed practical nurses (LPN) participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of new or worsened pressure injuries; -The specific guidance in the resident assessment instrument (RAI) manual will be followed when staging pressure injuries and coding the minimum data set (MDS); -All pressure injuries will be tracked. A focused review will be completed on pressure injuries that develop or worsen in the facility. Corrective actions will be taken immediately, as needed; -Data to be used in the surveillance activities may include, but not limited to: -24 hour shift reports, incident reports, focused incident reviews; -Quarterly pressure injury/wound assessments; -Medication and treatment records; -Skills validations for dressing changes, turning/repositioning, personal care; -Weekly skin evaluations; -Rounding observation data. Review of Resident#1's care plan, revised 1/31/23, showed: -Focus: The resident is incontinent of bowel and bladder. He/She requires assistance with transfers, mobility and toileting and is at risk for skin breakdown; -Goal: Level of incontinence will improve and will not suffer any consequences; -Interventions: Check/change, assist with toileting, encourage fluid intake, provide barrier ointment as needed, monitor for skin breakdown and notify the nurse of changes. Review of the resident's progress notes, showed: -On 2/10/23 at 5:57 P.M., the resident readmitted to the facility from the hospital; -The readmission progress note showed the skin assessment: -#1: New issue- pressure injury to coccyx above the buttocks. Measurements: length 1 centimeter (cm) x width 1 cm x depth 1 cm. No odor, no tunneling, no undermining, not painful. Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (moist dead tissue), may also present as an intact or open/ruptured blister; -#2: New issue- pressure injury to left buttock. Measurements: Length 2 cm x width 3 cm x 0 depth. No tunneling or undermining. Stage I (non-blanchable skin). Skin is intact; -Braden score: -Sensory perception: No impairment; -Moisture: Very moist; -Activity: Chair fast; -Mobility: No limitations; -Nutrition: Adequate; -Friction and shear: Potential problem -Result: At risk. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/16/23, showed: -readmitted [DATE]; -Severe cognitive impairment; -Extensive assistance of one staff assistance required for transfers, dressing, mobility, toileting and personal hygiene; -Independent in bed mobility; -Always incontinent of bowel and bladder; -Diagnoses included: fracture, heart disease, osteoporosis (weak and brittle bones), and dementia; -Not at risk to develop pressure injury; -No unhealed pressure injuries; -No pressure reducing devices on the bed or chair. Review of the resident's physician order sheet, showed an order dated 2/10/23, for Venelex ointment (provides a barrier for wound healing). Apply to sacrum (tailbone area) and left buttock daily. Review of the resident's February 2023 treatment administration record (TAR), showed an order dated 2/10/23 for Venelex ointment. Apply to sacrum and left buttock daily, every day shift for wound care. Cover with a foam pad. Documented on 2/11/23 and 2/12/23 as see progress note. On 2/13/23 and 2/14/23, left blank. Review of the resident's progress notes, showed: -On 2/11/23 through 2/14/23, no documentation of the Venelex ointment treatment as referred to in the TAR; -On 2/16/23 at 8:25 A.M., redness and excoriation noted to the buttocks and coccyx. The resident's family and physician notified. New order received for protective ointment every shift. Review of the resident's February 2023 TAR, showed an order dated 2/16/23 at 8:37 A.M., apply zinc oxide cream (used to promote wound healing) to the buttocks and coccyx every shift for redness and excoriation. Scheduled at 7:00 A.M., 3:00 P.M., and 11:00 P.M. Observation and interview on 2/16/23, showed: -At 9:42 A.M., Certified Nurse Aide (CNA) A said the resident readmitted to the facility several days ago. The resident is incontinent of bowel and bladder and had remained in bed during the day shift since re-admission as the resident wore a right leg immobilizer. The resident had a very red groin and buttock area. There was also an open wound to the tailbone. He/she had notified the nurse about an hour ago of the redness and open area; -At 10:01 A.M., CNA A greeted the resident, explained care and removed the resident's saturated brief. The resident wore a right leg immobilizer that extended from just above the right ankle to the upper right thigh. The front of the resident's groin was very red. CNA A provided care. When the front groin and in between the legs were cleaned the resident yelled, oh baby, that hurts, it's so sore. CNA A assisted the resident on to his/her side and exposed the buttocks. The right and left buttocks were red and large areas of the outer layer of skin peeled from the buttocks. Open, uncovered areas noted to the right and left upper buttocks near the coccyx. The wounds had yellow, string like tissue that covered the wound bed. CNA A used clean gloves and applied barrier ointment over the entire buttocks, on the open wound, and the front groin. CNA A secured the clean brief in place. CNA A said the resident's buttocks and wound had gotten worse. He/She had told the nurses several times. The wound did not a have a treatment in place. The resident had remained in bed almost constantly since his/her readmission. The resident lay on a standard mattress. Observation and interview on 2/16/23 at 11:23 A.M., showed the resident awake in bed. He/She continued to lay on a standard mattress. No wedges or pillows were noted in use to aid in positioning. The resident said his/her butt hurt. During an interview on 2/16/23 at 11:41 A.M., the Wound Nurse and Director of Nursing (DON) said the charge nurse will report any skin changes to the Wound Nurse. The Wound Nurse cares for wounds in the main building and the separate memory care buildings. He/She is not aware of any skin issues Resident #1 had and the resident is not currently on the wound report. After review of the admission progress note, regarding the areas to the buttock and coccyx, the Wound Nurse said he/she should have been notified the resident had skin impairment. When the charge nurse is notified of a skin issue, the charge nurse should immediately assess, obtain measurements and notify the Wound Nurse and the DON. If the Wound Nurse is at the facility, she will assess the wound, contact the physician for orders and notify the wound care physician to add the resident onto the visit roster. Stage III pressure ulcers have slough (yellow, stringy tissue) and can have necrotic (black) tissue. If treatments are not completed, the wound can worsen. During an observation and interview on 2/16/23 at 12:08 P.M., CNA A and the Staffing Coordinator assisted the resident into his/her wheelchair for lunch. CNA A said he/she provided care to the resident and the resident's wound remained uncovered. He/she notified the nurse again, but the nurse was busy and the resident needed to get out of bed to eat. During an interview on 2/16/23 at 12:15 P.M., the DON said the resident had one shower since his/her re-admission. The shower sheet noted redness to the buttocks and the resident had an order for ointment to be applied. The Wound Nurse did not need to be notified about redness to the buttocks. The DON said she could not locate any further skin assessments for the resident. The Braden scale put the resident at risk to develop pressure injuries. The resident is bed bound most of the time, is incontinent of bowel and bladder and wears a right leg immobilizer. During an observation and interview on 2/16/23 at 12:45 P.M., the Wound Nurse and the DON entered the resident's room and explained the assessment. The resident lay on a standard mattress on his/her back. The DON unfastened the wet brief. Redness was noted to the front and in between the resident's legs. The resident was assisted onto his/her side and exposed the buttocks. Buttocks were red and excoriated. An open, uncovered wound was noted to the left buttock. Staff measured the area as 0.9 cm length x 0.7 cm width x 0.1 deep with approximately 20% granulation (new tissue growth) tissue noted. An open, uncovered wound noted to the right buttock. Staff measured the area as 0.5 cm length x 0.5 cm width x 0.1 cm deep with 25% granulation tissue noted. Slough noted to both wound edges and the wound base not completely visible. The wounds did not have drainage and the peri-wound (surrounding tissue) appeared red. The Wound Nurse said both wounds are a stage III pressure ulcer. She was not notified of the re-admission skin impairments. The wounds had worsened since the admission. The current ointment was not appropriate for the wounds. The facility does not have a process in place to notify the Wound Nurse of re-admissions. If she had been notified upon re-admission of the redness, the resident would have been added to the wound report for weekly tracking and assessments. The Wound Nurse relied on staff to notify her of changes. During an interview on 2/16/23 at 1:01 P.M., the Administrator said the facility does not have a process in place to notify the wound nurse of re-admission skin concerns. Management expected nurses and aide to tell the DON and Wound Nurse of changes. Given the resident's re-admission medical information, a low air loss mattress (used to relieve pressure) should have been put in place. Staff should have notified the Wound Nurse immediately of the skin impairment upon admission. The Wound Nurse would have added the resident to the wound report for tracking. The wound had worsened since the resident's admission. The Wound Nurse scheduled the resident to be seen by the wound physician and also obtained new wound orders. The resident is moving to the main building to ensure he/she will be turned and repositioned frequently and a low air loss mattress have been ordered.

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents. The facility had four manors (smaller residential settings, licensed and certified for skilled nursing care- which are physically separate from the main building) in addition to the main building. On [DATE] at around 10:15 P.M., the [NAME] Manor was left without any staff present. During that time, one resident (Resident #1), who had dementia and confusion, pulled the fire alarm in the [NAME] Manor and exited the building. Staff were not aware the fire alarm went off or that a resident had exited the building. When the fire department arrived, the resident was found outside, on the ground, in a pile of snow. The temperature was 7 degrees Fahrenheit (F) with a wind-chill factor of negative 12 degrees F. The resident wore a white t-shirt, light sleep pants, and no shoes. When the fire department entered the building, no staff were found. The resident was sent to the emergency room and was found to be hypothermic and required emergency medical treatment. The census on the [NAME] Manor the night of the incident was 19. The facility census was 144. The administrator was notified on [DATE] at 1:57 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of the facility's Facility Assessment, last updated [DATE], showed: -The facility is designed for mostly long-term care (LTC) residents on hospice or skilled needs. We have four separate manor buildings which three service a specific level of dementia care and the fourth specifically short term rehab; -List all buildings and/or other physical structures: -Brookview: 137 bed, the main nursing center (original facility); -Aspen: 21 bed manor rehab building; -[NAME]: 22 bed manor Alzheimer's dementia building; -Cypress: 21 bed manor Alzheimer's dementia building; -Magnolia: 22 bed manor Alzheimer's dementia building; -Other pertinent facts taken into account to determine staffing and resource needs: Facility layout, budget, staff strengths/weaknesses; -Average daily census 179.99; -Staffing hours per shift/day: -Nursing staff with administrative duties calculated separately from the registered nurse (RN), licensed practical nurse (LPN), nurse aide, and medication tech hours; -RN: Main building (Brookview) 8 hours per day. No hours listed in the Magnolia, Cypress, [NAME], and Aspen Manors; -LPN: Total facility 104 hours on the day, evening, and night shift to equal 312 hours/day; -Main building: 72 hours for the day, evening, and night shift to equal 216 hours/day; -Magnolia Manor: 8 hours for the day, evening, and night shift to equal 24 hours/day; -Cypress Manor: 8 hours for the day, evening, and night shift to equal 24 hours/day; -[NAME] Manor: 8 hours for the day, evening, and night shift to equal 24 hours/day; -Aspen Manor: 8 hours for the day, evening, and night shift to equal 24 hours/day; -Nurse aides: Total facility 105 hours for the day shift, 120 hours for the evening shift, and 75 hours for the night shift to equal 300 hours/day; -Main building: 60 hours for the day, 60 hours for the evening, and 45 hours for the night shift to equal 165 hours/day; -Magnolia Manor: 15 hours for the day, 15 hours for the evening, and 7.5 hours for the night shift to equal 37.5 hours/day; -Cypress Manor: 7.5 hours for the day, 15 hours for the evening, and 7.5 hours for the night shift to equal 30 hours/day; -[NAME] Manor: 15 hours for the day, 15 hours for the evening, and 7.5 hours for the night shift to equal 37.5 hours/day; -Aspen Manor: 7.5 hours for the day, 15 hours for the evening, and 7.5 hours for the night shift to equal 30 hours/day; -Medication tech: 22.5 hours on the day shift and 22.5 hours on the evening shift total hours/day in the facility. The hours not designated to their location in the main building or manor houses; -Day, evening, and night shift identified as: Day 7:00 A.M. to 3:00 P.M., evening 3:00 P.M. to 11:00 P.M., night 11:00 P.M. to 7:00 A.M.; -The degree of fluctuation in census is driving the staffing patterns, we are in the process so acuity of our patients will drive our staffing needs. During an interview on [DATE] at 1:25 P.M., the staffing coordinator said he/she works as a certified medication technician (CMT) on the floor as well. He/she was responsible for scheduling. The day shift is from 7:00 A.M. to 3:00 P.M., evening shift is 3:00 P.M. to 11:00 P.M. and night shift is 11:00 P.M. to 7:00 A.M. The nurses are not off until 30 minutes after the scheduled time, so they can complete their rounds. In the manors, there are one or two CNAs per building, one CMT and one nurse. The CMT will have two buildings and the nurse the other two buildings on the day and evening shifts. On the night shift, there is one nurse assigned to all four manors and one CNA in each building. If there's enough staff in the main building, they will be sent to the manors if they need assistance. If there is only one person in each manor and if there are two CNAs in the main building, the nurse will send the other CNA up to the manors to help. 2. Review of the facility's midnight census report for [DATE], showed 19 residents resided in [NAME] Manor. Review of the facility's staffing sheet for [DATE], showed: -On the evening shift: -One nurse assigned to Magnolia and Aspen. One nurse assigned to [NAME] and Cypress; -One CNA assigned to each manor: Magnolia, Aspen, [NAME] and Cypress; -On the night shift: -One nurse assigned to Magnolia, Aspen, [NAME] and Cypress. A hand written note: The nurse will oversee all four buildings; -One CNA assigned to each manor: Magnolia, Aspen, [NAME] and Cypress. During an interview on [DATE] at 9:31 AM, LPN A said he/she arrived to the facility on [DATE] at 7:00 P.M. and worked until 7:00 A.M. the next morning. He/she was assigned to all four manors. There was an aide assigned to Magnolia, Aspen and [NAME], but not Cypress, only four staff total for all four manors, one in each. There was no aide on Cypress until the next morning. That is how it is normally scheduled. 3. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), showed: -Hearing: Highly impaired- absence of useful hearing; -Sometimes understands- responds adequately to simple, direct communication only; -Vision: Severely impaired- no vision or sight only light, colors or shapes. Eyes do not appear to follow objects; -Brief interview for mental status (BIMS, a brief cognitive screening tool) blank; -Staff assessment for mental status: Short term and long term memory problem; -Daily decision making: Moderately impaired- decision poor, cues/supervision required; -Wandering: Behavior not exhibited; -Supervision- oversight, encouragement, or cueing require for bed mobility, transfer, walking in room, locomotion on the unit and eating; -Limited assistance required for dressing and toilet use; -Extensive assistance required for personal hygiene; -Primary medical condition category: Progressive neurological conditions; -Diagnoses included: High blood pressure, kidney disease, diabetes, arthritis, Alzheimer's disease and dementia; -Care area assessment summary (CAAs), showed care areas triggered and indicated as addressed in the care plan included: Cognitive loss/dementia, visual function, communication, activity of daily living (ADL) function/rehabilitation potential, and psychotropic drug use. Review of the resident's care plan, reviewed on [DATE], showed: -Focus: At risk for falls due to aggressive, anxious, or depressive behavioral tendencies. Impaired gait including: weakness, poor endurance, unstable balance, requires assist of others for transfer or mobility. Impaired vision. Newly admitted or moved in less than 3 months, wanders. On [DATE], left out of the building, was found on ground in the parking lot with no injury. Was sent to hospital for evaluation: -Goal: Manage the risk of injury from falls over the next quarter while honoring wishes for independence and autonomy; -Interventions/tasks included: Ensure the resident has appropriate foot wear. Monitor for unsteadiness/weakness. Staff to evaluate per facility fall protocol and make frequent rounds and monitor safety daily; -Focus: Impaired cognitive function/dementia or impaired thought process related to dementia. BIMS 00 (Rarely/never understood): -Goal: Will be able to communicate basic needs on a daily basis; -Interventions/tasks included: Monitor/document/report to physician any changes in cognitive function, specifically changes in: Decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status; -Focus: Risk for wandering/elopement identified. I have pulled the fire alarm and exited the building on ,d+[DATE]. Was transferred to the hospital by the police: -Goal: Have no successful elopement attempts through next review; -Interventions/tasks included: Ensure all doors were alarmed and secured. Staff to respond to alarms immediately when alarm goes off. Review of the resident's progress notes, showed: -On [DATE] at 12:33 A.M., alert note. Police arrived, found the resident outside the building on the ground yelling help, help after pulling the fire alarm and exited the unit. Call placed to this writer to assist, responded and found resident sitting with a warm blanket with the cops and fire fighters asking questions about the fire alarm and safety, then transferred to the hospital by the police. Family, administrator, and the doctor made aware. Police and fire fighters at the scene secured the doors, taking statement concerning residents whereabouts, a watch log started for the doors and windows every 30 minutes until the alarm was reset. A head count was initiated to make sure all residents were accounted for. Head maintenance arrived and reset the fire alarm. All doors were alarmed and secured by 12:08 A.M. Will continue to monitor; -On [DATE] at 8:43 A.M., a call was placed to the hospital to check on the resident. Was informed the resident was admitted with an admitting diagnosis of fall and hypothermia (a condition of having an abnormally low body temperature). Stated the resident was fine but confused. Review of the resident's hospital records, for dates of service [DATE] through [DATE], showed: -Diagnoses: Hypothermia and dementia with behavioral disturbances; -Reason for hospitalization : Fall with hypothermia. The patient was outside the facility for about a little over 5 minutes; -History of present illness: A resident at the facility in a dementia unit reportedly had pulled the fire alarm. The front door was open and he/she went out. The firefighter and police came in and found the resident sitting in front of the door. According to the investigation, talking to the executive director, in reviewing the records, it seemed like the fire alarm went off at 10:21 P.M., and the police and firefighters were on the scene by 10:26 P.M. They then brought the resident to the emergency room . His/her core temperature and rectal temperature was 96 degrees (normal 97 to 99 degrees Fahrenheit), signifying hypothermia. The patient was placed on a [NAME] (a forced air patient warming device designed to maintain normal core body temperature) and his/her mental status returned to near baseline, where he/she remained confused, disoriented with marked memory impairment. Review of the resident's progress notes, showed: -On [DATE] at 11:38 P.M., resident lying in bed with eyes closed, at this time resident is without any signs of distress or discomfort. Review of the facility's Final Investigation Form, showed: -Date/time of occurrence: [DATE] at or about 10:21 (A.M. or P.M. not identified); -Name of Resident(s): Resident #1; -Location of event: Front of [NAME] Building; -Summary of findings: -Senior management reviewed the resident's medical record and conducted staff interviews with those familiar with the resident's care. The outcome of the chart review and interviews revealed Alzheimer's and Neurocognitive Disorder with Lewy Bodies dementia. Staff did mention the resident often speaks of going home and awaiting someone to pick him/her up. The resident has displayed agitation at times and have had outbursts; -Upon the completion of the investigation, the facility is unsure why the CNA did not wait until the nurse returned to the building before leaving to look for his/her phone. Review of Level One Medication Aide (L1MA) G's written statement, dated [DATE], showed around 10:15 P.M., he/she went to the next building looking for the phone and took a 15 minute break. Before he/she left the building, every resident was sleeping. When he/she came back to [NAME], he/she saw police and ambulance with the resident and was told he/she got out of the building. During an interview on [DATE] at 3:42 PM, L1MA G said he/she worked for the facility for two months and had worked in all the manors. He/she never really worked with the resident before. The resident walks around the manor. L1MA G never witnessed any behaviors or witnessed the resident attempt to pull the fire alarm or leave. The majority of the residents on [NAME] Manor have dementia or other cognitive deficits. [NAME] is a secured building that requires an access code to enter and exit. L1MA G did not remember what time he/she arrived on [DATE], but he/she was assigned to [NAME] and normally works the evening and night shift. He/she was not assigned to another building, just [NAME]. At approximately 10:00 P.M., L1MA G left [NAME] and walked to Cypress, which was across the walkway. L1MA G did not notify anyone that he/she needed to leave, because he/she knew the nurse was right next door at Cypress. L1MA G went to get his/her phone and items he/she needed such as wipes and briefs. The facility's policy is to notify the nurse and have the nurse come sit in the building if staff needed to leave the building. He/she did not notify the nurse, because he/she was not going to be that long. It was a short period of time and no one was able to cover the building anyway. Everyone was assigned to their own building that night, one per manor. The charge nurse was LPN A. LPN A was working in Cypress, but L1MA G did not see him/her when he/she was in the building and he/she only went to Cypress, no other building. He/she was alerted about the resident's elopement when he/she arrived back to [NAME]. The fire department had the resident. They asked where the nurse was and they talked about the alarm. They took the resident to the hospital. L1MA G tried to call around for the nurse when he/she returned to [NAME], but the nurse showed up before he/she reached him/her. L1MA G never heard the alarm from [NAME] while at Cypress. When he/she returned to [NAME], the alarm was still on and it was not a loud alarm. L1MA G said he/she could not have heard the alarm in another building. The resident was found outside, but they did not say where. L1MA G was not sure which exit, but he/she believed it was the side door. The resident did not have any injuries. He/she wore jogging pants and t-shirt, thought he/she had shoes, but L1MA G was not sure if the resident had on a jacket or not. The resident was not an elopement risk prior to [DATE]. He/she was aware of another resident that was an elopement risk. Looking back, he/she would have tried to have someone cover the building or have someone bring him/her the items she needed for that night. Normally L1MA G will go and get the supplies he/she needs, but has never left the building unattended prior to [DATE]. Observation on [DATE] at 1:49 P.M., of the walk from the main building to the [NAME] Manor, showed when coming from main building, staff have to cross a driveway and walk up a flight of steps, enter through a gate at the top of the steps and walk down a walkway. Four buildings were visible, two on the left and two on the right. The first two buildings you come to are; on the left Aspen and on the right Magnolia, with the main entrances right across the walkway from each other. Further down path, past a grassy area between the buildings, on the left is Cypress and on the right [NAME]. The door the resident was found outside of by the fire department was the side door. At 2:22 P.M., the plant supervisor verified the location of the door in which the resident was found by the fire department. The door to the outside had a delayed egress 15 second door with a fire alarm pull station right next to the door. During an interview on [DATE] 11:32 A.M., the deputy chief of the fire department said that on [DATE] at 10:18 P.M., the fire department and emergency medical services responded to the fire alarm at the [NAME] building of the facility. Upon arrival to the scene at 10:26 P.M., crews made their way to the entrance of the [NAME] building, there was nothing visible from the exterior and no evacuation was in progress, but it was noticed there did not appear to be any movement inside, which is out of the ordinary. As the crews started to make their way into the building, and at 10:28 P.M., they heard a cry for help at which point they found an elderly resident lying in a pile of snow, just outside of an emergency exit door, covering him/herself with what light clothing he/she had on, to shield him/herself from the elements. At the time of the incident the temperature outside was 7 degrees with a wind-chill factor of -12. An ambulance was immediately added to the alarm and the crew was assigned to assist with moving the resident inside where it was warm and they tended to the resident's emergency medical needs until the ambulance could arrive