Every finding on record at Tallahatchie General Hosp Ecf

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the call light was within reach for one (1) of 24 sampled residents reviewed (Resident #10). This deficient practice resulted in the resident not having access to staff assistance when needed. Findings Include:Review of the facility policy titled Call Light with a revision date of 9/08 revealed, .Be sure call light is within reach at all times.On 10/27/25 at 12:30 PM, the surveyor observed the call light hanging behind the bed and out of the resident's reach. The resident stated, It doesn't work half the time.During an observation of resident's room and an interview with Licensed Practical Nurse (LPN) #2 on 10/28/25 at 1:15 PM, an observation was made of Resident #10's call light, behind her bed and out of reach. LPN #1 stated, Yes, I know it is out of reach. It is intentional because if we give her the call light, she will push it repeatedly. She usually just yells loud, and we can all hear her and we come in and check on her.An interview with the Director of Nursing (DON) on 10/28/25 at 1:50 PM revealed that the call light should always be in reach of the resident. The DON stated, At all times, the call light should be in reach of the resident.Record review of the admission Record revealed the facility admitted Resident #10 on 3/11/2013 with a diagnosis of Crohn's Disease.Record review of Resident #10's admission Minimum Data Set (MDS), Section C, dated 7/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicates moderate cognitive impairment.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure an active order for an as needed pain medication for a resident with pain management needs was available when medication was needed for one (1) of 20 sampled residents. Resident #96 Findings include: Record review of facility policy titled, Pain Assessment and Management with effective date of 7/13 revealed, The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. The pain management program is based on a facility-wide commitment to resident comfort. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his/her clinical condition and established treatment goals. 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions . An interview with Resident #96 on [DATE] at 2:55 PM, revealed there were times he did not receive his pain medicine because the prescription expired and the Nurse Practitioner (NP) had to reorder this medication. He stated he had generalized pain which was most frequent in his legs and knees. He revealed his pain level scores were usually four to five and at times it was six to seven on a scale of 1-10 with 10 being the worst pain it could be. He revealed there was an incident recently when he asked for his pain medicine and was told that it had expired and they would contact the NP. He stated he got angry and knocked filing cabinets over and knocked things off of the carts and he told the staff he would continue this behavior until he received his medicine. He revealed he was sent to Behavioral Health for an evaluation and treatment. He stated he hated he acted that way, but there were only so many times that he could hear that the provider had to be notified for a new prescription for him to receive the medication for his pain relief. He revealed it was the staff's responsibility to ensure the medications and prescriptions were available when he needed his medications and this did not occur. During interviews on [DATE] at 3:45 PM and [DATE] at 9:45 AM, the Director of Nursing (DON) revealed that as needed (PRN) pain medication had to be renewed every 30 days in order to meet the federal regulations related to psychotropic and pain medication use. When the provider gave an order for an as needed pain medication, the facility staff put a 30-day stop date into the computer system. She revealed in the facility's computer charting system, there was not a way to trigger a notification for a medication that would be expiring. The charge nurses and the NP review orders to ensure the orders were reordered prior to expiration, but this one slipped through. She acknowledged that even though the medication was available in the medication cart, it could not be administered to the resident due to the order being expired. She revealed the incident occurred when Resident #96 asked for his pain medication and was told the prescription had expired and staff would notify the provider. He became angry and knocked over filing cabinet, pushed items off the medication cart, and tried to turn over the linen cart and the medication cart. She acknowledged the staff notified the NP and received the order and the resident received his medication within approximately 20 - 30 minutes. She acknowledged it was her expectation that each resident's right to receive the PRN pain medication as needed and as ordered was honored. She confirmed that even though it was only a brief time frame before the medication was administered, the facility failed to have the active orders in place that would allow the pain medicine to be given when needed by the resident. A phone interview with the Nurse