and assume patient care. Further investigation revealed the resident had pulled the fire alarm at the emergency exit door before going outside. The crews walked the interior of the building confirming there were no hazards, during which they encountered patients in rooms requesting assistance for things like drinks of water. At this point in the incident there were zero staff members or representatives from the facility present anywhere in the building. A crew member went to check the other buildings to see if they could locate an employee, which eventually they did in another building. The crew was finally able to talk with LPN A and he/she informed the crew that the aide who was supposed to be in the [NAME] building left to go to another building for an unknown amount of time. During an interview on [DATE] at 9:31 AM, LPN A said he/she often floats buildings depending on the need. He/she has worked on [NAME] before and was familiar with the resident. It was the first time the resident got out of the building, but he/she always attempted, and staff would redirect him/her. LPN A was on Cypress when the incident happened. He/she would have no way of knowing what happened unless he/she was told, because he/she could not hear an alarm. Most of the residents that reside on [NAME] have cognitive deficits or some type of behavior. [NAME] is a secured building that requires an access code to enter and exit. He/she arrived to the facility on [DATE] at 7:00 P.M. and worked until 7:00 A.M. the next morning. He/she started his/her shift on the evening shift before and was assigned to all four manors. There was an aide assigned to Magnolia, Aspen, and [NAME], but not Cypress. There was no aide on Cypress until the next morning. That is how it is normally scheduled. Most of the time, there is one nurse for all four buildings on nights. He/she was notified of the incident when the staffing coordinator called him/her. The staffing coordinator told LPN A on the phone to go to [NAME], a resident got out, and the police and firefighters were there. He/she had to leave Cypress, where he/she was the only staff person. When LPN A arrived to [NAME], there were police outside. The resident sat with the police inside. The fire department said, where were you, and that they were banging on the door, and asked you did not hear the alarm? LPN A said he/she did not hear the alarm. LPN A did not have a clue L1MA G left the building. He/she was supposed to notify LPN A if he/she left. Staffing was a problem because LPN A did not have anyone on Cypress, so he/she would not have been able to leave to watch [NAME] anyway. LPN A had been at [NAME] at approximately 9:00 P.M., administering a medication. He/she saw Resident #1 and he/she was still awake. He/she did not want to go to bed. After he/she left [NAME], LPN A returned to Cypress to assist the residents. He/she did not know what happened after that on [NAME]. LPN A said the facility's policy is to contact the nurse if staff needed to leave, but even if that happened, there was no one else there on Cypress to cover that building. When LPN A first arrived to [NAME], L1MA G was already with the police. He/she did not know L1MA G had been gone, but L1MA G told LPN A that he/she needed to take a break, because he/she had been working since 6:00 P.M. L1MA G told him/her all the residents were asleep, so he/she thought the resident was asleep. LPN A did not remember what the temperature was, but it was snowing that evening. The resident was an exit seeker prior to [DATE]. There are about five residents that exit seek who reside on [NAME]. During an interview on [DATE] at 2:00 P.M., CNA O said he/she arrived to the facility on [DATE] at 2:30 P.M. or 2:45 P.M. He/she normally works the evening shift. CNA O was assigned to work in the Magnolia manor. It was the only building he/she was assigned. LPN A was assigned to all four manors. At the time of the incident, he/she was in Magnolia. There was a beeping noise he/she heard over on Magnolia, but did not know where it was coming from or what it was. It was a different beeping noise from the fire alarm, but he/she wondered what the beeping noise was. He/she called over to Aspen, but no one answered. Around that time, it was the last hour of the shift, so it was time for them to leave. CNA O figured staff was just doing rounds on Aspen. LPN A came to Magnolia to let him/her know what happened. He/she was not aware L1MA G left [NAME] and did not see him/her at any time. The facility policy on leaving the unit is to call the charge nurse and have someone come to relieve him/her. Even if his/her shift was over, he/she cannot leave until staff arrives. He/she did not know the temperature, but it was snowing outside. During an interview on [DATE] at 1:25 P.M., the staffing coordinator said on [DATE], the CNA scheduled on Cypress did not work, so NA N was sent there around 3:30 P.M. or 4:00 P.M. until 8:00 P.M. when he/she left. When this happens, staff work together. After NA N left, LPN A was the only staff at Cypress. No other staff was sent to Cypress. If LPN A needed to go to another building, they can call the CNA in another building or call the staffing phone and tell someone they needed a break or to leave the building. The nurse on the main building will take over for the CNA in the main building and the CNA can go to the manors to help. One person is fine on the night shift, the residents are asleep. The staffing coordinator said she worked in the main building on [DATE] during the evening shift. She was at the medication cart when notified by CNA H on the phone the police were there, no one was in [NAME], and a resident got out. L1MA G was supposed to be there. The staffing coordinator called LPN A and told him/her a resident got out and he/she needed to get there. LPN A stayed on the phone with the staffing coordinator, but no one covered LPN A's building. L1MA G cannot leave the building unless he/she called a nurse or staff to relieve them. L1MA G said he/she left because he/she was looking for his/her phone. During an interview on [DATE] at 3:18 P.M., CNA H said he/she was scheduled on Aspen on [DATE] evening shift. He/she arrived to the facility at 3:00 P.M. He/she normally works evening shift. He/she was not assigned to another building, only Aspen. There were no other staff working with him/her during that time. He/she did not take a break that shift. CNA H was notified of the resident's elopement when he/she was told by the fire department. The fire department went to Aspen, they told CNA H that the fire alarm was going off and a resident was outside. CNA H left Aspen unattended to see what was going on. L1MA G was not there when he/she arrived to [NAME], but when L1MA G returned, CNA H went back to Aspen. CNA H was not aware L1MA G left [NAME]. The facility's policy on leaving the unit is to notify the nurse or call to the main building. CNA H did not see any staff from the main building come up to [NAME]. CNA H could not hear the alarm while inside Aspen, so he/she did not know what was going on until the fire department banged on the door. He/she could not remember if the alarm was still sounding when he/she arrived to [NAME]. The resident was sitting inside when CNA H arrived to [NAME]. The fire department said the resident was trying to go out. He/she did not know if the resident had any injuries and he/she did not remember the temperature, but it was freezing. It was right after the mini blizzard. The resident was wrapped in a blanket when CNA H saw him/her. He/she did not feel there was enough staff coverage. During an interview on [DATE] at 11:00 A.M., the resident's daughter said on the night this happened, the facility called her. They did not call her until 11:45 P.M. that night. They could not tell her where the resident was being taken. She finally tracked the resident down by calling the nearest hospitals. She was aware staff left the building. The resident could have died if the fire department and police were not there. The resident has dementia and when he/she has his/her mind set on something, like I want to go home, he/she will try to leave. He/she will sit by the door. He/she pulled the alarm before. When staff called her on [DATE], they said, they do not even call every time he/she pulls the alarm. The resident was admitted to the hospital for hypothermia. He/she is not a good historian due to the dementia, but when he/she was in the hospital, he/she continued to say, I was freezing to death. During an interview on [DATE] at 1:50 P.M., the Director of Nursing (DON) said she has worked for the facility for over one month. She was familiar with the manors and had worked in them. The goal is to have a nurse, CMT and a CNA assigned in the manors. On the night shift they have the same goal, to have three staff in each building. The DON worked on [NAME] before and was familiar with the residents there. The residents on the unit have cognitive deficits. [NAME] is a secured building because it requires an access code. She was not familiar with the resident who eloped and the DON was not in the building at the time it happened. After the resident returned from the hospital, he/she talked about going home for two days. She was notified about the elopement by staff calling her. If staff needed to leave, they need to call the nurse manager. They are never to leave the building unattended. They should not leave unless there is someone to relieve them. L1MA G would have been required to contact the nurse before leaving [NAME]. One person in the building is not conducive to what the facility wants. If one person is in a manor, they need to call the main building if they need help. It is not adequate staffing to have one CNA per manor and a nurse that floats between the four manors. The staff could not leave until the other person got there. There is no reason to leave unless there is an emergency. It is unacceptable. In a medical emergency such as a fall or the need to provide cardiopulmonary resuscitation (CPR), if staff needed assistance, the CNA could contact the nurse by using the walkie-talkies and they can call down to the main building. There is communication available to them. The CNAs are not waiting for nurses to come because they can call 911. The elopement was a bad situation. The DON was not aware one nurse left at 6:00 P.M., another nurse did not come in, and between the hours of 8:00 P.M. and 11:00 P.M., LPN A was the only nurse in the manors and the only staff assigned to Cypress on [DATE]. The DON said that was not appropriate staffing. The DON did not receive a call to float or work. During an interview on [DATE] at 9:00 A.M., the administrator said she would expect staff to notify the nurse manager or charge nurse if they need to leave their assigned building at any time. She would expect the manors to be adequately staffed, so there is not only one person working. The administrator agreed that in scenarios when there is one staff assigned in each area, it would not be appropriate for staff to leave the residents. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00211636 MO00212101 MO00211644 35394

Based on interview and record review, the facility failed to ensure two of fourteen sampled residents (Residents #9 and Resident #10) were free from mental abuse, after an employee used a cell phone to video tape the residents in an intimate/sexual situation and transmit the video to former staff. The census was 185. Review of the facility's Abuse/Neglect/Exploitation Compliance and Overview policy, dated October 2017, showed the following: -The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -Screening: The facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employer and/or current employers, and checking with the appropriate licensing boards and registries; -Training: New employees will be educated by the department manager, or designee on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. The facility will perform ongoing, competency testing to ensure staff education relative to abuse prohibition practices and abuse reporting requirements; -Prevention: The facility will provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of a resident's property is more likely to occur; -Identification: The facility will identify events, occurrences, patterns and trends that may constitute: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being; *Verbal abuse: means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability; *Sexual abuse: includes, but is not limited to sexual harassment, sexual coercion, or sexual assault; *Physical abuse: includes hitting, slapping, and pinching, kicking and controlling behavior through corporal punishment; *Mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation, or abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident; -Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below; -Protection: The facility will protect resident from harm during an investigation; -Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency, law enforcement and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences; -Procedure for response and reporting allegations of abuse/neglect/exploitation: -Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation; -When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated; -The licensed nurse will: *Respond to the needs of the resident and protect him/her from further incident; *Remove the accused employee from the resident care area: *Notify the Director of Nursing (DON) Services and the Administrator; *Notify the attending physician, residents' family/legal representative and Medical Director; *Monitor and document the residents' condition including response to medical treatment or nursing interventions; *Document actions taken in the medical record; *Complete an incident report and initiate an investigation; -The Director of Nursing Services, Administrator or designee will: *Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after the discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming of the suspicion; *Obtain statements from direct care staff; *Suspend the accused employee pending completion of the investigation; *Follow up with appropriate agencies, during business hours, to confirm the report was received; *Report to the state nurse aide registry or nursing board of any knowledge of any actions, which would indicate an employee is unfit for service; -The Administrator should follow up with government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final as required by state agencies; -Employee Training: New employees should be educated by the department manager on alleged violations and reporting requirements during initial orientation. Annual education and training is provided to all existing employees. Frontline supervisors can provide education as the situation arise. Review of the facility's Videotaping, Photographing, and other imaging of residents' policy, dated April 2017, showed the following: -Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images and recordings during resident care or other facility activities; -For the purpose of this policy, resident image mean the likeness of a resident captured through still photography, videotaping, digital imaging, scans and audio recordings; -Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigations of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family; -Transmitting unauthorized images of any resident through email, Internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such; -Staff should immediately report suspected sexual abuse to immediate supervisor. Review of the facility's policy for Sexual Expression of Residents, dated October 2017, showed the following: -It is the policy of this facility to respect all residents and their rights. This policy applies to individuals who exhibit intact cognitive decision-making capacity. Residents residing in the facility will be allowed to express themselves in the way they prefer, given they have the mental capacity to make informed decisions. -Policy Interpretation and Implementation: -The staff will document observation of residents engaging in intimacy and/or sexual activity and notify social services and the DON; -Social Services will notify the interdisciplinary team (IDT); -Social Service staff will educate the resident about any disease processes and the residents' rights; -Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression; -Residents with decisional capacity have a right to privacy, including private space for sexual expression; -Residents with decisional capacity have a right to confidentiality; -The physician will be notified regarding all residents participating in sex for clinical and cognitive evaluation to determine intact cognitive decision-making capacity and the capacity to give consent; -The decision to conduct a cognitive re-assessment will be made by the IDT and based upon noticing a change in residents' behavior; -Care plan meetings with the IDT shall be scheduled as soon as possible from the initial notification from the social service staff; -The IDT shall conduct a review of the situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of, and protects those involved; -Outcomes of the IDT review will be shared with the residents involved and documented in the care plan; -Based on the plan of care, intimacy and sexual expression shall be permitted if both parties consent and the risks do not exceed the benefits; -The facility will ensure the resident's right to privacy, including providing a private place for intimacy and/or sexual expression; -The staff will re-direct residents engaging in intimacy and/or sexual expression in public areas; -Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, and who to contact to report issues; -If, at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s); -The facility shall provide initial staff orientation and ongoing staff training, regarding abuse, intimacy and/or sexual expression as well as sensitivity awareness about residents sexual rights and staff documenting and reporting responsibilities; -The facility shall obtain consultation regarding intimacy and/or sexual expression in cases that are deemed complex or controversial; -All infection control precautions to be followed as per facility protocol. Sexual expression should be prevented where the potential for transmission of sexually transmitted infection exist; -Staff should immediately report suspected sexual abuse to immediate supervisor. -The facility's policy did not address: *What staff would assess the residents for sexual consent; *Residents that could not or were unable to express their ability to consent; *Where staff would document resident's ability to consent to a sexual relationship. Review of the facility's undated policy, Resident's Rights for Long Term Care, provided to residents, showed the following: -Have privacy and respect; You have the right to privacy in medical treatment, personal care, telephone and email communications and visits with family and meeting of resident groups. You should be treated with consideration and respect, with full recognition of your dignity and individuality. You should not be required to do things against your will; -Retain Martial Privileges; you have the right to a private visit with your spouse and may share a room with your spouse if you are both residents; -The Residents' Rights policy did not address: *Residents have the right to share a room with whomever they wish, as long as both residents are in agreement. These arrangements could include opposite-sex and same-sex married couples or domestic partners, siblings, or friends. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed the following; -Brief Interview for Mental Status (BIMS) score of 9 out of 15 (a score of 8-13 indicates moderately impaired cognition); -Able to communicate needs; -No behaviors affecting others; -Supervision required for activities of daily living (ADLs); -[DIAGNOSES REDACTED]. Review of the resident's progress notes, dated 8/1/19 at 8:53 P.M., showed the following: -Found in another room with a female resident engaging in sexual activity; -When confronted by staff, resident returned to his/her room; -Supervisor spoke with resident and told him/her, we don't encourage that kind of behavior; -Resident replied I know you don't, It just happened; -Resident's responsible party informed of the same. Stated he/she would talk with the resident about the issue; -Resident remains in his/her room with covers pulled over his/her head. Review of the resident's care plan, updated on 8/21/19, showed the following: Problem: Psychosocial, I have formed a close relationship with another resident at the facility; -Goal: I am a consenting adult and will have the support from staff through next review; -Interventions: I will be discrete while having sexual relations with respect to all concerned and respect for other residents. -The care plan did not address: *How the facility assessed the resident's ability to consent to sexual activity; *How the facility was going to accommodate the resident's wish to participate in sexual activity and provide privacy and education to the resident about sexual activity; *The resident's emotional status after finding out staff videotaped him/her in a sexual encounter. During an interview on 8/8/19 at 10:29 A.M., the resident said the following: -He/she is very embarrassed by the whole situation; -He/she is grown and is able to make his/her own decisions; -He/she was a willing participant in the sexual activity with another resident; -He/she said that kind of activity should be private; -No one told him/her that someone videotaped his/her activity on 8/1/19; -He/she would never consent to having the activity videotaped; -It makes him/her very upset to know the activity was videotaped and viewed by other people; -He/she still wants to be friends with the other resident, but has been told he/she is not allowed to sit with or go into the other resident's room; -It makes him/her sad that he/she is not allowed to visit with the other resident any longer; -He/she would like the person who made the video tape go to jail. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -BIMS score of 13; -Impaired vision; -Able to communicate needs; -No behaviors affecting others; -Required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, dated 8/1/19, at 8:15 P.M., showed the following: -Found in room with a resident of the opposite sex, engaged in sexual activity; -When confronted by staff, the resident asked, Can't (he/she) have company when I want to; -Supervisor spoke with resident and told him/her, we don't encourage that kind of behavior; -Resident's responsible party notified and told staff to Keep them separated; -Resident remains in his/her room; -Other resident returned to his/her room; -Staff instructed to monitor both residents. Review of the resident's progress notes, dated 8/2/19 at 9:23 A.M., showed the following: -The administrator spoke with the resident; -The resident said he/she liked Resident #9 and wanted him/her to continue to visit; -When asked if he/she were in a sexual relationship with Resident #9, the resident said no, we just pitter-patter and Resident #9 just touched his/her breast and other parts of his/her body; -When asked if the resident enjoyed the activity, the resident laughed and said yes, of course; -He/she enjoyed Resident #9's visits. Further review of the resident's progress' notes, showed no documentation the facility notified him/her of the videotape. Review of the resident's care plan, updated on 8/21/19, showed the following: Problem: Psychosocial, I have formed a close relationship with another resident at the facility; -Goal: I am a consenting adult and will have the support from staff through next review; -Interventions: I will be discrete while having sexual relations with respect to all concerned and respect for other residents. -The care plan did not address: *How the facility assessed the resident's ability to consent to sexual activity; *How staff would address and accommodate the resident's expressed wish to continue with a sexual relationship with another resident; *The resident's emotional status after finding out staff videotaped him/her in a sexual encounter. During an interview on 8/8/19 at 11:20 A.M., the resident said the following: -The interaction with Resident #9 was consensual. He/she was in the privacy of his/her own bedroom; -He/she enjoys the company of the other resident; -He/she would never give anyone permission to videotape private activities; -He/she was unaware the activity had been videotaped; -No one told him/her there was a videotape; -He/she wants the person who videotaped the activity to go to jail; -The police have not spoken to him/her or asked for a statement; -He/she has never and would never put him/herself on display; -It is disgusting and he/she is very upset about it; -He/she cried throughout the interview. Review of the facility's undated and unsigned investigation provided by the administrator on 8/8/19, showed the following: -8/1/19 at 11:08 P.M., the DON called the administrator and told her of a supposed video made by one of the facility's staff, of two residents having sex and that the video was sent to a former staff person working at another long term care facility; -The administrator replied that is a heck of an allegation, and said we need to find out the name of the staff person and need the video; -The DON said she would call the DON at the other facility to obtain the name of the staff person and get a copy of the video; -8/2/19 at 12:24 A.M., the administrator received a call from the facility's evening/night nurse supervisor. The nurse reported he/she received a call from the DON of another long-term care facility. That DON reported one of his/her staff had received a video of two of the facility's residents involved in sexual activity; -The administrator asked the supervisor if the residents were Resident #9 and Resident #10, who had engaged in sexual activity earlier in the evening and the supervisor said yes; -The administrator was aware the residents had been involved in a consensual sex act; -The supervisor was not aware the incident had been videotaped by staff; -The supervisor asked the administrator who videotaped the residents and the administrator said she believed it was Certified Nursing Assistant (CNA) B; -The supervisor told the administrator that CNA B left the facility at 9:00 P.M.: -The administrator told the supervisor she needed a copy of the video before making such an allegation; -1:11 (no date or AM/PM noted), the administrator sent a text to their facility's DON and told her to try and get to work by 7:00 A.M., so they could terminate CNA B if need be; -5:25 A.M., the facility's DON sent a text saying she had a copy of the video; -6:18 A.M., the administrator sent a text to the Human Resource (HR) department head to be in the administrator's office by 7:00 regarding an employee situation; -6:55 A.M., the DON, HR director and administrator met. The DON had viewed the video she received from an employee at another nursing facility; -She felt the situation between the residents was clearly consensual intimacy between the residents and it was proof CNA B had indeed created a video; -The agreement was they would terminate CNA B for a Health Insurance Portability and Accountability Act-(HIPPAA- legislation that provides data privacy and security provisions for safeguarding medical information) violation as well as violating Residents' Rights and would report to the State; -7:00 A.M., CNA B has not arrived for his/her shift; -8:00 A.M., HR and the administrator met with CNA B. He/she had his/her phone. HR explained to CNA B he/she was being suspended for a violation of HIPPAA; -CNA B questioned why he/she was being suspended; -The administrator told CNA B, he/she was being suspended for a HIPPA violation. The facility had evidence he/she videotaped residents on his/her phone and sent the video to at least one former employee who worked at a nearby facility; -CNA B denied the allegation; -The administrator told CNA B to delete the video off his/her phone and have his/her friends delete the video off of their phones or CNA B would be liable for up to $25,000.00 fine; -CNA B continued to deny the allegation and refused to sign the suspension notice and left the building; -8:20 A.M., a message was left for the Region 7 Program Manager; -8:30 A.M., a call was placed to the Region 7 office. The office was informed of the allegation and was told the facility had been in contact with the other facility and with the police; -The sexual act on the tape was consensual. The Region 7 office would provide the facility with a report number; -12:30 P.M., a police officer called the administrator and the administrator provided the police officer with CNA B's name and contact information; -The police officer said he/she would follow up with CNA B and present the case to the prosecuting attorney. This was seen as a sex crime because of the resident's breast being exposed in the video; -2:30 P.M., HR called CNA B to tell him/her, he/she was terminated from the facility; -Attachments to the statement included the following: -Written statements from the DON, the evening/night supervisor and the direct care staff working on the evening shift of 8/1/19; -Staffing assignments for 8/1/19; -Inservice and training information provided to staff, on 7/17/19, regarding residents' rights and the staff roster who attended the inservice (the roster included CNA B's signature); -Additional inservice training done by the facility on 8/5/19 and 8/7/19; -Inservice training was provide to staff on 8/5/19 and 8/7/19, was the same inservice information provided to staff on 7/16 and 7/17/19, No new additional information was provided; -Review of the attendance roster for the inservices provided on 8/5 and 8/7/19, showed 21 staff signatures. -The investigation did not include: *A written statement from CNA B; *Any inservice training provided to staff after the 8/1/19 incident and prior to 8/5/19; *Any written statements from any residents including Residents #9 and #10; *A conclusion of the investigation. Review of the undated, typed statement provided by the facility's DON, showed the following: -On 8/1/19, he/she received a phone call around 10:45 P.M., from former employee (FE) E; -FE E said something about a video and people having sex; -The DON was not quite awake and was not sure what the FE was talking about; -The DON called the FE E back at 10:51 P.M., and asked him/her to explain in detail what was going on; -FE E went on to say that a CNA from the facility had made and sent a video recording of two residents having sex; -The CNA was a friend of another nurse, (FE) F working at his/her facility; -FE F was able to identify Resident #10 by name, but did not know who Resident #9 was; -FE F reported the incident to his/her DON and his/her DON was going to report the incident to the State; -FE E did not provide the name of the CNA that recorded and sent the video; -At 11:08 P.M., he/she notified the administrator of the allegation a current employee had videotaped two of their residents during sexual activity; -FE E reported, the DON at the other facility said he/she was going to notify the State agency of the video; -At 5:30 A.M., he/she woke up and checked his/her phone for messages. The nurse from the other facility had sent the video and the name of CNA B; -He/she notified the administrator he/she had a copy of the video and the name of the sender. Review of the Department of Health and Senior Services (DHSS) Region 7's call log, showed the facility notified the State Agency on 8/2/19 at 9:56 A.M., of the allegation. Review of the evening/night shift supervisor's typed and signed statement, dated 8/1/19, showed the following: -Time; 8:15 P.M., -Incident involved Residents #9 and #10; -Was called to the residents' hall by Certified Medication Technician (CMT) C; -He/she spoke with Resident #10 about Resident #9 being in his/her room; -Resident #10 was upset and asked, Can't I have company, if I want to? The resident was upset Resident #9 had left the room; -At 9:30 P.M., he/she received a telephone call from a person that identified himself or herself as the DON at another facility. The person said one of the nurses at his/her facility had received a video text on his/her personal cell phone of two residents at the facility engaged in sexual activity. He/she said it was a CNA who worked at the facility that sent the video; -The supervisor asked for the name of the CNA that sent the video; 11:40 P.M., The caller called the facility back and gave the supervisor the name of the CNA. The caller did not send the video. The supervisor said she would notify his/her administrator; -12:24 A.M., the supervisor notified the administrator of the allegation, a staff member had videotaped and texted the video to a former employee at another facility. He/she provided the administrator with the CNA's name and reported CNA B had left the facility around 9:00 P.M. During an interview on 8/2/19 at 8:40 A.M., with the DON and administrator, the administrator said the following: -CNA B has been terminated from the facility; -No one has a copy of the video because she was told by the police, to delete it; -The police have a copy of the video and will pursue the issue; -CNA B was told to delete the video and tell his/her friends to do the same; -All allegations of abuse or neglect should be reported immediately to the State agency; -CNA B did not provide a written statement prior to exiting the facility; -Both residents' responsible parties (RP) have been notified of them being involved with sexual activity, but neither the residents nor their RPs have been notified the residents had been videotaped; -Inservice training was provided to staff on 8/5/19 and 8/7/19, It was the same inservice provided on 7/16 and 7/17/19, No new additional information was provided; -Review of the attendance roster for the inservice training provided on 8/5 and 8/7/19, showed 17 staff signatures. During an interview on 8/8/19 at 9:41 A.M., the DON said the following: -On 8/1/19, at around 10:45 P.M., she was notified by a former employee that a current employee had posted a video of two residents at the facility engaged in sexual activity; -The former employee was able to verify the female resident by name; he/she could not identify the male resident; -The former employee would try to send the DON a copy of the video; -The former employee identified the person who originally sent the video as CNA B; -On 8/1/19 at approximately 11:08 P.M., she notified the administrator of the allegation a current employee had videotaped residents in sexual activity and posted it online; -The administrator is the abuse/neglect coordinator at the facility and usually calls the State agency with self-reports; -The former employee texted the DON the video on 8/2/19, at approximately 5:30 A.M.; -The DON viewed the video and was able to positively identify Residents #9 and #10 as current residents, residing in the facility; -The administrator and the HR director met with CNA B at approximately 8:00 A.M., on 8/2/19, and suspended him/her for a HIPPA violation; -The DON was told to delete the video and does not have a copy of it; -The corporate nurse may have a copy of the video. During an interview on 8/8/19 at 12:00 P.M., the facility's corporate nurse said she would be able to provide a copy of the video. She provided a copy to the surveyor at 12:12 P.M. She positively identified the people in the video as Resident #9 and Resident #10. The allegation is a reportable offense and should have been reported to the State agency in the required time frame. Review of the (undated, with no time) video, showed the following: -Resident #9 sitting on the edge of Resident #10's bed; -Resident #10 was lying in the bed; the sheet was below his/her waist, exposing his/her left breast; -Resident #9 was rubbing his/her hand between Resident #10's legs. Resident #9 asked Resident #10 does that feel good? Resident #10 replied yes. Resident #9 then leans over and kisses Resident #10 on his/her left breast area; -The video does not contain: *Any images of who is holding the camera; *Any images of other staff or residents; *Any identifiable voices other than Resident #9 and Resident #10. During interviews on 8/12/19 at 10:32 A.M. and 1:50 P.M., the DON at another facility said the following: -He/she was informed about the video on 8/1/19 at approximately 10:22 P.M., by FE F; -The video had been sent to FE F in a group text; -FE F called him/her to ask what action should be taken, because he/she knew who the female resident was but did not know who the male resident was in the video and was not sure the sexual activity was consensual; -The DON said he/she would call the facility and ask them to make sure the residents were safe and inform them of the video and the contents of the video; -The DON contacted the facility and spoke to the nursing supervisor to make sure the residents were okay and inform him/her about the video; -He/she then told FE F to delete the video; -He/she called the local police department to report a suspicion of a crime; -The police came to his/her facility to view the video; -He/she did not report the allegation on behalf of the other facility; -The administrator nor the DON at the other facility ever contacted him/her for a statement; -He/she never saw the video, he/she was just told about it. He/she never saw who sent the video. During an interview on 8/12/19 at 10:40 A.M., FE F said the following: -On 8/1/19 at approximate 8:00 P.M., he/she received the video on his/her cell phone; -He/she did not know who sent it. It was sent by an anonymous application (app); -He/she texted the person back and asked, Who sent the video? but did not get an answer right away; -Later he/she learned the video was sent from CNA B; -FE E was with him/her when the video arrived and they watched the video together; -FE E and FE F are former employees of the residents' facility; -FE E recognized one of the residents from the facility and knew where the video originated; -FE F called his/her DON to report the incident; -FE E called the DON from the resident's facility to tell her about the video and give her a heads up that the incident was going to be reported to the State agency and the police; -The DON from the resident's facility asked FE E to send the video to her; -FE E forwarded the video the DON at the resident's facility; -FE E said he/she received the video from LPN G; -He/she has deleted the video and knows that sending a video of any resident in a long-term care facility is a reportable offense. During an interview on 8/12/19 at 10:45 P.M., FE E said the following: -On 8/1/19 around 8:00 P.M. he/she was with

Based on interview and record review, the facility failed to ensure two of fourteen sampled residents (Residents #9 and Resident #10) were free from mental abuse, after an employee used a cell phone to video tape the residents in an intimate/sexual situation and transmit the video to former staff. The census was 185. Review of the facility's Abuse/Neglect/Exploitation Compliance and Overview policy, dated (MONTH) (YEAR), showed the following: -The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -Screening: The facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employer and/or current employers, and checking with the appropriate licensing boards and registries; -Training: New employees will be educated by the department manager, or designee on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. The facility will perform ongoing, competency testing to ensure staff education relative to abuse prohibition practices and abuse reporting requirements; -Prevention: The facility will provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of a resident's property is more likely to occur; -Identification: The facility will identify events, occurrences, patterns and trends that may constitute: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being; *Verbal abuse: means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability; *Sexual abuse: includes, but is not limited to sexual harassment, sexual coercion, or sexual assault; *Physical abuse: includes hitting, slapping, and pinching, kicking and controlling behavior through corporal punishment; *Mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation, or abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident; -Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below; -Protection: The facility will protect resident from harm during an investigation; -Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency, law enforcement and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences; -Procedure for response and reporting allegations of abuse/neglect/exploitation: -Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation; -When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated; -The licensed nurse will: *Respond to the needs of the resident and protect him/her from further incident; *Remove the accused employee from the resident care area: *Notify the Director of Nursing (DON) Services and the Administrator; *Notify the attending physician, residents' family/legal representative and Medical Director; *Monitor and document the residents' condition including response to medical treatment or nursing interventions; *Document actions taken in the medical record; *Complete an incident report and initiate an investigation; -The Director of Nursing Services, Administrator or designee will: *Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after the discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming of the suspicion; *Obtain statements from direct care staff; *Suspend the accused employee pending completion of the investigation; *Follow up with appropriate agencies, during business hours, to confirm the report was received; *Report to the state nurse aide registry or nursing board of any knowledge of any actions, which would indicate an employee is unfit for service; -The Administrator should follow up with government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final as required by state agencies; -Employee Training: New employees should be educated by the department manager on alleged violations and reporting requirements during initial orientation. Annual education and training is provided to all existing employees. Frontline supervisors can provide education as the situation arise. Review of the facility's Videotaping, Photographing, and other imaging of residents' policy, dated (MONTH) (YEAR), showed the following: -Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images and recordings during resident care or other facility activities; -For the purpose of this policy, resident image mean the likeness of a resident captured through still photography, videotaping, digital imaging, scans and audio recordings; -Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigations of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family; -Transmitting unauthorized images of any resident through email, Internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such; -Staff should immediately report suspected sexual abuse to immediate supervisor. Review of the facility's policy for Sexual Expression of Residents, dated (MONTH) (YEAR), showed the following: -It is the policy of this facility to respect all residents and their rights. This policy applies to individuals who exhibit intact cognitive decision-making capacity. Residents residing in the facility will be allowed to express themselves in the way they prefer, given they have the mental capacity to make informed decisions. -Policy Interpretation and Implementation: -The staff will document observation of residents engaging in intimacy and/or sexual activity and notify social services and the DON; -Social Services will notify the interdisciplinary team (IDT); -Social Service staff will educate the resident about any disease processes and the residents' rights; -Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression; -Residents with decisional capacity have a right to privacy, including private space for sexual expression; -Residents with decisional capacity have a right to confidentiality; -The physician will be notified regarding all residents participating in sex for clinical and cognitive evaluation to determine intact cognitive decision-making capacity and the capacity to give consent; -The decision to conduct a cognitive re-assessment will be made by the IDT and based upon noticing a change in residents' behavior; -Care plan meetings with the IDT shall be scheduled as soon as possible from the initial notification from the social service staff; -The IDT shall conduct a review of the situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of, and protects those involved; -Outcomes of the IDT review will be shared with the residents involved and documented in the care plan; -Based on the plan of care, intimacy and sexual expression shall be permitted if both parties consent and the risks do not exceed the benefits; -The facility will ensure the resident's right to privacy, including providing a private place for intimacy and/or sexual expression; -The staff will re-direct residents engaging in intimacy and/or sexual expression in public areas; -Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, and who to contact to report issues; -If, at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s); -The facility shall provide initial staff orientation and ongoing staff training, regarding abuse, intimacy and/or sexual expression as well as sensitivity awareness about residents sexual rights and staff documenting and reporting responsibilities; -The facility shall obtain consultation regarding intimacy and/or sexual expression in cases that are deemed complex or controversial; -All infection control precautions to be followed as per facility protocol. Sexual expression should be prevented where the potential for transmission of sexually transmitted infection exist; -Staff should immediately report suspected sexual abuse to immediate supervisor. -The facility's policy did not address: *What staff would assess the residents for sexual consent; *Residents that could not or were unable to express their ability to consent; *Where staff would document resident's ability to consent to a sexual relationship. Review of the facility's undated policy, Resident's Rights for Long Term Care, provided to residents, showed the following: -Have privacy and respect; You have the right to privacy in medical treatment, personal care, telephone and email communications and visits with family and meeting of resident groups. You should be treated with consideration and respect, with full recognition of your dignity and individuality. You should not be required to do things against your will; -Retain Martial Privileges; you have the right to a private visit with your spouse and may share a room with your spouse if you are both residents; -The Residents' Rights policy did not address: *Residents have the right to share a room with whomever they wish, as long as both residents are in agreement. These arrangements could include opposite-sex and same-sex married couples or domestic partners, siblings, or friends. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed the following; -Brief Interview for Mental Status (BIMS) score of 9 out of 15 (a score of 8-13 indicates moderately impaired cognition); -Able to communicate needs; -No behaviors affecting others; -Supervision required for activities of daily living (ADLs); -[DIAGNOSES REDACTED]. Review of the resident's progress notes, dated 8/1/19 at 8:53 P.M., showed the following: -Found in another room with a female resident engaging in sexual activity; -When confronted by staff, resident returned to his/her room; -Supervisor spoke with resident and told him/her, we don't encourage that kind of behavior; -Resident replied I know you don't, It just happened; -Resident's responsible party informed of the same. Stated he/she would talk with the resident about the issue; -Resident remains in his/her room with covers pulled over his/her head. Review of the resident's care plan, updated on 8/21/19, showed the following: Problem: Psychosocial, I have formed a close relationship with another resident at the facility; -Goal: I am a consenting adult and will have the support from staff through next review; -Interventions: I will be discrete while having sexual relations with respect to all concerned and respect for other residents. -The care plan did not address: *How the facility assessed the resident's ability to consent to sexual activity; *How the facility was going to accommodate the resident's wish to participate in sexual activity and provide privacy and education to the resident about sexual activity; *The resident's emotional status after finding out staff videotaped him/her in a sexual encounter. During an interview on 8/8/19 at 10:29 [NAME]M., the resident said the following: -He/she is very embarrassed by the whole situation; -He/she is grown and is able to make his/her own decisions; -He/she was a willing participant in the sexual activity with another resident; -He/she said that kind of activity should be private; -No one told him/her that someone videotaped his/her activity on 8/1/19; -He/she would never consent to having the activity videotaped; -It makes him/her very upset to know the activity was videotaped and viewed by other people; -He/she still wants to be friends with the other resident, but has been told he/she is not allowed to sit with or go into the other resident's room; -It makes him/her sad that he/she is not allowed to visit with the other resident any longer; -He/she would like the person who made the video tape go to jail. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -BIMS score of 13; -Impaired vision; -Able to communicate needs; -No behaviors affecting others; -Required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, dated 8/1/19, at 8:15 P.M., showed the following: -Found in room with a resident of the opposite sex, engaged in sexual activity; -When confronted by staff, the resident asked, Can't (he/she) have company when I want to; -Supervisor spoke with resident and told him/her, we don't encourage that kind of behavior; -Resident's responsible party notified and told staff to Keep them separated; -Resident remains in his/her room; -Other resident returned to his/her room; -Staff instructed to monitor both residents. Review of the resident's progress notes, dated 8/2/19 at 9:23 [NAME]M., showed the following: -The administrator spoke with the resident; -The resident said he/she liked Resident #9 and wanted him/her to continue to visit; -When asked if he/she were in a sexual relationship with Resident #9, the resident said no, we just pitter-patter and Resident #9 just touched his/her breast and other parts of his/her body; -When asked if the resident enjoyed the activity, the resident laughed and said yes, of course; -He/she enjoyed Resident #9's visits. Further review of the resident's progress' notes, showed no documentation the facility notified him/her of the videotape. Review of the resident's care plan, updated on 8/21/19, showed the following: Problem: Psychosocial, I have formed a close relationship with another resident at the facility; -Goal: I am a consenting adult and will have the support from staff through next review; -Interventions: I will be discrete while having sexual relations with respect to all concerned and respect for other residents. -The care plan did not address: *How the facility assessed the resident's ability to consent to sexual activity; *How staff would address and accommodate the resident's expressed wish to continue with a sexual relationship with another resident; *The resident's emotional status after finding out staff videotaped him/her in a sexual encounter. During an interview on 8/8/19 at 11:20 [NAME]M., the resident said the following: -The interaction with Resident #9 was consensual. He/she was in the privacy of his/her own bedroom; -He/she enjoys the company of the other resident; -He/she would never give anyone permission to videotape private activities; -He/she was unaware the activity had been videotaped; -No one told him/her there was a videotape; -He/she wants the person who videotaped the activity to go to jail; -The police have not spoken to him/her or asked for a statement; -He/she has never and would never put him/herself on display; -It is disgusting and he/she is very upset about it; -He/she cried throughout the interview. Review of the facility's undated and unsigned investigation provided by the administrator on 8/8/19, showed the following: -8/1/19 at 11:08 P.M., the DON called the administrator and told her of a supposed video made by one of the facility's staff, of two residents having sex and that the video was sent to a former staff person working at another long term care facility; -The administrator replied that is a heck of an allegation, and said we need to find out the name of the staff person and need the video; -The DON said she would call the DON at the other facility to obtain the name of the staff person and get a copy of the video; -8/2/19 at 12:24 [NAME]M., the administrator received a call from the facility's evening/night nurse supervisor. The nurse reported he/she received a call from the DON of another long-term care facility. That DON reported one of his/her staff had received a video of two of the facility's residents involved in sexual activity; -The administrator asked the supervisor if the residents were Resident #9 and Resident #10, who had engaged in sexual activity earlier in the evening and the supervisor said yes; -The administrator was aware the residents had been involved in a consensual sex act; -The supervisor was not aware the incident had been videotaped by staff; -The supervisor asked the administrator who videotaped the residents and the administrator said she believed it was Certified Nursing Assistant (CNA) B; -The supervisor told the administrator that CNA B left the facility at 9:00 P.M.: -The administrator told the supervisor she needed a copy of the video before making such an allegation; -1:11 (no date or AM/PM noted), the administrator sent a text to their facility's DON and told her to try and get to work by 7:00 [NAME]M., so they could terminate CNA B if need be; -5:25 [NAME]M., the facility's