Practitioner on [DATE] at 4:05 PM, revealed she was notified of the incident with Resident #96 and responded back within 20-30 minutes with an active order. He had requested his pain medication, but the PRN (as needed) pain medication had fallen off the active order list and could not be administered until renewed. The resident got angry and threatened the nurse, knocked filing cabinets over, pushed things off medicine cart, tried to overturn linen cart and medication cart. She acknowledged she viewed the video footage and the resident waited around 20-30 minutes for the medication and was acting out during that time. She stated this had been an issue and this was the 2nd or 3rd time it had occurred with the resident needing his pain medication and that it had expired in the system and could not be given until the NP was notified. An interview by phone with Licensed Practical Nurse (LPN) #3 on [DATE] at 9:30 AM, revealed she was the charge nurse when the incident with Resident #96 occurred. The floor nurse informed her that Resident #96's pain medication had dropped off and was no longer available to be administered to the resident. She stated the floor nurse informed the resident that they were getting in touch with the provider but he was not hearing it. He became extremely angry and knocked over filing cabinets, pushed items off of the med cart, tried to overturn carts, and stated he was going to continue this behavior until he received his medication. She stated he tore up the nurses' station. She notified the NP who renewed the order and the medication was administered in less than 30 minutes from the start of the incident. She revealed that once the medication was administered, the resident was immediately better. Record review of Order Recap Report revealed an order dated [DATE] with end date of [DATE] for Tramadol 50 milligrams (mg) every six hours as needed for pain for 30 days. Record review of Progress Note dated [DATE] at 3:07 AM revealed resident received Tylenol 325 mg tablets two tablets for 650 mg for complaints of pain. Review of Progress Note dated [DATE] at 5:50 AM revealed a follow-up pain scale of three and the administration of the Tylenol was ineffective. Review of Progress Note dated [DATE] for [DATE] revealed Tramadol was restarted. Record review of Order Recap Report revealed an order dated [DATE] with end date of [DATE] for Tramadol 50 mg every six hours as needed for pain for 30 days. Record review of Progress Note dated [DATE] revealed, Resident angry and states he is moving out Monday b/c (because) he was unable to get his pain meds. Advised resident PRN (as needed) orders expire and have to be renewed/reordered. Resident was advised that this nurse had already got his tramadol ordered for him. Record review of Order Recap Report revealed an order dated [DATE] with end date of [DATE] for Tramadol 50 mg every six hours as needed for pain. Record review of Order Recap Report revealed an order dated [DATE] with end date of [DATE] for Tramadol 50 mg every six hours as needed for pain for 30 days and give one tablet by mouth one time a day for pain. Record review of Progress Note dated [DATE] revealed, Resident requested to see NP (Nurse Practitioner) regarding pain meds. NP did see resident who states that the tramadol does not work very long or very well anymore and that he needs something stronger. Stated he saw ortho and they recommend knee replacement, and he states he is not quite ready for that. New order received for Norco 5-325 every 6 hours as needed for pain. Record review of Order Recap Report revealed an order dated [DATE] with end date of [DATE] for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg one tablet every 6 hours as needed for pain for 30 days. Record review of Progress Note dated [DATE] revealed, Resident yelling and cursing at staff due to PRN medication Norco not being available for administration at the time. Medication was showing completed on EMAR. Resident was informed that NP (Proper name removed) was being contacted on behalf of medication to get new order Norco. Resident was offered PRN Tylenol at the time until order was approved by NP. Resident proceed to flip bend and attempt to flip med cart. Resident stated that he would continue behavior until he could get his pain medication. No injuries noted. Record review of Order Recap Report revealed an order dated [DATE] for Hydrocodone-Acetaminophen Oral Tablet 5-325 one tablet by mouth every 6 hours as needed for pain. Record review of Nurse Practitioner note dated [DATE] revealed the reason for visit, This is a follow up visit for NH (Nursing Home) resident date of service [DATE]. On [DATE], resident became combative, cursing at staff, and trying to flip med cart over after not being able to receive pain medication due to order expiring on MAR (Medication Administration Record). Pain medication reordered and administered. Record review of Resident #96's admission Record revealed the facility admitted the resident on [DATE]. Resident had a diagnosis of pain. Record review of Resident #96's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was intact cognitively.