DON sent a text saying she had a copy of the video; -6:18 [NAME]M., the administrator sent a text to the Human Resource (HR) department head to be in the administrator's office by 7:00 regarding an employee situation; -6:55 [NAME]M., the DON, HR director and administrator met. The DON had viewed the video she received from an employee at another nursing facility; -She felt the situation between the residents was clearly consensual intimacy between the residents and it was proof CNA B had indeed created a video; -The agreement was they would terminate CNA B for a Health Insurance Portability and Accountability Act-(HIPPAA- legislation that provides data privacy and security provisions for safeguarding medical information) violation as well as violating Residents' Rights and would report to the State; -7:00 [NAME]M., CNA B has not arrived for his/her shift; -8:00 [NAME]M., HR and the administrator met with CNA B. He/she had his/her phone. HR explained to CNA B he/she was being suspended for a violation of HIPPAA; -CNA B questioned why he/she was being suspended; -The administrator told CNA B, he/she was being suspended for a HIPPA violation. The facility had evidence he/she videotaped residents on his/her phone and sent the video to at least one former employee who worked at a nearby facility; -CNA B denied the allegation; -The administrator told CNA B to delete the video off his/her phone and have his/her friends delete the video off of their phones or CNA B would be liable for up to $25,000.00 fine; -CNA B continued to deny the allegation and refused to sign the suspension notice and left the building; -8:20 [NAME]M., a message was left for the Region 7 Program Manager; -8:30 [NAME]M., a call was placed to the Region 7 office. The office was informed of the allegation and was told the facility had been in contact with the other facility and with the police; -The sexual act on the tape was consensual. The Region 7 office would provide the facility with a report number; -12:30 P.M., a police officer called the administrator and the administrator provided the police officer with CNA B's name and contact information; -The police officer said he/she would follow up with CNA B and present the case to the prosecuting attorney. This was seen as a sex crime because of the resident's breast being exposed in the video; -2:30 P.M., HR called CNA B to tell him/her, he/she was terminated from the facility; -Attachments to the statement included the following: -Written statements from the DON, the evening/night supervisor and the direct care staff working on the evening shift of 8/1/19; -Staffing assignments for 8/1/19; -Inservice and training information provided to staff, on 7/17/19, regarding residents' rights and the staff roster who attended the inservice (the roster included CNA B's signature); -Additional inservice training done by the facility on 8/5/19 and 8/7/19; -Inservice training was provide to staff on 8/5/19 and 8/7/19, was the same inservice information provided to staff on 7/16 and 7/17/19, No new additional information was provided; -Review of the attendance roster for the inservices provided on 8/5 and 8/7/19, showed 21 staff signatures. -The investigation did not include: *A written statement from CNA B; *Any inservice training provided to staff after the 8/1/19 incident and prior to 8/5/19; *Any written statements from any residents including Residents #9 and #10; *A conclusion of the investigation. Review of the undated, typed statement provided by the facility's DON, showed the following: -On 8/1/19, he/she received a phone call around 10:45 P.M., from former employee (FE) E; -FE [NAME] said something about a video and people having sex; -The DON was not quite awake and was not sure what the FE was talking about; -The DON called the FE [NAME] back at 10:51 P.M., and asked him/her to explain in detail what was going on; -FE [NAME] went on to say that a CNA from the facility had made and sent a video recording of two residents having sex; -The CNA was a friend of another nurse, (FE) F working at his/her facility; -FE F was able to identify Resident #10 by name, but did not know who Resident #9 was; -FE F reported the incident to his/her DON and his/her DON was going to report the incident to the State; -FE [NAME] did not provide the name of the CNA that recorded and sent the video; -At 11:08 P.M., he/she notified the administrator of the allegation a current employee had videotaped two of their residents during sexual activity; -FE [NAME] reported, the DON at the other facility said he/she was going to notify the State agency of the video; -At 5:30 [NAME]M., he/she woke up and checked his/her phone for messages. The nurse from the other facility had sent the video and the name of CNA B; -He/she notified the administrator he/she had a copy of the video and the name of the sender. Review of the Department of Health and Senior Services (DHSS) Region 7's call log, showed the facility notified the State Agency on 8/2/19 at 9:56 [NAME]M., of the allegation. Review of the evening/night shift supervisor's typed and signed statement, dated 8/1/19, showed the following: -Time; 8:15 P.M., -Incident involved Residents #9 and #10; -Was called to the residents' hall by Certified Medication Technician (CMT) C; -He/she spoke with Resident #10 about Resident #9 being in his/her room; -Resident #10 was upset and asked, Can't I have company, if I want to? The resident was upset Resident #9 had left the room; -At 9:30 P.M., he/she received a telephone call from a person that identified himself or herself as the DON at another facility. The person said one of the nurses at his/her facility had received a video text on his/her personal cell phone of two residents at the facility engaged in sexual activity. He/she said it was a CNA who worked at the facility that sent the video; -The supervisor asked for the name of the CNA that sent the video; 11:40 P.M., The caller called the facility back and gave the supervisor the name of the CN[NAME] The caller did not send the video. The supervisor said she would notify his/her administrator; -12:24 [NAME]M., the supervisor notified the administrator of the allegation, a staff member had videotaped and texted the video to a former employee at another facility. He/she provided the administrator with the CNA's name and reported CNA B had left the facility around 9:00 P.M. During an interview on 8/2/19 at 8:40 [NAME]M., with the DON and administrator, the administrator said the following: -CNA B has been terminated from the facility; -No one has a copy of the video because she was told by the police, to delete it; -The police have a copy of the video and will pursue the issue; -CNA B was told to delete the video and tell his/her friends to do the same; -All allegations of abuse or neglect should be reported immediately to the State agency; -CNA B did not provide a written statement prior to exiting the facility; -Both residents' responsible parties (RP) have been notified of them being involved with sexual activity, but neither the residents nor their RPs have been notified the residents had been videotaped; -Inservice training was provided to staff on 8/5/19 and 8/7/19, It was the same inservice provided on 7/16 and 7/17/19, No new additional information was provided; -Review of the attendance roster for the inservice training provided on 8/5 and 8/7/19, showed 17 staff signatures. During an interview on 8/8/19 at 9:41 [NAME]M., the DON said the following: -On 8/1/19, at around 10:45 P.M., she was notified by a former employee that a current employee had posted a video of two residents at the facility engaged in sexual activity; -The former employee was able to verify the female resident by name; he/she could not identify the male resident; -The former employee would try to send the DON a copy of the video; -The former employee identified the person who originally sent the video as CNA B; -On 8/1/19 at approximately 11:08 P.M., she notified the administrator of the allegation a current employee had videotaped residents in sexual activity and posted it online; -The administrator is the abuse/neglect coordinator at the facility and usually calls the State agency with self-reports; -The former employee texted the DON the video on 8/2/19, at approximately 5:30 [NAME]M.; -The DON viewed the video and was able to positively identify Residents #9 and #10 as current residents, residing in the facility; -The administrator and the HR director met with CNA B at approximately 8:00 [NAME]M., on 8/2/19, and suspended him/her for a HIPPA violation; -The DON was told to delete the video and does not have a copy of it; -The corporate nurse may have a copy of the video. During an interview on 8/8/19 at 12:00 P.M., the facility's corporate nurse said she would be able to provide a copy of the video. She provided a copy to the surveyor at 12:12 P.M. She positively identified the people in the video as Resident #9 and Resident #10. The allegation is a reportable offense and should have been reported to the State agency in the required time frame. Review of the (undated, with no time) video, showed the following: -Resident #9 sitting on the edge of Resident #10's bed; -Resident #10 was lying in the bed; the sheet was below his/her waist, exposing his/her left breast; -Resident #9 was rubbing his/her hand between Resident #10's legs. Resident #9 asked Resident #10 does that feel good? Resident #10 replied yes. Resident #9 then leans over and kisses Resident #10 on his/her left breast area; -The video does not contain: *Any images of who is holding the camera; *Any images of other staff or residents; *Any identifiable voices other than Resident #9 and Resident #10. During interviews on 8/12/19 at 10:32 [NAME]M. and 1:50 P.M., the DON at another facility said the following: -He/she was informed about the video on 8/1/19 at approximately 10:22 P.M., by FE F; -The video had been sent to FE F in a group text; -FE F called him/her to ask what action should be taken, because he/she knew who the female resident was but did not know who the male resident was in the video and was not sure the sexual activity was consensual; -The DON said he/she would call the facility and ask them to make sure the residents were safe and inform them of the video and the contents of the video; -The DON contacted the facility and spoke to the nursing supervisor to make sure the residents were okay and inform him/her about the video; -He/she then told FE F to delete the video; -He/she called the local police department to report a suspicion of a crime; -The police came to his/her facility to view the video; -He/she did not report the allegation on behalf of the other facility; -The administrator nor the DON at the other facility ever contacted him/her for a statement; -He/she never saw the video, he/she was just told about it. He/she never saw who sent the video. During an interview on 8/12/19 at 10:40 [NAME]M., FE F said the following: -On 8/1/19 at approximate 8:00 P.M., he/she received the video on his/her cell phone; -He/she did not know who sent it. It was sent by an anonymous application (app); -He/she texted the person back and asked, Who sent the video? but did not get an answer right away; -Later he/she learned the video was sent from CNA B; -FE [NAME] was with him/her when the video arrived and they watched the video together; -FE [NAME] and FE F are former employees of the residents' facility; -FE [NAME] recognized one of the residents from the facility and knew where the video originated; -FE F called his/her DON to report the incident; -FE [NAME] called the DON from the resident's facility to tell her about the video and give her a heads up that the incident was going to be reported to the State agency and the police; -The DON from the resident's facility asked FE [NAME] to send the video to her; -FE [NAME] forwarded the video the DON at the resident's facility; -FE [NAME] said he/she received the video from LPN G; -He/she has deleted the video and knows that sending a video of any resident in a long-term care facility is a reportable offense. During an interview on 8/12/19 at 10:45 P.M., FE [NAME] said the following: -On 8/1/19 around 8:00 P.M. he

Based on observation, interview and record review, the facility failed to obtain x-rays in a reasonable time frame after one resident complained of left hip pain. Once facility staff learned the resident had a [MEDICAL CONDITION] they failed to obtain new orders within a reasonable time when the resident complained of left hip pain. The facility also failed to follow their hospice contract, which stated to notify the hospice physician when one resident had repeated emesis through his/her tracheotomy. This effected two of 25 sampled residents (Residents #5 and #16). The census was 186. 1. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/17, showed the following: -Brief interview of mental status (BIMS) score of 0 out of a possible score of 15, (0-7 indicates severe impairment); -[DIAGNOSES REDACTED]. -Limited assistance, with one person physical assist for dressing, toileting, personal hygiene and bathing; -Cane used for mobility; -Two falls without injury; -Two non-major falls with injuries such as skin tears, bruising or sprains. Review of the resident's care plan, dated 7/14/17 through 7/20/17, showed the following: -Focus: -At risk for falls related to being unaware of safety needs, wandering, gait/balance problems, and dementia; -Used wheeled walker, which resident will leave behind; -On 4/16/17, had an incident where he/she was found asleep on the floor with a blanket and pillow. He/she was found with a hematoma and bruise; -On 5/31/17, had an actually fall with abrasions to the elbow; -On 7/15/17, had a fall with pain noted to his/her hip; -On 7/15/17, had a fall with an injury to his/her head; -Goal: be free from falls through the next review date; -Interventions: -Use longer extension on the resident's oxygen to assist when he/she tries to get out of his/her wheelchair or bed started on 4/21/17; -Anticipate and meet the resident's needs; -Encourage the resident to participate in activities that promote exercise. Physical therapy for strengthening and improved mobility; -Follow the fall protocol; -Ensure appropriate footwear when ambulating or mobilizing; -Physical and occupational therapy evaluations as ordered or as needed; -Forgetful of his/her walker and attempts to sit on it. Staff to monitor and assist to site when needed. Occupational therapy to evaluate if the use of his/her seated walker continues to be functional; -Send to the hospital to evaluate and treat left [MEDICAL CONDITION]. Review of the resident's nurse's notes, dated 7/15/17, showed the following: -At 6:33 P.M., Nurse B heard the resident yell help. He/she entered the room and observed the resident alert to self, sitting on the floor with his/her pants and brief next to him/her. The resident said help me. Passive range of motion of all extremities, the resident complained of left hip pain. The legs appeared the same length with no visible deformity. A body assessment was completed with no redness noted. Vital signs and neuro checks (assessments to monitor for level of consciousness changes after a head injury) within normal range. Passed to oncoming nurse to notify the physician and family; -At 8:42 P.M., Nurse G made several attempts to contact the primary care physician through the weekend on-call phone and exchange, the attempts were unsuccessful. Resident complained of left hip pain. Orders obtained from the physician to get an x-ray to the hip; -At 8:47 P.M., Assistant Director of Nurses (ADON) JJ observed the resident on the floor next sitting on his/her buttocks. Blood noted to the left side of his/her head. Hematoma (a collection of blood outside of a blood vessel) with small open area noted. The resident said he/she tried to get out of bed, fell and bumped his/her head. Neuro checks were within normal limits. Several attempts to contact the physician were made without success. The resident's family member was notified and said to call in the morning with any changes or if the resident was sent to the emergency room . The resident rested in bed with the head of bed elevated. No pain or discomfort at this time. Bed in low position and call light in place; -At 10:03 P.M., Nurse G received an x-ray claim number for the left hip; -At 10:43 P.M., the resident remained on fall follow up. Review of the residents Medication Administration Record [REDACTED] -During the 7:00 A.M. through 3:00 P.M. shift, pain was 0 of 10 (no pain); -During the 3:00 P.M. through 11:00 P.M. shift, pain was 4 of 10 (moderate pain); -During the 11:00 P.M. through 7:00 A.M. shift, pain was 5 of 10 (moderate to severe pain); -No documentation of the administration of any pain medication during these shifts. Review of the resident's nurse's notes, dated 7/16/17, showed the following: -At 6:49 A.M., remained on fall follow up. Slept until 6:00 A.M., he/she wanted to get up but couldn't because of pain to his/her left hip. An as needed Tylenol ([MEDICATION NAME], over the counter pain medication) given. Nurse X followed up with the x-ray company, changed it to stat and was informed the x-ray technician would be out within an hour; -At 12:41 P.M., at or around 10:30 A.M., the resident's family member approached this nurse and had concerns about the x-ray to the resident's left hip being obtained. This nurse explained the company had been notified twice. The family member said the resident was in pain. The nurse explained the resident received a pain pill and the family member would be notified of the x-ray results when they were available; -At 12:44 P.M., the weekend on-call phone had been paged twice regarding the results of the x-ray which showed concern for a left intertrochanteric fracture with mild displacement of the left hip. Will continue to attempt to contact the physician to report the results; -At 1:41 P.M., the resident remains on fall follow up. Remained in bed the entire shift and complained of pain to the left hip when touched. Resident given an as needed [MEDICATION NAME] 650 milligrams (mg), which was not effective. Resident x-ray completed and the results are in. It is now 1:44 P.M. and the physician has been paged four times with no call back. Resident had a fracture to the left hip, will continue to keep paging the physician for further instructions. Bilateral lower extremities elevated, [MEDICAL CONDITION] (swelling) to the bilateral lower extremities, but no evidence of pain when palpated. Staff will continue to monitor; -At 5:34 P.M., several attempts to report the x-ray results to the physician. Call placed to physician, was given an order to send the resident to the emergency room . Director of Nursing (DON) and power of attorney made aware of the results; -At 6:25 P.M., the resident was transported to the hospital. Review of the resident's MAR, dated 7/16/17, showed the following: -During the 7:00 A.M. through 3:00 P.M. shift, pain was 5 of 10; -At 9:50 A.M., 650 mg of [MEDICATION NAME] was administered. The pain level was 5 of 10; -During the 3:00 P.M. through 11:00 P.M. shift, pain was 8 of 10 (very severe pain); -At 6:08 P.M., 650 mg of [MEDICATION NAME] was administered. The pain level was 7 of 10 (severe to very severe pain). Review of the resident's nurse's notes, dated 7/19/17 at 6:36 P.M., showed he/she returned to the facility with 20 staples to the left side of his/her hip. During an interview on 8/15/17 at 10:40 A.M., the resident would only said hi and did not engage in further conversation. During an interview on 8/18/17 at 11:37 A.M., Certified Nursing Assistant (CNA) E said he/she heard the resident say ouch when the nurse touched his/her hip for evaluations on 7/15/17 during the first or second shift. During an interview on 8/25/17, at 1:08 P.M. Nurse G said he/she could not recall what time she arrived at the facility on 7/15/17, but it was for the second shift. When Nurse G arrived the resident sat on his/her seated walker and seemed fine. When he/she asked the resident to stand up straight the resident said he/she felt pain in his/her hip. Nurse G started calling the resident's primary care physician at approximately 3:30 P.M., but could not reach him/her and could not leave a voicemail. Nurse G contacted the DON, the DON said she had the physician's personal phone number and would call and provided no further instructions. She reached the on-call physician at approximately 4:30 P.M. Nurse G did not recall what time he/she spoke to the x-ray company. He/she charted the x-ray confirmation at 10:03 P.M. but it was not the actual time it was called in. Nurse G called in the x-ray as stat. Ideally stat means right away, but that is not how it goes. Nurse G did not work in the resident's building the entire night, he/she switched to another building. He/she thought he/she administered pain medication to the resident before leaving, but was uncertain. Nurse G provided report to the nurse covering the building before he/she left. During an interview on 8/18/17 at 11:10 A.M., Nurse C said the resident was always up and about on his/her third shifts, and it was abnormal for the resident to remain in bed all night on 7/15/17. He/she received information during shift change about the resident's condition and re-called the x-ray company because they had not come and they said it would be within the hour. The resident appeared fine all night, it was not until the resident woke up that he/she complained of pain. If staff could not reach a physician they have the DON's phone number and are to call her so she can try to reach out to the physician and provide guidance. During an interview on 8/18/17 at 11:55 A.M., Nurse D, during the first shift on 7/16/17, he/she knew the resident fell on [DATE] and the x-ray had not been completed. On 7/16/17, the resident's family member asked what was taking so long and said it needed to be done because the resident was in pain. Nurse D called the x-ray company and asked what the delay was. The x-ray company said they were still working on it and had no explanation why it was taking so long. The nurse knew it was not the first call to the x-ray company. When he/she had trouble reaching the physician or getting the x-ray he/she should have called the DON and see if the DON could reach the physician. He/she was not sure why he/she did not call the DON after several attempts to reach the physician, but probably should have. The resident was in pain, he/she grimaced, said it hurts and it felt like he/she got shot. It was not normal for the resident to be in bed an entire shift, he/she is usually up. During an interview on 8/18/17 at 11:24 A.M., CNA F, during the second shift on 7/16/17 he/she said the resident was in pain, he/she grimaced. The CNA felt uncomfortable with providing care because of the resident's pain and he/she did not want to cause additional pain. He/she had the resident turn himself/herself and encouraged the resident to take it slow and easy. The resident said he/she was fine except his/her hip hurt. The resident was in bed the entire time but usually is up wheeling himself/herself around the unit. During an interview on 8/17/17 at 8:57 A.M., ADON JJ said she would have expected staff to call the physician and responsible person as soon as the resident complained of pain after the fall. Staff should have informed her or someone if they could not reach the physician. It should have only taken approximately two hours for the x-ray to be completed. The x-ray company is usually at the facility within an hour or two. The resident should have been sent out if staff could not reach the physician. Five hours was too long for the resident to have had a confirmed fracture and not been sent out for treatment or have orders from the physician. During an interview on 8/30/17 at 8:29 A.M., a dispatcher with the x-ray company said the order was called in by Nurse G on 7/15/17 at 3:59 as a regular order. The x-ray technician had not been out to the facility on [DATE] so the order was changed on 7/16/17 at 2:00 A.M. to be done on 7/16/17. At 7/16/17 at 6:32 A.M. the facility changed the order to stat. The x-ray was completed at 10:35 A.M. and the results were faxed at 11:40 A.M. There are no set turn around times for stat or regular orders. During interviews on 8/17/17 at 1:00 P.M. and 8/18/17 at 2:54 P.M., the DON said the resident fell twice on 7/15/17, once at 6:30 P.M. and then again at 8:40 P.M. X-rays usually takes up to four hours to get. Staff should offer pain medication when a resident had complaints of pain, however it is not always documented if they had offered and the resident refused. The number listed in the notes is confirmation the x-ray was ordered, however the note is when the nurse had time to make the note not necessarily when the x-ray was ordered. The x-ray should have been completed before 10:30 A.M., the next day, when the resident's family member asked about it. The physician should have been notified the x-ray was taking longer than expected. She expected staff to contact her if they could not reach the physician. There is no policy, but they should know to contact her and they have her cell phone number. She has the physicians' personal phone numbers staff do not have access to. In the past, she has had to call physicians using those numbers and is usually successful at reaching them. Staff can send out a resident without an order if it is an emergency situation, there is no policy that says they would have to wait. The staff should have called her and if she couldn't have gotten a response from the physician then she would have sent the resident out. During an interview on 8/17/17 at 1:00 P.M., the administrator said nurses do not have to get an order or call the physician in an emergency situation, a resident can be sent out to the hospital. During an interview on 8/31/17 at 8:15 A.M., the resident's physician, who is also the facility medical director, said if the resident had an order for [REDACTED]. X-rays are usually done rather quickly, he was uncertain what took so long. He was under the impression there were delays in orders because the on-call physician did not call back quickly. It was a nursing decision, but the nurse could have called the x-ray company every hour to get the x-ray more quickly. Once the fracture was identified, neither the facility nor the hospital would done much other than sedate the resident because surgery would not have been done until the weekday. It was a nursing call, but if the resident had complaints of pain and the pain medication was ineffective the nurse should have asked for more pain medications. The pain needed to be controlled. The resident had surgery to repair the [MEDICAL CONDITION]. 2. Review of Resident #16's care plan, dated 6/27/17 and in use at the time of the survey, showed: -Focus: Activities of daily living (ADLs, dressing, eating, bathing, etc.) care: -Goal: Requires two person assist; -Interventions: Extensive assistance needed with ADLs; -Focus: Hospice level of care: -Goal: All needs will be anticipated and met by the nursing and hospice staff; -Interventions: Give medications as ordered, make sure the call light is in reach, monitor/document level of consciousness, mental status and lethargy (a feeling of weariness, tiredness, or lack of energy) as needed; -Focus: Alteration in neurological status: -Goal: Maintain optimal status and quality of life within limitations imposed by neurological deficits; -Interventions: Assess for effects of [MEDICAL CONDITION] medications, range of motion with AM/PM care daily and reposition/ambulation as tolerated at least every two hours; -Focus: Hypertension (high blood pressure) medications: [REDACTED] -Goal: Remain free of complications related to hypertension; -Interventions: Monitor/document/report to physician as needed any signs or symptoms of malignant hypertension: Headache, visual problems, nausea and vomiting; -Focus: [MEDICAL CONDITION] (tube surgically inserted into the trachea (throat) for the purpose of breathing) related to impaired breathing mechanics: -Goal: Have no signs or symptoms of infection; -Interventions: Monitor/document level of consciousness, mental status and lethargy, suction as necessary; -Focus: Alteration in gastro-intestinal status disease process gastrostomy tube ([DEVICE], a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication), increased salivation: -Goal: Remain free from discomfort, complications or signs and symptoms related to gastro-intestinal alteration; -Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. Head of bed elevated 45 degrees to avoid aspiration (breathing in solids or fluids). Review of the resident's admission MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -A brief interview of mental status (BIMS) score of 0 out of a possible score of 15, showed the resident had severe cognitive impairment; -Total dependence required for eating, personal hygiene, bathing and transfer; -Feeding tube. Review of the resident's hospice company interdisciplinary care plan, dated 6/27/17, showed hospice staff will instruct facility staff to notify hospice of any change in condition. Review of the resident's hospice company case sheet, dated 6/28/17, showed: -Referral date of 6/27/17; -Primary Diagnoses: [REDACTED]. -Secondary Diagnoses: [REDACTED]. Review of the hospice care facility responsibility policy, revised November 2016, showed: -It is the policy of the facility to improve quality and consistency of care between hospice and the facility in provision of care to our residents in order to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -The facility must delegate a member of the facility's interdisciplinary team that is responsible for working with hospice representatives to coordinate care; -The designated interdisciplinary team member is responsible for: -Collaborating with hospice representatives and coordinating the facility staff participation in the hospice care planning process for those residents receiving these services; -Communicating with hospice and other healthcare providers participating in the provision of care for the terminal illness, related conditions and other conditions, to ensure quality of care for the patient and family; -Ensuring that the facility communicates with the hospice medical director, the patient's attending physician and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. Review of the coordination of hospice services policy, updated November 2016, showed: -To assure that residents receiving hospice services receive coordinated care that provides the highest quality care and services possible in accordance with the resident's wishes; -The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of hospice care; -Treatment: Factors influencing the choice of treatments include: -The underlying [DIAGNOSES REDACTED].> -The cause, location, nature and severity of the [DIAGNOSES REDACTED].> -Possible adverse effects; -Other symptoms such as uncontrolled nausea, constipation or vomiting; -Promote a comforting environment with the following interventions but not limited to: -Turning and repositioning to a comfortable position; -Cognitive/behavioral interventions (e.g., music, diversions, pain education); -Procedure: -The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility; -The facility will monitor and evaluate the resident's response to the hospice care plans; -The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities; -The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary; -The facility will monitor for medications and medical supplies to ensure they are provided by hospice as needed for palliation and management of the terminal illness. Review of the undated hospice company's hospice guidelines, showed the hospice company is available 24 hours a day and seven days a week. Telecare staff are just a phone call away. Clinicians in Telecare are hospice-trained nurses and secretaries ready to assist with any after-hour patient needs, such as supplies, equipment questions, medication help or answers to questions. Telecare nurses will assess symptom issues and provide the appropriate direction over the phone to help alleviate the symptoms as quickly as possible. When necessary, Telecare can dispatch a nurse, social worker or Chaplin to help with any symptoms or issues. When to call: -When there are pain issues; -When there are breathing problems; -If the patient falls; -If there is nausea or vomiting; -When there is a change in condition; -If the patient is running a fever; -If low on medications; -If low on covered supplies; -If there are any questions; -If you think you need to call 911; -If you think the person needs to go to the hospital; -Any time you need any assistance. Review of the resident's POS, dated July 2017, showed: -An order dated 6/27/17, to be admitted to hospice; -An order dated 6/28/17, to suction as needed every two hours for [MEDICAL CONDITION]; -No orders for medications to treat nausea and vomiting. Review of the resident's progress notes, showed: -On 6/27/17 at 11:20 P.M., the resident arrived to the facility with an intact [MEDICAL CONDITION]; -On 8/15/17 at 5:38 P.M., that the resident had emesis (vomiting) times two; -On 8/16/17 at 8:04 A.M., the resident had an emesis times two and one time had been projectile (used to describe severe vomiting that forcefully projects outward). The emesis dark brown and watery in color, with dark brown [MEDICAL CONDITION]. The doctor notified and advised to contact hospice for the resident's nurse. Observation on 8/16/17 at 5:15 A.M., showed: -The resident in bed with the head of bed slightly raised; -Dark color emesis, splattered on the resident's neck, around the [MEDICAL CONDITION] insertion site, on the resident's chest, a towel, the resident's gown and on the bed linen; -Dark colored emesis on the window blind, air conditioning unit, the floor, a chair and the wall at the foot of the bed. That emesis was expelled a distance of 4 feet up to 6 feet from the resident's [MEDICAL CONDITION] stoma. During an interview on 8/16/17 at 5:15 A.M., Licensed Practical Nurse (LPN) O said an episode of emesis had happened earlier in the shift, also. Review of the resident's hospice visit summary sheet, dated 8/16/17, showed: -The hospice nurse visited at 9:35 A.M.; -The resident nauseated and vomiting; -Low grade temperature; -[MEDICATION NAME] (medication to treat nausea and vomiting) and Bactrim (antibiotic) started; -Facility staff educated on dosage and signs and symptoms of side effects. During an interview on 8/16/17 at 8:30 A.M., the DON said that resident is on hospice and staff are keeping him/her comfortable. If the emesis was continuous, if he/she had two bouts, staff should notify the physician. She would expect staff to conduct an assessment and would want to know the cause, maybe he/she had an upset stomach or the bed may have been lowered to fast. On 8/16/17 at 1:00 P.M., the DON said that she had not read the hospice guidelines but she would expect staff to call hospice per their guidelines. Residents on hospice should receive the same services as resident who are not on hospice. Review of an undated statement, provided by the facility on 8/21/17, showed on 8/16/17 at 8:26 A.M., the hospice company ordered [MEDICATION NAME] 10 milligram per [DEVICE] every six hours and to hold the tube feeding from 11:30 A.M. to 6:00 A.M. on 8/17/17, contact hospice with any further changes. On August 17 and 18, the resident had no further emesis. 3. Review of the facility Change in a Resident's Condition or Status policy, revised 11/2015, showed the following: -Our facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: An accident or incident involving the resident, a discovery of injuries of an unknown source, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, a need to transfer the resident to a hospital/treatment center; -A significant change of condition is a decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more that one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan and ultimately is based on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument; -Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status; -The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to adequately assess and put safety measures in place for one resident, who complained of his/her leg falling off the wheelchair pedal. Staff were aware of the problem. During transport, his/her leg fell off the wheelchair pedal and was caught under the wheelchair resulting in a fracture. In addition, the facility left a confused resident unattended at a doctor's appointment, failed to update one residents care plan to address multiple falls, ensure the safety of one resident with half side rails and left carpet cleaner in a unlocked cabinet in an area assessable to confused residents. (Residents #11, #9, #18, #5 and #2). The census was 185. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/16, showed the following: -[DIAGNOSES REDACTED]. -Short term memory loss; -No behaviors; -Required extensive staff assistance for bed mobility; -Required total staff assistance for transfer, dressing, personal hygiene and bathing. Review of the resident's care plan, updated 7/23/16, showed the following: -Problem: Self care deficit related to dementia and limited mobility. Required extensive to total care with activities of daily living, dressing, and toileting; -Interventions: Required extensive to total care with showering, and mobility. Wheelchair for mobility. Transferred with the assist of two staff and a standup lift (mechanical device used for resident's able to bear weight). Review of the resident's radiology report, dated 8/16/16, showed the following: -Faxed to the facility at 10:49 P.M.; -Examination: Right foot. Conclusion: Right foot swelling, no fracture or osteo[DIAGNOSES REDACTED] (bone infection); -Right ankle results: Ankle swelling, distal tibial (shin bone) shaft fracture. Review of the resident's progress notes, showed the following: -No progress note for 8/16/16; -(First progress note regarding the resident's right lower leg) 8/17/16 at 12:50 A.M.: Resident called 911 from his/her cell phone to be sent to the hospital because his/her foot hurt. The nurse asked the resident why he/she didn't ask for a pain pill, the resident said he/she didn't know why. Emergency medical technicians (EMTs) transported the resident to the hospital. Review of the resident's hospital discharge instructions, dated 8/17/16 at 6:46 A.M., showed the following: -Diagnosis: [REDACTED]. -Medications given in the emergency room : hydromorphone (Dilaudid, a narcotic medication used to treat moderate to severe pain) 1 milligram (mg) intravenous, given for pain; -Placed in split cast and is expected to heal without surgery, keep elevated as much as possible, non weight bearing; -Pain control: Percocet (oxycodone with 325 mg acetaminophen, narcotic used to treat moderate to severe pain) every six hours as needed for pain. During an interview on 9/19/16 at 1:20 P.M., the resident said his/her right leg was fractured after his/her foot fell off the pedal and was caught under the wheelchair. The wheelchair pedal doesn't lock well and his/her leg falls off. He/she has told several staff members about the wheelchair pedal. These aren't the original wheelchair pedals, staff misplaced the original pedals. He/she called the 911 ambulance because his/her foot hurt. The ambulance driver put the Velcro strap around his/her leg to keep his/her leg from falling off after the incident occurred. During an interview on 9/20/16 at 8:35 A.M., the resident's family member said the resident called him/her at home and said the leg injury occurred when the transportation aide was bringing the resident into the facility. During an interview on 9/20/16 at 8:40 A.M., Certified Medication Technician (CMT) HH said they need to make the leg rest shorter to accommodate the resident's leg. He/she didn't recall the resident telling him/her, his/her leg was falling off the pedal. The Velcro strap on the wheelchair used to hold the leg in place wasn't applied until after the resident hurt his/her right leg. During an interview on 9/20/16 at 9:45 A.M., the therapy director said the last time the resident was seen by therapy was April 2015. She didn't recall any staff reporting a problem with the wheelchair pedals. During an interview on 9/21/16 at 5:40 A.M., Certified Nurse Aide (CNA) DD said the resident would tell him/her each time he/she returned from dialysis, the wheelchair pedal on the right side wouldn't lock in place and his/her leg would fall off. The resident has had the wheelchair for about six months and said the right wheelchair pedal comes loose and swings outward. He/she didn't tell anyone about the wheelchair pedal. During an interview on 9/21/16 at 7:48 A.M., CNA CC said the resident's brake on the wheelchair wouldn't lock during transfers. He/she didn't know the resident's leg was broken but noticed he/she was using a Velcro strap to hold the leg in place. During an interview on 9/21/16 at 9:07 A.M., CMT N said he/she noticed one day the right wheelchair pedal had fallen off and was in the van. This happened before the resident's leg was broken. He/she noticed the Velcro strap being used after the resident's leg was broken. He/she didn't know who put the Velcro strap on the wheelchair. During an interview on 9/21/16 at 11:00 A.M., van driver Z said he/she takes the resident to dialysis three times per week on Tuesday, Thursday and Saturday. On Tuesday 8/16/16, he/she returned with the resident from dialysis and while pushing the resident into the building, the resident's right foot came off the pedal and was caught under the wheelchair. The resident said to stop because his/her foot had come of the pedal. He/she stopped at that time, placed the resident' foot back on the pedal and reported it to the nurse. The resident said he/she wasn't feeling well and his/her foot hurt. He/she reported the incident to the East Unit manager prior to taking the resident to his/her room. He/she wrote a statement about the incident and gave it to the East Unit nurse manager. When he/she returned from vacation on 9/6/16, he/she asked therapy for a strap to hold the resident's leg in place. One of the therapists instructed him/her to get one of the Velcro straps from the shelf to use. During an interview on 9/21/16 at 12:10 P.M., Nurse EE said he/she worked the evening shift on 8/16/16. The resident informed him/her van driver Z bumped his/her foot when he/she returned to the facility from dialysis. He/she assessed the right foot and didn't see any bruising or swelling. The resident complained of pain, asked for his/her pain medication and he/she administered oxycodone. The van driver told the unit manager of the incident. The East Unit Manager told him/her the x-ray of the resident's right foot was ordered for that evening. Nurse EE didn't recall when the x-ray was done or whether he/she saw the results prior to leaving his/her shift. The nurse didn't know why he/she didn't document the resident's complaints of pain or the incident in the progress notes. Review of the resident's medication administration record (MAR) for August 2016, showed no documentation the resident received any medication for pain. In addition, the order, for oxycodone was obtained after the resident returned from the emergency room . During an interview on 9/21/16 at 1:06 P.M., CMT HH said he/she took care of the resident on the evening of 8/16/16. The resident usually returned from dialysis around 4:30 P.M. or 5:00 P.M. Another CNA helped him/her transfer the resident to bed with a Hoyer (a mechanical lift used to to transfer residents who are unable to bear weight) but doesn't remember who the CNA was. The resident complained of pain when he/she turned him/her in bed, but CMT HH thought the pain was from the pressure of the resident's weight on the right side. When he/she brought the resident his/her evening tray he/she complained of pain and wanted a pain pill, and the CMT told the nurse. During an interview on 9/23/16 at 7:50 A.M., CNA J said he/she worked on the evening of 8/16/16, but didn't assist with putting the resident to bed. He/she answered the resident's call light that evening and the resident was crying, complaining of pain and saying his/her right foot fell off the wheelchair pedal when the van driver was bringing him/her into the building. He/she told the nurse but doesn't know how long it took the nurse to go and see the resident. The CNA recalled the resident's foot would fall off the leg pedal occasionally. During an interview on 9/23/16 at 8:08 A.M., Nurse FF said he/she worked the night shift on 8/16/16. He/She knew the x-ray to the resident's right foot had been ordered but didn't know it was done. The resident hadn't complained of pain to him/her and was surprised to see the ambulance. He/she asked the resident why he/she didn't report his/her complaints of pain and the resident said he/she didn't know why. The nurse realized the resident's leg was fractured when he/she was preparing the paperwork for the EMTs and saw the x-ray results on the fax machine. He/she informed the EMTs of the x-ray results at that time. If he/she had known the x-ray had been done, he/she would have checked for the results sooner. The x-ray company faxes all results even if there are alerts or problems. During an interview on 9/23/16 at 8:20 A.M., CNA GG said he/she worked the evening of 8/16/16, but didn't recall helping staff put the resident to bed. He/she saw the resident in his/her room when after he/she returned from dialysis. The resident was crying about right leg pain and was ready to go to bed. He/She went to get the charge nurse. He/she complained of being in a lot of pain. During an interview on 9/23/16 at 11:20 A.M., East Unit Manager said he/she recalled the van driver informing him/her the resident's right foot was caught under the wheelchair while coming into the facility. He/she also recalled telling Nurse EE to follow-up on the incident. He/she informed the van driver he needed to write a statement about the incident. He/she didn't recall staff reporting problems with the wheelchair or that the resident's leg would fall off the pedal. The Velcro strap the resident wear's to keep his/her leg from falling off was obtained from therapy. He/she wasn't aware the van driver obtained the Velcro strap from therapy. He/she reviewed the resident's progress notes and noted there was no note written regarding the incident or the X-ray of the resident's right foot. He/she said a progress note should have been written regarding the incident. During an interview on 9/23/16 at 10:00 A.M., the maintenance director said if staff or residents are having problems with a wheelchair, staff are to enter the problem into the maintenance portal. He will assess it to repair the problem. No one reported a problem with the resident's wheelchair. During an interview on 9/23/16 at 12:15 P.M., the Director of Nurses (DON) said if a resident or staff complains of a wheelchair not functioning, staff should notify maintenance via the maintenance portal. Maintenance would look at it to repair it or determine if it needs to be replaced. Staff should have notified the nurse of any concerns with the resident's wheelchair. When the resident's right leg fell off the wheelchair pedal, the nurse should have done an assessment and documented it in the nurse's notes. The nurse should have notified the oncoming shift of the pending x-ray. Therapy should have been notified after the incident so the resident could be assessed for a positioning device. She was unaware there were problems with the resident's wheelchair. During an interview on 9/28/16 at 11:35 A.M., the resident's physician said he/she would have expected staff to notify the nurse of any problems with the wheelchair so they could obtain an order for [REDACTED]. 2. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Limited assistance of one person required for bed mobility, dressing, toilet use and personal hygiene; -[DIAGNOSES REDACTED]. Review of the resident's care plan, updated 11/2/16, showed the following: -Problem: Impaired cognitive function/dementia or impaired thought processes; -Goal: Will maintain current level of decision making by next review date; -Interventions: Communicate with resident and my family regarding changes in needs. Engage in simple, structured activities that avoid overly demanding tasks. Identify yourself at each interaction, face and make eye contact when speaking. Provide necessary cues-stop and return if agitated. Keep routines consistent and try to provide consistencies givers as much as possible to decrease confusion. Monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status; -Problem: Activity of daily living self care performance due to dementia, seizure activity, Parkinson's and a recent fracture; -Goal-(none documented); -Interventions: Explain all procedures/tasks before starting and promote dignity by ensuring privacy. Monitor/document/report to nurse as needed any changes in ADL ability, any potential for CNA improvement and reasons for inability to perform ADLs. Review of the resident's progress notes, dated 7/5/16 at 12:32 P.M., showed he/she left with facility transportation for a doctor's appointment. During an interview on 7/5/16 at 4:20 P.M., charge nurse AA, who works at the resident's physician's office, said the facility van driver brought the resident to his/her appointment and left him/her unattended. The resident's paperwork was given to the secretary and although other patients were seated in the waiting room, the resident did not have family members present and no one from the facility accompanied him/her. The resident, unable to answer questions, became frustrated and kept wheeling himself/herself out of the room and into the hallway. The resident knew only his/her name and did not know where he/she was or why he/she was there. The resident was panicking saying, he/she was far from home, no one knew where he/she was and he/she needed to get back home. Staff at the physician's office had to keep the resident with them at all times because there was an elevator located outside the physician's office, and the resident was so confused and upset, staff were worried the resident might try to leave and find his/her way home. Charge nurse AA took the resident into his/her office, to watch him/her, until the facility van driver returned to pick him/her up. During an interview on 9/22/16 at 2:21 P.M., the resident's power of attorney (POA) said he/she received a call from a lady at a physician's office on 7/5/16, regarding the resident not being accompanied to his/her appointment earlier in the day. The lady was really upset and told him/her someone from the facility had dropped the resident off without supervision and the resident should not have been left alone. The POA said normally he/she accompanied the resident to appointments, but no one from the nursing facility made him/her aware of the resident's appointment for that day. During an interview on 9/22/16 at 1:35 P.M., CNA X said he/she recalled a phone call from someone at a physician's office, the caller was upset and wanted to know why the resident was left alone at the physician's office. CNA X said he/she did not have an answer and gave the phone to the unit manager. During an interview on 9/21/16 at 9:10 A.M., unit manager S said he/she recalled an incident when the resident went to a physician's appointment by himself/herself. He/she found out when the resident's POA phoned and was very upset because the resident went to a physician's appointment by him/herself and wanted to know why he/she was left alone. The resident's POA normally accompanied the resident to his/her physician's appointments. Review of the resident's progress notes, dated 7/5/16 at 5:39 P.M., showed the resident returned from doctor's appointment with a note, that the resident was to return on 7/12/16 at 12:45 P.M. The resident's POA, aware and will accompany the resident to the appointment. Further review of the resident's medical record, showed no incident report, investigation or documentation regarding the resident having been unaccompanied to his/her physician's appointment on 7/5/16. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependence of one person required for bed mobility, dressing, toilet use and personal hygiene. Observations of the resident, showed the following: -On 9/20/16 at 12:19 P.M., he/she sat in the assisted dining room, making nonsensical statements to the other residents seated beside him/her; -On 9/21/16 at 9:05 A.M., he/she self propelled down the hallway, passed the nurse's station, smiled and said aloud, so long, so long, I guess I'm free. When asked where he/she was going the resident stopped, stared blankly and was unable to answer the question. During an interview on 9/21/16 at 8:47 A.M., Nurse H said the resident should not go to appointments without supervision because he/she has dementia and could easily lose his/her way and would not be able to answer questions. During an interview on 9/21/16 at 11:31 P.M., van driver Z said he/she transported the resident to his/her doctor's appointment, on 7/5/16 at 12:32 P.M., and usually the resident's family goes along because the resident is too confused to leave alone. The resident's family, a man and a woman were in the waiting room when he/she arrived, and the man said he would take the resident. Van driver Z was unable to describe the man who took the resident. The resident's family could not stay until the end of the appointment and left before he/she returned. When he/she arrived to pick up the resident, the man and woman was not there and the resident was waiting in the back of the office with a receptionist. During an interview on 9/23/16 at 2:00 P.M., the DON said that yesterday was the first day she was made aware of the incident. The van driver should have asked the physician's office staff if it was ok to leave the resident unaccompanied. The resident is someone who should not be left alone. She expected staff to document in the nurse's notes and inform her of any incidents. 3. Review of Resident #18's orthopedic physician office visit, dated 7/18/16, showed a right proximal humerus (bone in the shoulder joint) fracture after he/she fell on [DATE] at home prior to admission. Review of the resident's admission MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -Locomotion on the unit required oversight, encouragement or cueing; -No fall within the month prior to admission; -Unable to determine a fall(s) two to six months before admission; -Unable to determine if the resident had a fracture related to a fall within the last six months prior to admission; -Falls checked in care area assessment; -Falls checked for addressed in care plan. Review of the resident's care plan, dated 8/5/16 and 8/16/16, showed no information for falls. Review of the nurse's notes dated 8/3/16 at 2:15 P.M., showed the following: -Resident arrived at 10:00 A.M at the facility, he/she previously resided at his/her home; -Ambulates in a wheelchair; -Resident walked until he/she fell at his/her previous residence and fractured his/her left humerus; -Arm in splint. Review of the resident's occupational therapy plan of care, dated 8/19/16, showed the following: -[DIAGNOSES REDACTED]. -Fall precaution; -Decline in balance for participation in activities of daily living (ADLs) due to frequent falls at home; -Frequent falls and increased dementia characterized by decreased balance and functional mobility; -ADL: -Dressing required modified independence (assistive device or extra time needed); -Standing balance able to maintain balance while turning head/body, but moderate challenges; -Moderate fall risk for balance. Review of the resident's physical therapy plan of care, dated 8/22/16, showed the following: -Medical history related to [DIAGNOSES REDACTED]. -A fall on 7/16/16, at his/her home resulted in a fracture of the left humerus due to unsteady gait pattern; -Two falls in the last six months per chart; -Impaired balance and gait abnormalities; -Functional deficits showed: -Gait required supervision but no assistive devices; -Transfers, sit to stand and stand to sit require modified independence (assistive device or extra time needed). Further review of the resident's nurse's notes, showed: -On 9/7/16 at 10:33 P.M.: -Resident observed on the floor and complained of right shoulder pain; -An as needed (PRN) medication provided and red area on right hip and shoulder noted; -On 9/7/16 at 10:46 P.M., physician called and said to continue to monitor, resident may need an x-ray. Review of the resident's fall risk assessment, dated 9/7/16, showed a score of 17 (high risk of falling) and one to two falls within the last six months. Further review of the resident's nurse's notes, showed continued observations from a fall and no signs of distress or discomfort on 9/8/16 and 9/10/16. Review of the resident's fall risk assessment, dated 9/8/16, showed a score of 14 (moderate risk of falling) and no history of falls within the last six months; Further review of the resident's nurse's notes, dated 9/11/16 at 2:06 P.M., showed the resident fell out of bed and sustained a 3 inch laceration to the left side of his/her forehead, neurological checks completed and were within normal limits (no notification of the physician documented). Review of the resident's nurse's note, dated 9/12/16 at 11:43 P.M., showed continued observations from a fall and to note signs of distress or discomfort. Review of the resident's fall risk assessment, dated 9/12/16, showed a score of 16 (high risk of falling), and multiple falls within the last six months. Review of the resident's fall risk assessment, dated 9/14/16, showed a score of 12 (moderate risk of falling) and one to two falls within the last six months. Review of the resident's nurse's notes, showed the following: -On 9/15/16 at 10:59 A.M., an appointment set for an orthopedic follow-up for left humerus fracture and x-ray of the left arm; -On 9/19/16 at 2:44 P.M., new order for x-ray to left humerus; -On 9/20/16 at 6:25 P.M., staff found the resident on the floor in the activity area. He/she said he/she stepped back, fell and hit his/her head against the wall. Neurological checks for 72 hours. Observation on 9/19/16, showed the following: -At 2:00 P.M., in the TV area of Magnolia, the resident sat on the armrest of the chair closest to the TV by room 412 while he/she talked to another resident's family member. He/she fell backwards and hit his/her head on the wooden armrest of the chair directly beside it. Activity aide A walked with another resident in the area, he/she observed the fall and got CNA T; -At 2:03 P.M. CNA T asked the resident several times are you okay and helped the resident to a seated position. Then the resident got up and started dancing with Activity aide A; -As of 2:20 P.M., licensed nursing staff had not assessed the resident. Observation of the resident, on 9/20/16 at 1:25 P.M., showed the following: -He/she lost balance while standing, fell backwards and hit his/her head against the wall; -He/she yelled out in pain and Nurse B responded immediately and assessed the resident; -Nurse B and CNA LL assisted the resident to his/her room. Review of the resident's nurse's notes, showed the following: -On 9/21/16 at 6:48 A.M., observe post fall with injury, laceration to left forehead with light bruising, continue neurological checks for 72 hours; -On 9/22/16 at 6:42 A. M., gait was unsteady at times and continue to monitor. Review of the resident's medical record on 9/20/16, 9/21/16, 9/22/16 and 9/23/16, showed no documentation of a fall or incident on 9/19/16. During an interview on 9/22/16, at approximately 9:30 A.M., CNA MM said, if a resident fell a CNA was to get the nurse, the nurse checks the resident's vitals and helps the resident up and get them off the floor. When a nurse is notified about a fall, they treat the fall, call the 1-800 number at the nurse's station and talk to the DON. During an interview on 9/23/16, at 10:25 A.M. the Assistant Director of Nursing (ADON) said there was no fall on 9/19/16. The only documentation of a fall is on 9/20/16. The document on 9/19/16, is the x-ray from the injury the resident came in with. During an interview on 9/23/16, at 12:15 P.M., the Director of Nursing said if a resident comes into the facility because of a fall(s) it should be an area of concern on the care plan. She expects the care plan to reflect the resident's needs. It was her expectation that a licensed nursing staff followed up after the fall and completed documentation. 4. Review of Resident #5's Side Rail Assessment, dated 7/6/16, showed the following: -Recommended for safety positioning; -Contributing factors: unable to support trunk in upright position, balance deficit, side rails provide a sense of security for the resident and a history of sliding to the floor; -Assistance-turning side to side; -Restrictions-None; -Recommended Type: one-half rails; -Care Conference: Plan of Care has been updated to include side rail(s) intervention; -Reevaluation: Will be reevaluated quarterly or sooner if there is a significant change in condition. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Brief Interview of mental status (BIMS) score of 9; -BIMS score of 8-12 indicates moderately impaired cognition; -Extensive assistance required for bed mobility. Review of the resident's nurse's note dated 7/23/16 at 11:15 P.M., showed the resident was found with his/her right leg in between the bed and the bar (rail). The leg was dented in right and quickly went back to normal. Will monitor for redness or discoloration. Review of the resident's Fall Risk Assessment, dated 8/2/16, showed the following: -Moderate Risk; -No history of falls within the last six months. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -No mention of the need for side rails. Review of the resident's care plan, initiated on 2/2/16, revised on 5/7/16, 7/7/16, 9/21/16, and in use during the survey, showed the following: -Problem: Right hip pain; -Goal: No interruptions in normal activities; -Approaches: Administer analgesic (pain reliever) as per physicians orders, notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care; -Problem: Moderate risk for falls; unaware of safety needs, confusion, psychoactive drug use, gait/balance problems and bowel/bladder incontinence; -Goal: No serious injury through the review date; -Approaches: Safe environment with even floors free from spills and/or clutter; adequate, glare-free lighting, a working and reachable call light, the bed in a low position at night, handrails on walls and personal items within reach; -Problem: Right hip fracture with a risk for falls; -Goal: Remain free of complications related to hip fracture, such as contracture, formation, embolism and immobility through the review date; -Approaches: Anticipate and meet needs, be sure call light is within reach and respond promptly to all requests for assistance; -Problem: Activities of Daily Living (ADLs) self care performance; -Goal: Improve current level of function in ADLs through the review date; -Approaches: Required staff assistance of one with toileting, dressing, personal hygiene and bathing, staff participation times one to two with transfers per pivot and monitor/document/report to physician as needed any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function; -No mention of the need for side rails. Observation on 9/21/16 at 5:00 A.M., showed the resident lay on his/her back with his/her eyes closed, with 1/2 rails up on both sides. During an interview on 9/21/16 at 7:40 A.M., Certified Nurse Aide (CNA) G said he/she was not working when the resident's foot was caught in the side rail, but worked with him/her and was aware of the incident. The resident tried getting out of bed on a few occasions. The resident will let staff know when he/she is ready to get up so it does not happen often. The only time he/she tries to get up is when he/she is left in bed for a long period of time. During an interview on 9/22/16 at 6:45 A.M., Nurse V said the incident with the side rails happened in July and they did not think the incident made sense. He/she said the resident was found by a CNA. He/she said the protocol would be to reassess the resident if he/she got caught in the side rail and notify the physician. During an interview on 9/23/16 at 12:15 P.M., the Director of Nursing (DON) said a resident would receive side rails to assist with mobility. She is not sure if a physician's orders [REDACTED]. The information regarding the side rails should be documented in the resident's MDS and Care Plan. If a resident is involved in an incident with the side rails, an investigation should take place. Staff should have notified her of the incident. The DON would have reevaluated the resident and made the appropriate changes. 5. Review of Resident #2's MDS, dated [DATE], showed the following: -Brief interview for mental status (BIMS) score of 0 out of a possible score of 15, -A BIMS score of 0-7 shows the resident has severe cognitive impairment; -[DIAGNOSES REDACTED]. -Wandering behaviors exhibited daily; -Supervision for locomotion on the unit. Observation on 9/20/16 at 7:40 A.M., 9/21/16 at 6:37 A.M., 9/22/16 at 7:05 A.M. and 9/23/16 at 8:13 A.M., in Magnolia's (a locked memory care unit) private dining room, showed a gallon bottle, approximately 75% full, of Daley International's Mark Foam carpet de-foamer in an unlocked cabinet. Observation of Magnolia's private dining room, showed the following: -On 9/21/16: -At 8:35 A.M., the resident walked around in the private dining room, he/she opened the cupboard that stored the Mark Foam, no staff present in the area; -At 12:10 P.M., the resident walked around the private dining room with no staff present; -On 9/22/16 at 2:35 P.M., the resident walked around the private dining area with no staff present. Review of Daley International's Mark Foam, the material safety data sheet, showed the following precautions: -Do not get in eyes, on skin or clothing; -Use with adequate ventilation; -Wash thoroughly after handling; -For eye contact rinse thoroughly with plenty of water for at least 15 minutes and consult a physician; -For skin contact wash with water for 5-10 minutes, remove any contaminated clothing and wash before reuse. If conditions persist,

Based on observation, interview and record review, the facility failed to provide appropriate care and services to prevent the development and/or to aid in the healing of pressure ulcers. The facility failed to provide appropriate interventions to prevent the formation of pressure ulcers and staff failed to communicate resident skin issues to the nurse per the facility policy. Staff reported that they noticed the open areas as early as evening shift on 9/19/16. Nursing staff failed to assess the open areas until 9/21/16 at 9:56 P.M. and failed to notify the physician the areas were pressure ulcers until 9/22/16 at 8:58 A.M. This failure resulted in three unidentified and untreated pressure ulcers for one of 25 sampled residents (Resident #3). The census was 185. 1. Review of Resident #3's Minimum Data Set (MDS), a federally required assessment completed by facility staff, showed no admission MDS completed, an entry MDS was completed on 9/9/16 with an admission date of [DATE]. Review of the resident's physician order [REDACTED].M., showed the following: -No weekly skin assessments; -No orders for the treatment of [REDACTED]. -No interim care plan completed for the resident since admission. Review of the resident's admission face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the resident's admission braden scale assessment (a tool used to assess risk for pressure ulcer development), dated 9/10/16, showed the following: -Skin constantly moist: Skin is kept moist almost constantly by perspiration, or urine. Dampness is detected every time the resident is moved or turned; -Confined to bed; -Very limited mobility: Makes occasional slight changed in body or extremity position but is unable to make frequent or significant changes independently; -Received tube feeding (a medical device used to provide nutrition to those who cannot obtain nutrition by mouth, unable to swallow safely or need nutritional supplementation, inserted into the stomach); -Friction and shear are a problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in the bed or chair, requires frequent repositioning with maximum assistance; -Braden score: 8 (Very high risk for pressure ulcer). Review of the resident's weekly skin evaluation, dated 9/10/16, showed the resident was admited with an area to the top of the scalp with 42 staples that are intact. No new open areas noted and normal skin care required. Review of the resident's skilled nursing assessment completed on each eight hour shift, showed: -On 9/10/16, on the day, evening and night shift, showed no skilled nursing assessment completed; -On 9/11/16, on the day shift, showed the resident's skin was normal; -On 9/11/16, on the evening shift, showed the resident had normal skin and bowel and bladder incontinence; -On 9/11/16, on the night shift, showed no skilled nursing assessment completed. Review of the resident's shower sheets, dated 9/11/16 through 9/22/16, showed; -On 9/11/16 at 6:23 P.M., no new skin issues; -On 9/12/16 at 5:49 P.M., no new skin issues; -On 9/13/16 at 2:29 P.M., 2:30 P.M. and 9:39 P.M., no new skin issues; -On 9/14/16 at 11:22 A.M., no new skin issues; -On 9/15/16 at 6:45 P.M., no new skin issues; -On 9/16/16 at 8:49 P.M., no new skin issues; -On 9/20/16 at 11:04 A.M. and at 9:53 P.M., no new skin issues; -On 9/22/16 at 2:37 P.M., no new skin issues. Review of the resident's registered dietician (RD) nutritional assessment, dated 9/12/16, showed a recommendation to increase the tube feeding to 90 milliliters (ml) per hour (hr) for 23 hours (allowed off for an hour daily), flush with 200 ml of water very six hours. This will provide 2484 calories and 115 grams of protein. The facility RD noted that the RD at the hospital was basing calorie needs off of the ideal body weight, tube feeding was meeting lower needs. The new tube feeding order better meets the needs and will meet protein needs. During an observation and interview on 9/20/16 at 6:50 A.M. through 12:15 P.M., showed the resident lay on his/her back in bed. Nurse D and LPN E said the resident was admitted to the facility on [DATE] and there had been no care plan created. All care plans are done in the computer, and if the care plan is not in the computer, then it was not done. Staff do not know much about the resident and a care plan would help the Certified Nurse Aides (CNAs) care for him/her. During an observation and interview on 9/21/16 at 5:05 A.M., Certified Medication Technician (CMT) F assisted the resident to turn onto his/her right side, exposing the resident's buttocks. There was an open area to the resident's coccyx (tail bone) with pink wound edges, beefy red wound bed and a yellow/tan substance covered approximately 25 percent of the wound bed and an open area on the left and right buttocks with pink wound edges and beefy red wound beds. The CMT said oh Jesus when he/she saw the sores to the resident's buttocks area. CMT F said there was currently no treatment to the resident's skin. The CMT did not apply any skin barrier or get the nurse on duty. He/she positioned the resident back onto his/her back. CMT F said he/she thought the nurses already knew about the skin areas. Observation on 9/21/16 from 5:30 A.M. through 1:15 P.M., showed the resident remained on his/her back in bed. Further review of the resident's medical record, showed a weekly skin evaluation dated 9/21/16 at 9:56 P.M., showed the resident had redness to the buttocks and coccyx with excoriation/shearing (redness and damage to the skin caused by friction) on the skin. The right buttock measured 3.8 centimeter (cm) by 1.4 cm. The left buttock measured 2.8 cm by 3.6 cm. The coccyx measured 6.2 cm by 2.2 cm. The left buttock crease measured 2.1 cm by 3.1 cm. Observation on 9/22/16 from 6:40 A.M through 1:30 P.M., showed the resident remained on his/her back in bed. No low air loss mattress (a mattress that provides a constant flow of air in the mattress to help prevent pressure ulcers) was on the bed. During an interview on 9/22/16 at 8:05 A.M., CNA G said the resident is always incontinent of bowel and bladder, he/she does not know much about him/her and it usually takes two people to help provide him/her with care. The resident is unable to provide any help with his/her care at all. They do not know how to access the resident's care plan in the computer. The resident should be turned every two hours to help with his/her skin but that does not happen because it can be hard to find enough help. Further review of the resident's POS, showed the following: -An order dated 9/22/16 at 8:58 A.M., to reassess the open areas on the resident's buttocks and coccyx and notify the physician for continued or new treatment orders; -An order dated 9/22/16 at 8:58 A.M., for risamine ointment (ointment used to prevent and heal skin irritation caused by urine, sweat and diarrhea) 0.44-20.625%, apply to the buttocks and coccyx topically every shift for excoriation/incontinence [MEDICAL CONDITION] (skin damage associated with exposure to urine or stool). During an interview on 9/22/16 at 9:00 A.M., Nurse H said he/she was told in morning report that the resident had areas to his/her buttocks that were red or open. This was the first report he/she had of the open areas. He/she was told to put extra protective cream (EPC) on the buttocks as preventative. Nurse H and Restorative Therapy Aide (RTA) I both said the resident appeared to have matted hair and he/she should have been getting a shower three times a week since admission. Nurse H said the night nurse wanted him/her to call the physician to get orders, but he/she had not had time yet. Observation at that time, showed the resident had thick white cream to his/her buttock and had facial grimacing as Nurse H cleaned the resident's buttocks and coccyx areas. The wound to the coccyx area began to bleed. Nurse H said he/she would stage all three areas as stage II pressure ulcers (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister). The coccyx area measured 4 cm by 2 cm, the left buttock measured 3 cm by 0.5 cm and the left upper buttock measured 2.5 cm by 1 cm. Nurse H applied dry dressings to the ulcer sites and secured it with tape. Nurse H said that until the resident's physician can be reached for orders this is the treatment he/she will use. All incontinent and bedbound residents should be checked and turned every two hours at a minimum to prevent pressure areas from developing. The CNAs should tell the nurse right away if they notice any changes in the resident skin conditions. RTA I said all bed bound, incontinent residents should get turned every two hours to prevent pressure sores, he/she does not have access to a cushion to help keep the resident on his/her side but there are pillows available for staff to use. During an interview on 9/22/16 at 9:40 A.M., CNA J said he/she helped to take care of the resident on 9/20/16. The resident had several red and open areas on his/her bottom at that time. At that time, CNA K was helping another CNA who was supposed to report it to the charge nurse. He/she did not report it to the charge nurse because he/she thought the staff already knew about the skin areas. During an interview on 9/22/16 at 9:45 A.M., CNA K said the evening charge nurse helped to give the resident care on 9/19/16 and the charge nurse saw the areas to the resident's bottom. He/she was told to apply EPC when giving perineal (peri-care, surface area between the thighs, extending from the pubic bone to the tail bone) to the resident. The areas to the resident's bottom looked worse on 9/21/16 and the charge nurse said to keep putting on the EPC. The nurses give the EPC to the aides to apply. During an interview on 9/22/16 at 10:00 A.M., RD L said she increased the tube feeding rate to better meet the resident's needs, and to maintain levels of protein when the resident was admitted . She goes to clinical meetings every Monday with the unit managers. She prints out dietary recommendations and will put those recommendations in the unit manager's mailbox. She will usually talk to the managers about dietary recommendations as well. She expects staff to contact the resident's physician and obtain an order for [REDACTED]. During an interview on 9/22/16 at 10:30 A.M., LPN D said the first time he/she was aware of the resident's skin issues was on 9/21/16 during the evening shift. He/she did a skin assessment at that time and found four to five areas. He/she called the physician that night and was told to use the EPC to the area, he/she told the physician that the areas were caused from shearing. He/she called the physician again the morning of 9/22/16 and got an order for [REDACTED]. The nurse should then perform a skin assessment, document findings and notify the doctor. During an interview on 9/22/16 at 11:00 A.M., Physician M said in the evening on 9/21/16 was the first time he/she was made aware of the resident's skin issues. The nurse told him/her the areas were from shearing. He/she expects staff to call him/her with changes in the resident's skin condition, and residents that are bedbound or incontinent should be changed frequently and turned often. During an interview on 9/22/16 at 11:25 A.M., CMT F said that he/she had noticed the areas to the resident's bottom on 9/19/16 during the night shift. He/she told the charge nurse at that time. He/she did not tell the oncoming day shift nurse but did inform the oncoming day shift CNA. He/she had been told by nurses to put on EPC to the area. During an observation and interview on 9/22/16 at 12:15 P.M., the Director of Nursing (DON) said the resident had three areas of pressure. These areas were all stage II. She expects incontinent or bedbound residents to be turned and repositioned a minimum of every two hours. She also expects full nursing admission assessments on every eight hour shift for three days as well as an interim care plan to be created within 24 hours after admission. She expects the CNA's to notify the nurses of any changes in a resident's skin condition, and the nurse should do a full skin assessment, document measurements, update the care plan and notify the resident's physician for any new orders. She expects RD recommendations to be in effect within 24 hours of the recommendation. Review of the resident's weekly wound assessment, dated 9/22/16 at 1:02 P.M., showed: -Pressure ulcer stage II (partial thickness skin loss involving top and second layer of skin, usually superficial and may present as a blister, abrasion or shallow crater) to the coccyx measured 2.2 cm by 6.2 cm by 0.5 cm; -Pressure ulcer stage II to the left buttock measured 3.6 cm by 2.8 cm by 0.1 cm; -Physician notified on 9/22/16 and ordered a low air loss mattress and new treatment for [REDACTED].>-Notified the resident's spouse, who stated the hospital had the resident on a special mattress as well; -Facility acquired stage II pressure ulcers; -Slough (layer of dead tissue separated from surrounding living tissue, usually yellow, stringy or thick and sticks to the tissue bed) tissue is present. Review of the facility pressure policy, revised on 3/2016 and in use during the survey, showed: -The purpose is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers; -Review the resident's care plan to assess for any special needs for the resident; -The pressure ulcer treatment program should focus on the following strategies: -Assessing the resident and the pressure ulcer(s); -Managing tissue loads; -Pressure ulcer care; -Managing bacterial colonization and infections; -Operative repair of the pressure ulcer(s); -Education and quality improvement; -When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed; -Stage II pressure ulcer is defined as a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled (clear fluid filled) blister. It may be shiny, dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation; -Stage II Protocol Intervention/Care Strategies: Clean, shallow, with minimal drainage: -Protect; -Manage drainage; -Promote moist wound healing; -Treatment: -Cleanse with normal saline or other skin cleanser in accordance with physician orders [REDACTED]. -Apply barrier cream, hydrogel (a gel in which water is the dispersion medium for wound healing) or hydrogel sheet (cut to fit); -Cover with non-adhesive light gauze or transparent dressing; -Alternate dressing (use of thin [MEDICATION NAME]) (a gel-forming bandaged used to block water and bacteria) and change per physician order [REDACTED]. -Manage pain; -Stage II pressure ulcer with medium drainage, follow the procedure and consider the need for alginate (absorbent dressing) or foam; -Stage III pressure ulcer is defined as full thickness tissue loss. Subcutaneous (under the skin) fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss; -The following information should be recorded in the resident's medical record: -The type of treatment and resident response; -The date and time the wound care was given; -The position in which the resident was placed; -The name and title of the individual performing the care; -Any change in the resident's condition; -All assessment data (color, size, pain, drainage, etc) when inspecting the wound; -Resident tolerance of the procedure; -Any problems or complains made by the resident related to the procedure; -Resident refusal of the treatment and the reason(s) why, and that risks of not complying, benefits of complying and alternatives explained; -The signature and title of the person recording the data.

Based on interview and record review, the facility failed to assess and provide services to one resident (Resident #1) with a significant change in condition, when the resident did not eat or drink and developed a reddened area on his/her buttocks. The nurses failed to assess the area and the resident continued to decline over the weekend ([DATE]). Facility staff failed to notify the physician of the decline despite being made aware of the resident's condition until the following Monday, when the resident had mental status changes. The resident was found to have a large open wound on his/her buttocks and was sent emergently to the hospital. The resident was admitted to the hospital and required intubation (tube inserted into the airway to help with breathing). Hospital [DIAGNOSES REDACTED]. The resident expired three days later. The facility census was 157. Review of Resident #1's admission face sheet, dated [DATE], showed he/she was admitted with [DIAGNOSES REDACTED]. Review of the resident's care plan, dated [DATE] and updated on [DATE], showed: -[DIAGNOSES REDACTED]. -Required assistance to turn/reposition at least every 2 hours, more often as needed or as requested; -Indwelling urinary catheter; -History of unstageable pressure ulcers; healed on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -No memory problem; -Required extensive assistance with bed mobility, locomotion and personal hygiene; -Total dependence with transfers, toilet use and bathing; -Independent with eating; -Occasional mild pain; -Prognosis: does not have a condition or chronic disease that may result in a life expectancy of less than 6 months; -No unhealed pressure ulcers or wounds; -Skin and ulcer treatments: -Pressure reducing device for chair and bed; -Turning/repositioning program; -Nutrition or hydration intervention to manage skin problems. -Mobility device; wheelchair; -Indwelling urinary catheter; -Ostomy (surgically created opening in abdomen to allow waste to leave body). Review of the resident's weekly skin assessments, dated [DATE], [DATE], [DATE], [DATE] and [DATE], showed intact skin. No skin assessments completed after [DATE]. Review of the resident's bath sheet skin checks, signed by evening shift Certified Nurse Aide (CNA) A and Nurse B, showed: -On [DATE] and [DATE], reddened areas in the groin; -On [DATE], reddened areas on the whole left buttock. Review of the resident's [DATE] CNA flow sheet report, showed: -Did not eat or nothing recorded for the following meals: -Breakfast and lunch on [DATE] (documentation left blank); -Breakfast, lunch and dinner on [DATE] (documentation left blank); -Lunch and dinner on [DATE] (documentation showed refused lunch and 0 for dinner); -No urinary catheter output on the following dates (documentation left blank on all dates): -Day shift on [DATE]; -Day and evening shift on [DATE]; -Day shift on [DATE]. -On [DATE], evening shift, 60 cubic centimeters of urinary output recorded. Review of the resident's [DATE] bowel movement (BM) log, showed documentation of 0 BM from ostomy on ,[DATE], ,[DATE] and [DATE]. Review of the resident's [DATE] physician's orders [REDACTED].>-Full Code, paralyzed from waist down; -Regular diet; -Up with walker; -Catheter care every shift; -[MEDICATION NAME]/APAP (narcotic/[MEDICATION NAME] pain medication), ,[DATE] milligrams (mg), take ,[DATE] tablets by mouth, every 4 hours as needed; -[MEDICATION NAME] (narcotic-like pain reliever, used to treat moderate to severe pain) 50 mg tablet, 1 tablet by mouth, every 6 hours as needed for pain; -Weekly skin assessment; -No treatment order for buttocks. Review of the resident's [DATE] medication administrator record (MAR), showed: -Between ,[DATE] and [DATE], the resident received [MEDICATION NAME] one time, on [DATE] at 8:50 P.M., for back pain; -The resident's blood sugars were as follows: -On [DATE] at 11:00 A.M. 282 (normal range 80 to 120) and at 4:00 P.M. 250; -On [DATE] at 11:00 A.M. 274, and at 4:00 P.M. 120; -On [DATE] at 11:00 A.M. 122, and at 4:00 P.M. 76. During an interview on [DATE] at 3:00 P.M., evening shift CNA A said: -On ,[DATE] and [DATE], the resident was doing great. -On [DATE], CNA A saw the reddened area, the size of a pencil dot, on the resident's left buttock. There were no red or open areas on the resident's right buttock. The resident was not responding, communicating or eating, he/she looked straight ahead and was not doing good. -CNA A told Nurse B about the resident's condition. -CNA A and Resident #1's roommate, Resident #2, knew something was wrong with Resident #1. -The resident's urinary catheter drained clear yellow urine with no odor. During an interview on [DATE] at 1:10 P.M., evening shift Nurse B said: -On [DATE], Nurse B signed the resident's bath sheet, which showed a reddened area on the left buttock. -Nurse B was not sure if he/she looked at the resident. -He/she should have assessed the resident and filled out a skin assessment sheet. During an interview on [DATE] at 10:50 A.M., Resident #2, Resident #1's roommate said: -Resident #2 knew something was wrong with Resident #1, who had signs of being ill. Resident #1 was not acting like himself/herself on ,[DATE] - [DATE], and was going downhill fast. Resident #1 complained of his/her stomach and back hurting. He/she moaned, moved his/her arms, stayed in bed, did not eat and slept the whole weekend. He/she usually ate before that weekend. Resident #1 was paralyzed from the waist down. -Resident #2 told staff about Resident #1 during that weekend. Resident #1 asked them to call the doctor because he/she had pain in his/her back and stomach. -Staff finally checked on Resident #1 on [DATE] and said they were waiting for the doctor to call back. When staff got Resident #1 ready to go to the hospital, staff didn't pull the curtain and Resident #2 saw him/her from the doorway of the room. Staff pulled the sheet out from under Resident #1, which was covered in blood. Resident #1 had a broken area on his/her whole buttock, which was horrible. It was covered with blood and pus and looked like a red, cooked pig. -Staff said Resident #1's wound had healed up in the past and staff put ointment on his/her buttock. That weekend Resident #2 did not see staff put cream on Resident #1's buttock. Resident #2 went to the dining room for meals and doesn't know if staff saw Resident #1 at those times. On [DATE] at 11:00 A.M., Resident #3, Resident #1's friend who lives across the hall, said: -Resident #1 never got out of bed that weekend, ,[DATE] through [DATE]. -Resident #3 saw Resident #1 in bed and he/she did not speak a word. -Resident #2 told Resident #3 what Resident #1 looked like when staff came to his/her room on [DATE], before he/she went to the hospital. During an interview on [DATE] at 3:10 P.M., day and evening shift CNA C said: -During the day and evening shifts on [DATE], the resident did not act like he/she normally did. He/she did not eat meals, complained of stomach and back pain and kept asking for a pain pill. The resident did not normally complain of pain to CNA C. -The resident had a dark red area on his/her right buttock, the size of a big fist. -CNA C told the day and evening nurse that the resident had a red area on his/her buttock, did not eat meals, wasn't himself/herself on those days and had lower back and stomach pain. During an interview on [DATE] at 2:25 P.M., day shift Nurse D said: -On [DATE], Nurse D saw the resident, who was his/her usual self, throughout the day. -The resident usually complained of back pain, but had no complaints of pain and ate all of his/her meals. -He/she emptied the resident's urinary catheter drainage bag and there were no problems. -The resident usually turned and pulled himself/herself up in bed, but Nurse D did not see him/her change position on that day. -There were no problems reported about the resident on that day. -The last skin assessment Nurse D did on the resident was in [DATE]. -The resident used to receive treatments to a pressure ulcer a long time ago. During an interview on [DATE] at 3:30 P.M., evening shift Nurse B said: -On [DATE], the resident was doing good. -The resident was usually alert and talkative. -Nurse B talked with the resident in the evening. -The day shift nurse on the weekend said Resident #1 was fine and there were no problems reported. During an interview on [DATE] at 12:27 P.M., night shift Nurse E said: -On [DATE], the resident was doing fine and had no complaints of pain. -No staff reported a red area on the resident's buttocks or a change of condition. -Nurse E did not do a skin assessment on the resident. -Staff should report any red areas or problems with the residents and pass the information on to the next shift. During an interview on [DATE] at 1:20 P.M., night shift CNA F who was assigned to care for the resident on ,[DATE] and [DATE], said he/she did not see the resident that weekend, because he/she did not have that assignment. Review of the [DATE], CNA flow sheet report, showed CNA F signed that he/she cared for the resident, but did not specify what he/she did, on [DATE] at 6:36 A.M., [DATE] at 3:20 A.M., and [DATE] at 2:36 A.M. During an interview on [DATE] 12:00 P.M., night shift CNA J said he/she did not take care of the resident on ,[DATE] and [DATE]. He/she thought CNA F was assigned to care for the resident on those nights. During an interview on [DATE] at 12:25 P.M., day shift Nurse G said: -On [DATE], the resident was doing fine, laid in bed on his/her back and slightly on his/her right side, read the paper and talked with Nurse G. -The resident had no complaint of back pain. -Nurse G did not do a skin assessment on the resident that day. -Staff did not report any red area or a change of condition with the resident. During an interview on [DATE] at 3:10 P.M, day and evening shift CNA C said: -On [DATE], the resident wasn't himself/herself at all. He/she knocked his/her juice over and CNA C had to clean his/her bed. The resident wasn't waking up and did not eat meals. He/she usually talked with CNA C, but not that weekend. -The resident was unable to turn himself/herself in bed. CNA C turned the resident, but he/she always ended up rolling on his/her right backside. -The resident had a dark red area on his/her right buttock, the size of a big fist. -CNA C told the day and evening nurse the resident had a red area on his/her buttock, he/she did not eat meals, wasn't himself/herself on those days and had lower back and stomach pain. During an interview on [DATE] at 3:30 P.M., evening shift Nurse B said: -On [DATE], the resident was doing good. -The resident was usually alert and talkative. -Nurse B talked with the resident on the evening shift. -The day shift nurse, on the weekend, said Resident #1 was fine and there were no problems reported. During an interview on [DATE] at 1:13 P.M., night shift Nurse H said: -On [DATE], the resident looked okay, normal and slept most of the night. -Nurse H said hello to the resident at the beginning and end of the shift and asked how he/she was doing. The resident said he/she was fine and had no complaint of pain. During an interview on [DATE] at 2:40 P.M., day shift CNA I said: -On [DATE], the resident complained that his/her stomach hurt and did not eat breakfast and lunch. CNA I told the nurse. -The resident usually did his/her own perineal care. -CNA I did not see the resident's buttocks because the resident would do his/her own care. -CNA I knew the resident had sores on his/her buttocks. -The resident was able to move himself/herself in bed. During an interview on [DATE] at 2:25 P.M., day shift Nurse D said: -On [DATE], the resident was his/her usual self, nothing different. -Nurse D saw the resident throughout the shift and he/she had no complaints of pain. -Nurse D emptied the resident's urinary catheter drainage bag and there were no problems. -The resident ate all of his/her meals. -The resident had a pressure ulcer a long time ago. -There were no reported problems with the resident. During an interview on [DATE] at 3:10 P.M., evening shift CNA A said: -On [DATE], the resident's catheter drained yellow urine, which was not cloudy and did not have an odor; -The resident still was not doing well and did not look right. -CNA A was not sure what time he/she first saw the resident. -CNA A told Nurse B, who said he/she was waiting for the resident's physician to call back. -Nurse B told CNA A to clean the resident before he/she went to the hospital. -CNA A turned the resident over in bed from his/her right to left side, the resident had sheets, blankets, the television remote control and reacher (used for grabbing items) under him/her. The resident's right buttock was completely open, oozing blood and pus. -CNA A told Nurse B to come and look at the resident. Nurse B looked at the resident and called 911. During an interview on [DATE] at 3:30 P.M., Nurse B said: -CNA C reported the resident had a red area on his/her buttock on ,[DATE] and [DATE], but Nurse B did not remember if he/she looked at it or if CNA C said the resident was not eating or acting like normal. Nurse B said he/she would have documented it if he/she saw the red area. Then Nurse B said he/she did not assess the resident's buttock until CNA A said Nurse B needed to look at it when the resident was going to be transferred to the hospital on [DATE]. -The first time Nurse B noticed the resident was not acting normal was on [DATE]. At 4:00 P.M., Nurse B checked the resident's blood sugar, which was low, so he/she did not give him/her insulin. -Between 6:00 P.M. and 6:30 P.M., the resident's roommate, Resident #2, came and told Nurse B that the resident was not acting right and he/she needed to see the resident. Nurse B went to see the resident and checked his/her vital signs. The resident's blood pressure was ,[DATE] (normal ,[DATE]) and the resident's blood pressure did not normally run that low. Nurse B called the physician and left a message with the exchange. -At 8:15 P.M., the resident's roommate, Resident #2, told Nurse B again the resident was not doing well. Nurse B called the physician again, who said to transfer the resident to the hospital. Nurse B did not feel it was urgent at first, until he/she saw the big open area with bleeding on the resident's right buttock. Then the resident was sent to the hospital as an emergency. Review of the resident's nurse's notes, showed: -No documentation on ,[DATE] through [DATE]; -[DATE] at 11:00 P.M., was the first nurse's note since [DATE], which showed the following, documented by Nurse B: -Resident's roommate came to nurse saying the resident did not seem right. -Nurse assessed resident, vital signs - temperature (T) 96.7 Fahrenheit (F) (normal 97.6 to 99.6 degrees F), pulse (P) 74 (normal ,[DATE]), respirations (R) 20 (normal ,[DATE]), blood pressure (B/P) ,[DATE], oxygen saturation (percentage of oxygen in the blood) 93% (normal 100%) on room air; -Blood sugar at 4:00 P.M. was 76 and insulin was held; -Did not eat dinner this evening and was very lethargic; -The primary physician was notified with no return call; -Assessed again at 8:15 P.M., with vital signs T 95.1, P 57, R 22 and B/P ,[DATE]; -The primary physician was called again. The on call physician gave orders to send the resident to the hospital for mental status changes. Ambulance was called. -While waiting for ambulance to arrive, the CNA cleaned the resident up and rolled him/her onto his/her side, blood was on the right side of buttock, present and dark. Call was then heightened and resident sent out emergent. Family and DON were notified. Review of the resident's hospital record, with admission on [DATE] at 9:43 P.M., showed: -The physician's history and physical (H/P), showed: -Sent to the emergency room and found to be septic, hypotensive and required intubation (tube inserted into the airway to help breathe); -Had multiple wounds on sacrum, buttocks and heel; -[DIAGNOSES REDACTED]. Review of the resident's hospital wound assessment, dated [DATE] at 11:55 P.M., showed: -Medical record reviewed and bedside assessment completed. Wounds to buttock, left ischial (lower buttock area), and heel that were present on admission. -Left ischial wound - dusky red, light purple, unstageable, defined edges, appears like prior wound to site may have been closed, peri wound (area of skin around the wound) red. Appearance suggestive of prior large ulcer that had healed; -Left upper buttock wound - dusky red, light purple, suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue), purple or maroon localized area of discolored intact skin, peri wound, entire buttocks area dusky; -Right buttock wound - dusky red, light purple, suspected deep tissue injury, purple or maroon localized area of discolored intact skin (appears to be evolving rapidly to eschar dead tissue), bloody exudate; -Left heel wound - light purple, dusky red, suspected deep tissue injury, purple or maroon localized area of discolored intact skin, toes purple. Review of the resident's hospital physician's H/P, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Surgery consulted for severe [MEDICAL CONDITION]/black eschar of gluteal/perineal area; -Family considering comfort care. Review of the resident's hospital physician's H/P, dated [DATE], showed: -[DIAGNOSES REDACTED]. -At 12:44 P.M., family member said the resident would not want this level of support and would want to be comfortable. Extubate (to remove tube from airway) and discontinue all medications except [MEDICATION NAME] for pain; -Resident was extubated at 1:13 P.M. and expired at 4:31 P.M. During an interview on [DATE] at 11:31 A.M., the resident's family member said they were not notified by the facility of the resident's change of condition or that the resident was transferred to the hospital until [DATE]. Review of the facility's undated policy/procedure regarding skin assessments, showed staff should document the status of the resident's skin in the resident's chart once per week and in the resident's monthly summary. Review of the facility's policy/procedure regarding change in a resident's condition, dated [DATE], showed the facility shall promptly notify the resident's attending physician, and representative of changes in a resident's medical/mental condition and/or status. During an interview on [DATE], the Director of Nurses said: -Staff should have assessed and monitored the reddened areas on the resident's buttocks, sacrum and left heel. -Staff should have notified the physician and family sooner of the resident's change of condition and reddened areas on ,[DATE] through [DATE]. During an interview on [DATE] at 1:30 P.M., the on call physician, who gave the order to send the resident to the hospital said: -Staff should have assessed, monitored and notified the physician sooner of the resident's change of condition and reddened areas on buttocks. -The wounds on the resident's buttocks, sacral area and left heel would not have developed so quickly in three days, ,[DATE] through [DATE]. During an interview on [DATE] at 1:00 P.M., the resident's primary care physician said: -Staff should have notified the physician sooner of the resident's condition. -Staff should have assessed and monitored the reddened area on the resident's buttocks. -The big wounds the resident was admitted to the hospital with [REDACTED]. -Staff should have assessed the resident's urine in the urinary catheter to see that it did not look good, notified the physician and obtained a culture before the resident went to the hospital on [DATE]. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan of correction which included inservicing staff regarding assessment and monitoring of a resident's change of condition and notifying the physician. Two licensed staff members will perform skin assessments and verify there has not been a change in condition on all current residents. Any new skin issues will be addressed with interventions per facility protocol. All newly admitted residents will have a skin assessment within two hours of admission. Skin assessments will be done weekly on all residents by licensed staff and reviewed by the DON/ADON or their designee weekly. Consumption documentation will be reviewed on all residents consuming less than 50% and interventions put into place. All residents' change of condition will be reported during daily morning standup meeting and followed up by the DON/ADON or their designee. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation. MO 393 MO 509

Based on interview, record review and observations, facility staff failed to accurately assess one resident (Resident #1) during the admission process to the "memory house" in the Hawthorne building; staff also failed to re-assess the resident after admission and to put measures into place to ensure the safety of the resident. The resident left the facility without staff knowledge on 04/13/11. A citizen called 911 at 6:15 P.M. and reported to 911 that an elderly person on a walker had fallen into the street. During the continued 911 call, the citizen told EMS (emergency medical services) that the person fell off the curb into the street. The hospital assessed the resident with a 2 X 2 cm hematoma (bruise) on the right posterior scalp (back of head). The location the resident was found was approximately two tenth of a mile (.2) from the facility on the same side of the road as a sewer construction project. The resident was enroute with EMS to the hospital at 6:19 P.M. The last time facility staff saw the resident on 04/13/11 was at approximately 5:55 P.M. Facility staff heard the front door alarm between 6:35 P.M. to 6:45 P.M., and staff counted the residents and were unable to locate the resident. Staff searched the building and grounds of the facility and were unable to locate the resident. Facility staff notified law enforcement at 7:30 P.M. that a resident was missing. The police arrived at the nursing home at 7:37 P.M., and Police Officer A said the description the facility provided of the resident matched an earlier dispatched call. The facility called the hospital at approximately 7:50 P.M., and the hospital confirmed that the resident was there. The total facility census was 200 residents. The "memory house" census in the Hawthorne building was 21 residents. 1. Record review of the facility "code white" instructions, undated, shows the following: - Section A: Upon notification that a resident is missing and failure to locate the resident by available staff, the following should be implemented: - Check the resident room, bathroom, living rooms and main area on the division;- Check the spas, therapy room, beauty shop, dining areas, laundry room and recreation room and dishroom; - Check the sign in/out log to see if family has visited and perhaps took them out of the building and forgot to sign out at the desk;- Did the resident have a doctor's appointment? - Section B: If the resident is not located within 15 minutes, immediately contact your supervisor. The supervisor will announce code white and notify the DON (Director of Nursing) and Administrator. The supervisor or designee will contact the family of the missing resident. The Administrator will determine when police should be notified. - Section C: Assemble all available staff-this includes nursing and non-nursing personnel. - Section D: Each division will be called and instructed of the name and description of the missing resident....Organize and institute a thorough search of the facility, surrounding grounds and buildings. - Section E: If the resident is found, please announce cancel code white... - Section F: If the search of facility grounds fails to locate the resident, the Administrator will notify the police. - Section G: Organize and institute an expanded search of the neighborhood surrounding the facility with the police. Record review of the facility policy for wandering residents, undated, showed the following: - Policy statement: Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement - Policy interpretation and implementation: The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 2. Record review of the facility nursing admission packet, provided by Administrator A, showed the facility exit-seeking/wandering assessment. The form guidelines and directions were dated 08/10. Record review of the exit-seeking/wandering assessment form guidelines and instructions (located on back of assessment), showed the following information: - Purpose: To provide a baseline and quarterly assessment of exit-seeking/wandering potential;- Procedure: Within eight hours of admission, the nurse will review shift documentation of wandering behaviors, and complete the admission section of the assessment form;- Reassessment will be done in conjunction with the quarterly MDS (Minimum Data Set- a federally required assessment completed by facility staff). Record review of the instructions for answering the questions on the exit-seeking/wandering assessment form (located on back of assessment), showed the assessment form had seven questions:- Question One: If a resident is bedfast or unable to propel his own wheelchair, answer "No". Ambulatory residents or those who can propel their own wheel chairs are capable of leaving the facility. - Question Two: Is the resident able to tell you where he/she is? Is the resident able to tell you what state they are in? - Question Three: Is the resident able to make decisions about activities of daily living? Can he/she decide on clothing to wear or when to go to meals? Does he/she use appropriate problem solving methods? - Question Four: Are statements about going home frequent? A newly admitted resident may state that he/she wishes he/she could be at home. Exit-seeking/wandering risk increases if statements about leaving are repetitive and the resident seems to dwell on this topic. - Question Five: Anger may be a symptom of depression, which can alter the resident's concern for his/her own safety. - Question Six: For initial assessment, refer to history of behaviors obtained prior to admission. Conversations with family members are helpful as well. - Question Seven: For initial assessment, refer to to shift documentation for previous 48 hours. For quarterly documentation, observe resident's behaviors. Wandering is defined as moving with no rational purpose, seemingly oblivious to needs or safety. - Review responses to answers one through seven. A "yes" in two or more sections increases the risk for wandering or exit-seeking behavior. Modify the resident's care plan to reflect findings of assessment, with goals and approaches appropriate to assessment findings. Record review of the facility exit-seeking/wandering assessment, showed if the answer to the first question was "no", disregard the following questions on the assessment. The bottom of the form had two sections for staff to check on the form: at risk for possible exit-seeking; complete profile and place in exit-seeking book; or not currently at risk for exit-seeking-will be evaluated quarterly or as needed. 3. Record review of Resident #1's facility admission evaluation, showed the following: - Diagnosis: [REDACTED]. - Arrival time: 5:00 P.M.; - admitted : 04/11/11; - Level of consciousness: alert and confused; (handwritten in comments section) increased confusion; - Neurological: memory loss; - Physical functioning: bed mobility-independent; transfer- independent; walking/locomotion- supervision; - Assistive device: walker; - Fall risk score: 14 (score of 10 or higher is at risk); - Initial discharge plan: Length of stay- two weeks. - List of diagnosis/problems, current needs section: (handwritten) increased confusion; requiring increased assistance with ADLs (activities of daily living); elopement risk; - Signature completion section: RN A, dated 04/11/11. Record review of the resident's initial care plan, showed the following:- Diagnosis: [REDACTED]. - Discharge plan: To return home; - 04/11/11: ADL decline/CVA checked: ambulation with walker;- 04/11/11: Cognitive decline checked: reality orientation PRN (as needed); cue as needed; - 04/11/11: Psychosocial well-being checked: orient to facility; encourage activities; one to one as needed; assist with ADLs as needed; encourage conversation; - 04/14/11: Behavior symptom alert checked: redirect by all staff; wanders; attempts elopement; wanderguard; check whereabouts frequently; psychiatric evaluation; - 04/14/11: Wanders/attempts elopements: goal- no further episodes; wanderguard; check whereabouts frequently; involve in activities; initiate 15 minute checks when behavior escalates; - 04/14/11: Fall/post fall alert: goal- no injury falls; adaptive device- uses wheeled walker. Record review of the resident's handwritten physician's order sheet, dated 04/11/11 through 04/25/11, showed the following: - 04/13/11- cognitive skills training added to OT (occupational therapy); - 04/13/11- skilled physical therapy five times per week for 30 days. - 04/14/11- speech therapy evaluation complete; resident to receive skilled speech therapy five times per week for 30 days for severe cognitive impairments and elopement risk; individually and in group sessions. Record review of the resident's restraint evaluation, dated 04/11/11, showed the following: - Cognitive level: alert; - Confused; - Memory: fair; - Ambulation status: up ad lib (as desired) with walker;- Gait: unsteady at times; - Safety awareness when ambulating: fair. Record review of the resident's facility exit-seeking/wandering assessment, dated 04/11/11, showed the first question: is resident physically able to leave the building on their own, was documented as "no". The bottom of the form was not checked for either at risk or not currently at risk" Record review of the resident's History and Physical, completed by his/her physician on 04/12/11, showed the following: - Memory loss was circled on the check-list; - Mental status: alert and oriented times one ; - Advanced dementia. Record review of the resident's Geriatric Psychiatry Consultation sheets, completed on 04/13/11 by the psychiatrist and his/her assistant, showed the following: - admitted for decreased cognitive dysfunction; - Impression: Dementia-severe with anxiety; - Findings: As per family member, the resident's memory rapidly declined in last year, and the resident was diagnosed with [REDACTED]. - Mood and affect: anxious. Record review of the resident's nursing notes, showed the following entries: - 04/11/11: 5:00 P.M.- Resident admitted from private home accompanied by his/her family and friend via private auto. Ambulated into facility with assistance of family--usually uses walker. Alert and cooperative, pleasant. Some confusion noted. Needs some assistance with ADLs (activities of daily living). Introduced to room and room-mate. - 04/11/11: 5:30 P.M.- Recent hospitalization for UTI (urinary tract infection); increased confusion. - 04/12/11: Alert but confused. - 04/13/11: 3:30 P.M.- Therapist received new order for the resident's physician. Add cognitive status training to OT (occupational therapy) plan of care. - 04/13/11: 5:55 P.M.- Informed resident had eloped (left facility). Called supervisor immediately, unable to reach. Then notified front desk. Staff continued to look for resident on Hawthorne. Three sweeps of building done by staff then initiated outdoor search. - 04/13/11: 7:55 P.M.- Informed by DON that resident was at the hospital. - 04/14/11: 12:15 A.M.: The resident's family member called the facility.... - 04/14/11: 12:20 A.M.: The resident returned from the hospital ER. Alert and oriented times one; wanderguard in place; one to one CNA provided. Will continue to monitor. Record review of the resident's physical therapy plan of treatment, dated 04/12/11, showed the following: - Certification period: From 04/12/11 through 05/11/11; - Prior hospitalization : 04/08/11 through 04/09/11; - History: Resident found confused by his/her family member and taken to the hospital. Resident has history of stroke, diabetes, ... and weakness most recent secondary to [DIAGNOSES REDACTED]. Of brain, altered mental status, left facial weakness noted upon hospitalization initially. - Assessment: Resident is alert and cooperative but he/she was not oriented to date or place. - DC plans: Unknown at this time, resident wants to return home as previously. - Precautions: Decreased cognition and dizziness. 4. During an interview on 04/20/11 at 10:20 A.M., LPN C (Hawthorne day charge nurse) said the following: - The resident ambulated independently with a walker. When the resident was admitted , the resident was alert, but confused. LPN C said when residents are admitted , the exit/seeking and wandering form is completed. LPN C said the resident was physically able to leave the building on his/her own but said now the doors were automatically locked. The resident walks pretty good, sometimes unsteady, but most of the time steady. LPN C said the resident had a moderate gait. LPN C said the new door lock system was started on Friday (03/14/11). LPN C said if a resident can ambulate on his/her own, LPN C said he/she views this as a resident being at risk for elopement. On 04/11/11, the resident was fine. On 04/12/11, the resident did activities and had therapy. On 04/13/11, the resident was pretty good. The resident had therapy and did activities. The resident was little confused, and the resident talked about going home. They got the resident involved in a music activity around 1:30 P.M., and the resident appeared fine. LPN C said upon admission, the resident's decision making was impaired, and LPN C said he/she did not think the resident was oriented to place. LPN C said in the beginning, the resident made statements about wanting to go home, but thought maybe this was due to confusion when the resident's family member would visit then leave. LPN C said the resident is now adjusting well and has a wanderguard (a device worn on the wrist or ankle that alarms when a resident gets close to an exit/door). LPN C said he/she was not sure if they were going to continue using wanderguard devices on residents once the new door alarm system was in place. - When asked how they determine whether a resident is at risk for elopement, during this interview, the ADON stopped by the nursing station and said the instructions for how to complete the exit-seeking/wandering assessment were on the back of the form. - LPN C said if staff check on the exit-seeking/wandering assessment form that a resident is at risk, then staff place a wanderguard on that resident. If a resident continues to go to the door, then they perform 15 minute checks on the resident. He/she said usually after a few days, the residents adjust and are fine. During an interview on 04/20/11 at 11:08 A.M., the resident's family member said the following: - A passing motorist saw the resident in the road, and the motorist called 911. The hospital called and left a voice mail on his/her home phone at approximately 6:38 P.M. Facility staff left a voice mail on his/her home answering machine at approximately 7:18 P.M. to call the facility as soon as possible. The family member did not return home until after 10:00 P.M. The family member said on 04/11/11, he/she left his/her cell phone and another family member's contact information during the admission. He/she said staff only wrote his/her home number on the admission face sheet form. Record review of Administrator A's (Adm A) facility written statement, dated 04/13/11, showed the following: - Approximately 7:40 P.M., he/she went to the hospital to check on the resident. The resident was in good spirits and no apparent injuries noted. The resident's mental status was the same as earlier today when he/she and the resident visited for a while around 4:30 P.M. The hospital tried to reach the family multiple times, and they reached the resident's family member around 11:00 P.M. Adm A stayed with the resident until the resident was discharged back to the facility. The hospital ordered a CT scan of the resident's head and neck; both were negative. They performed x-rays of the resident's pelvis, and it was negative. Before the resident returned to the facility, Adm A requested that the resident have one to one care for the next 72 hours for further monitoring. - On 04/14/11, the resident was reassessed for elopement precautions. The resident's care plan was updated for elopement precautions. The resident continues on one to one for 72 hours for follow up. All staff were in-serviced again on wandering/elopement procedures. During an interview on 04/20/11 at 3:47 P.M., Adm A said the following: - A family member of another resident told him/her that they had seen the scene of this incident on 04/13/11 with Resident #1. Adm A said Resident #1 was able to tell the other family member his/her name at the scene. When asked what time this occurred, Adm A said the other family said they remembered the time because it was just starting to get dark at approximately 6:20 P.M.. The police did not arrive on the scene, but EMS did. - Adm A said several staff drove around looking for the resident. When asked about the time this occurred, he/she said he/she would have to check his/her cell phone. The facility called 911, and he/she said the time is on the report the facility provided. He/she said maybe it was around 7:15 P.M. - Adm A said he/she arrived at the hospital at 7:40 P.M. The hospital was unable to reach Resident #1's family member until 11:00 P.M. Adm A said because the facility was so close, he/she did not know why EMS did not check with the facility first. During an interview on 04/20/11 at 4:30 P.M., RN A (Hawthorne evening charge nurse)said the following: - RN A said the resident could barely walk when he/she came into the facility. RN A said the resident was assisted into the building and to his/her room by the resident's family member and friend. RN A said staff walked the resident to the dining room and back to the resident's room after dinner. On 04/12/11, the resident's family brought the resident's walker to the facility. RN A said on admission he/she did not see any physical indication that the resident could leave the building. RN A said he/she asked the resident's family member if the resident might leave the facility, and the family said the resident probably could not open the door. RN A said when the resident was admitted , the resident was really confused and forgetful. The resident did not give appropriate answers to anything. RN A said he/she did not know what occurred on the other shifts with the resident because RN A was off for three days. - RN A said when staff checked the at risk section on the exit-seeking/wandering assessment, that meant staff were to place a wanderguard on that resident. During a telephone interview on 04/20/11 at 10:08 P.M., RN A said the following: - The day charge nurse completed the resident's initial care plan. On section G of the initial assessment form in the comments section, he/she did not write elopement risk. RN A said he/she wrote: increased confusion and requiring increased assistance with ADLs. Record review of Nurse Supervisor D's (NS D) facility written statement, dated 04/13/11, showed some of the following information: - He/she was notified by RN A around 6:55 P.M. that the resident was missing from the unit. Facility staff searched the unit room by room and the outside perimeter. After the initial search was completed and the resident was not found, NS D instructed the charge nurse to notify the family and/or see if the family had taken the resident leave of absence without notifying staff. The search was expanded to the nearby residential area. They were unable to contact family. The DON was notified at approximately 7:15 P.M. to notify him/her of the resident's possible elopement. - The police department was notified at approximately 7:20 P.M. to 7:30 P.M. Two police officers arrived at the facility at approximately 7:40 P.M. and stated the resident was at the hospital ER (emergency room ). NS D called the hospital at approximately 7:50 P.M. and verified that the resident was there being evaluated and that the resident was stable. During an interview on 04/20/11 at 5:35 P.M., Nurse Supervisor D (NS D), said the following: - NS D confirmed his/her facility written statement. - RN B called him/her on the supervisor cell phone at approximately 6:55 P.M. NS D was in the annex building in Brookview (main facility building) assisting with another resident when RN B first called him/her. NS D said a CNA (certified nurse assistant) said the resident was sitting in the dining room with another resident at approximately 6:00 P.M. by the front door. Staff had already initiated a search in house when RN B called him/her. They searched the perimeter of Hawthorne and other manor buildings. Some staff came up from Brookview and assisted. Staff also searched behind the human resources building, where there is a gate that leads to a creek. They did not find the resident after searching, and staff expanded the search to the nearby neighborhood. Staff went east and west on the street. He/she notified the DON at approximately 7:10 P.M. -7:15 P.M. before the perimeter search. The DON came to the facility and drove to the resident's home address. They were unable to contact the resident's family, and NS D thought the family may have taken the resident out without signing the resident out. NS D said he/she was thinking the resident could not have gotten that far with his/her walker. NS D called the police department, and Administrator B also came to the facility. The camera footage was reviewed, and he/she thought the resident went out the back door of Hawthorne. NS D said if the resident would have had a wanderguard, the door would have sounded/alarmed. NS D said the resident had not exhibited any behaviors of wandering off prior to admission. Until the resident came up missing, NS D said he/she did not know the resident's name since he/she supervises the entire campus (Brookview and all 4 manor buildings). He/she said he/she gave the incorrect name when he/she called 911. When the resident was admitted , the resident was ambulatory with a walker. The resident was alert and oriented times one to two. The resident was not aware of his/her situation; the resident knew his/herself, and the resident knew he/she was not at home. The resident could not tell you the name of the facility. - If a resident is bedbound or unable to propel his/her own wheelchair, the resident would not be able to physically leave the building. If a resident is ambulatory or can propel his/her own wheelchair, then the first question on the exit-seeking/wandering assessment form should be "yes" for physically being able to leave the facility. The resident was ambulatory. NS D said a CNA had told him that the CNA had seen the resident also walking without his/her walker. When staff check on the exit-seeking/wandering assessment form as at risk, then staff place a wanderguard on that resident. - NS D said when the police arrived at the facility, the police told them that the description the facility provided of the resident matched a patient that was sent to the hospital. NS D said he/she called the hospital and verified with the hospital ER nurse that the resident was at this hospital. - The resident was found at the nearest intersection down the street. NS D said apparently a driver called EMS. Resident stayed at the hospital until around midnight. - After the incident occurred, the door systems were changed. The staff implemented one on one upon the resident's return to the facility until the new door system was completed. Record review of RN B's (charge nurse) facility written statement, dated 04/11/11, showed the following: - RN B saw the resident at 4:30 P.M. when the psychiatrist and psychiatrist's assistant visited the resident. The resident was in the dining room at 5:00 P.M. to 5:50 P.M. RN B said he/she was informed at 6:55 P.M. that the resident was missing. RN B called NS D and the front desk. Staff continued to look for the resident on Hawthorn. Three sweeps of the building were done by staff, then staff initiated an outdoor search. During an interview on 04/20/11 at 5:58 P.M., RN B confirmed his/her facility written statement. RN B said this was the first time he/she was assigned to Hawthorne. When this incident occurred, RN B said he/she was in another resident's room attending to an emergency. RN B said Resident #1 was ambulatory with a walker. The resident was alert and oriented to the resident's name. RN B said he/she thinks the resident knew where the resident was, but thinks the resident did not want to be there. That day (04/13/11) the resident was restless; the resident was walking around the unit; the resident was up and down, and RN B said he/she tried to keep an eye out on the resident. RN B said he/she had an emergency that he/she had to attend to with another resident. After making phone calls for that emergency, then he/she found out that the resident had disappeared. Staff had initiated a search. RN B said he/she did not realize the resident was a new admission until around midnight after the family called the facility. RN B said he/she left voice messages on the family member's phone, and RN B said he/she only had one phone number to contact for the resident's contacts. - When RN B was asked about the exit-seeking/wandering assessment form, RN B said if a resident is up and ambulatory, he/she would consider that resident to be physically capable of leaving the building. If staff check at risk on the form, staff would initiate the use of the wanderguard. - RN B said Resident #1 did not have a wanderguard. Record review of CNA E's facility written statement, signed on 04/13/11, showed the following: - The resident was sitting in the dining room; the resident ate his/her dinner and approximately 5:50 P.M., CNA E assisted another resident to that resident's room. CNA E said Resident #1 was by his/her own room. CNA E said he/she was in a different resident's room for approximately 15 minutes, and when CNA E came out of that room, Resident #1 was not at his/her room door. At approximately 6:35 P.M.-6:40 P.M., CNA E heard the front door alarm. CNA E checked the alarm, and a resident was at the door. CNA E removed the resident from the door, then started checking to make sure all residents were accounted for. CNA E noticed that Resident #1 was not in his/her room or other areas. CNA E asked the CMT and other CNA if they had seen the resident, and they had not. They told the charge nurse they could not locate the resident, and they all checked all rooms, bathrooms, closets, and were unable to locate the resident. CNA E said he/she checked the grounds and all manor buildings (note: the facility has four manor buildings, including the Hawthorne building). CNA E said he/she went back in Hawthorne and re-checked the building while other staff checked the rest of the grounds. During a telephone interview on 04/21/11 at 5:05 A.M., CNA E confirmed his/her facility written statement. CNA E said he/she is usually assigned to work in the Hawthorne building. On 04/13/11, CNA E said the resident did not seem agitated but the resident seemed a little worried early in CNA E's shift. CNA E said a couple of times the the resident was worried about whether his/her sister was going to visit. This occurred in the sitting area and the dining room. CNA E said he/she tried to reassure the resident that his/her daughter would be visiting the resident. CNA E said the last time he/she physically saw the resident was at approximately 5:55 P.M. The resident did ambulate independently with his/her walker. CNA E said he/she saw the resident sitting in the dining room at a dining room table, and the resident was around another resident's family member while that family member was trying to visit with the other resident. CNA E said the family member called another aide over for assistance, but CNA E was not sure what was said. Record review of CMT F's facility written statement, dated 04/13/11, showed he/she last noticed the resident in the dining room with another resident and his/her family near the end of the dinner because the resident was bothering the family member. Record review of the DON's facility written statement, dated 04/14/11, showed the following: - He/she was notified at approximately 7:10 P.M. that the resident was not in the facility by NS D. NS D said staff had searched all of the manor buildings and had been unable to find the resident. The DON instructed NS D to initiate an outdoor search. The DON then called the front desk and instructed the staff to notify all wings that a resident was missing and to begin an outside search. The DON notified Administrator A and Administrator B at approximately 7:15 P.M. The DON arrived on the facility property at approximately 7:20 P.M. A large amount of staff were outside, and he/she directed them where to search, both up and down the street and to the resident's house on a different street. The pond, and storage sheds were also searched with no signs of the resident. NS D called 911. The DON instructed staff to search the manor houses again. The DON met with Administrator B in his/her office at about 7:30 P.M. to assist in pulling video camera footage. At about that time, a police officer arrived and informed them that the resident was at the hospital ER. Administrator A was notified, and Administrator A went to the hospital. RN B attempted to reach the family several times and was unsuccessful. The resident's physician was notified at 9:30 P.M. Record review of Administrator B's (Adm B) facility written statement, dated 04/14/11, showed the following: - Adm B was notified by the DON at approximately 7:15 P.M. that facility staff were unable to locate the resident and that NS D was notifying the police. Adm B arrived at the facility at 7:30 P.M. At approximately 7:35 P.M., NS D and a police officer entered his/her office. The office was communicating with his/her dispatcher and confirmed that the resident was at the hospital in the ER. The officer then left. The DON spoke to the police department and was told that they were dispatched on a call of an elderly lady who had fallen near the street intersection at 6:16 P.M. - The resident was last seen by staff at 5:55 P.M. and picked up by ambulance at approximately 6:20 P.M. Police received a call that an elderly lady had fallen and was dispatched to scene at approximately 6:16 P.M. The resident was taken to the hospital for evaluation and returned to the facility at approximately 12:20 A.M. by ambulance, no injury noted. During an interview on 04/21/11 at 9:35 A.M., the Administrator B (Adm B) and the DON said the following: - The DON said the resident did not leave by the front door of the facility. Adm B said they scanned the facility front door motion cameras. The time range of the cameras viewed was 5:00 P.M.-7:00 P.M. The DON said these cameras are motion activated. Adm B said they did not see anything on those cameras. Adm B said they also looked at the cameras on the Brookview building, and one motion camera captured a still shot of the resident at the back corner of Brookview on the side-walk at 6:03 P.M. The front camera of Brookview did not pick up anything because there was not enough motion, this camera is further away. - The DON said the directions for the exit-seeking/wandering assessment are on the back of the form. If a resident is ambulatory, the answer to the first question should be "yes". The DON said from what he/she understood, the resident came to the facility in a weakened state. The resident's family and friend walked him/her into the facility. At that time the resident's family member did not want the resident to have his/her walker. The next day (04/12/11), facility staff called the family member and asked him/her to bring the resident's walker to the facility because the resident was improving and trying to get out of bed. The DON said staff should have re-looked at the assessment. - Adm B said the exit-seeking/wandering assessment is a quarterly tool, and any improvement for a resident should be documented in the medical record. - The DON said the resident was confused upon admission and had periods of confusion. The resident was last seen on 04/13/11 right after dinner. The DON said he/she believed t