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure infection control practices were maintained for two (2) of 24 residents reviewed. (Resident #20 and #77) Findings include: A review of the policy titled, Infection Control effective 9/2016 revealed, 7. All resident specific equipment such as.suction supplies .will be stored in a covered container such as a clean bag in the resident's room and changed as appropriate. Record review of facility policy titled, Guidelines for Isolation Precautions with revision date 1/27/23, revealed, Enhanced Barrier Precautions (EBP) require the use of gown and gloves only for high-contact resident care activities (i.e indwelling medical device care and use .) Resident #20 On 10/27/25 at 2:00 PM, and again on 10/28/25 at 12:54 PM, a yanker suction catheter was observed out of its protective packaging on the bedside table in Resident #20's room. A suction canister was observed approximately one-fourth full of white liquid. During an interview and observation on 10/28/25, Licensed Practical Nurse (LPN) #2 confirmed the yanker was out of the packaging and the canister contained liquid. She stated, The yanker should be in its packaging because of infection control. The fluid in the canister could be an infection control issue and should have been disposed of. An interview with the Director of Nursing (DON) on 10/28/25 at 1:45 PM, confirmed that the yanker should have been stored in a plastic container when not in use and that the canister should have been disposed of or emptied and disinfected per facility policy. Review of the admission Record revealed the facility admitted Resident #20 on 11/02/2016 with diagnosis of Dementia. Record Review of Resident #20's admission Minimum Data Set (MDS), Section C, dated 8/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. Resident #77 During an observation of medication administration on 10/28/2025 at 9:00 AM for Resident #77 with Licensed Practical Nurse (LPN) #1, it was observed that the nurse failed to use Enhanced Barrier Precautions (EBP) while administering Percutaneous Endoscopic Gastrostomy (PEG) medications. Record review of the Order Summary Report revealed an order dated 5/2/24 for Enhanced Barrier Precautions due to PEG two times a day. During an interview on 10/28/2025 at 9:15 AM with LPN #1, she confirmed that EBP should have been used during medication administration for residents with PEG tubes. She further stated that EBP was ordered to help prevent the spread of infection. During an interview on 10/28/2025 at 9:54 AM with the Director of Nursing (DON), she stated EBP should be used with any tubes or wounds to prevent possible cross contamination. She further stated that her expectations were for staff to follow EBP with all care provided for residents with a tube or wound. Record review of the admission Record that Resident #77 was admitted to the facility on [DATE], with medical diagnoses that included spastic quadriplegic cerebral palsy and gastrostomy status. Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 7/29/25 revealed, under Section C, a BIMS score of 0 indicated that an interview should not be conducted because the resident was rarely/never understood.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure resident information was not accessible to the public during medication administration for one (1) of four (4) residents observed during medication administration. Resident #82. Findings Include: Record review of the facility policy, Administration of Drugs with revised date of 09/08 revealed, .Medication Administration Records should be kept covered to ensure privacy of information An observation on 12/03/24 at 9:00 AM, of a medication cart on the A-Hall, revealed an open computer screen with Resident #82's Electronic Medication Administration Record (EMAR) information visible to anyone passing by the medication cart. The visible information included Resident # 82's name, medications, and room number. An interview on 12/03/24 at 9:10 AM, with Licensed Practical Nurse (LPN) #1 revealed that she was assigned to the medication cart on A-Hall. She confirmed that the EMAR for Resident #82 was visible on the computer screen and that she should have clicked the privacy screen on before she walked away from the cart. LPN #1 agreed that this was a privacy issue and that the resident's information in the medical record should be kept confidential. An interview on 12/03/24 at 9:55 AM, with LPN Supervisor revealed that the nurses were supposed to lock the computer screen prior to leaving the medication cart unattended. She revealed that the purpose of the locked screen was to prevent anyone who might be walking by from seeing a resident's personal health information. LPN Supervisor stated, It's always a given to lock the cart and have the privacy screen on while administering medicine. An interview on 12/03/24 at 10:05 AM, with Director of Nursing (DON) revealed that a resident's personal information should never be left up on the computer screen while the medication cart is unattended. She revealed that there was a privacy button that was supposed to be pushed before the nurse stepped away from the computer. The DON confirmed that this was a privacy issue and that residents information should be kept confidential. Record review of Resident #82's Admission Record revealed an admitted [DATE].

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete a section of the Minimum Data Set (MDS) for a resident with significant weight loss for one (1) of 22 sampled residents MDS reviewed. Resident #6 Findings Include: Review of the facility policy titled Resident Assessment Instrument (RAI) revised September 2010, revealed under, Policy Interpretation and Implementation: . 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning . 7. All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. Record review of the Weight Summary for Resident #6 revealed the following values: 7/2/2024 176.6 Lbs. 7/8/2024 175.2 Lbs. 7/17/2024 173.6 Lbs. 7/24/2024 169.2 Lbs. 8/13/2024 169.2 Lbs. 9/5/2024 158.0 Lbs. 10/2/2024 157.6 Lbs. 10/9/2024 156.4 Lbs Record review of the Registered Dietician (RD) Assessment Summary dated 9/13/24 for Resident #6 revealed under, Weight changes: (minus) -6.6 % (percent) SWL (significant weight loss) x (times) 30 days . Record review of the Weight Note for Resident #6 dated 9/26/24 revealed the resident had an 11.2-pound weight loss in 30 days. Record review of Resident #6's Quarterly MDS, with an Assessment Reference Date (ARD) of 10/9/24, revealed under section K0300, loss of 5% (percent) or more in the last month or loss of 10% (percent) or more in last 6 months was answered and marked as No. An interview with the MDS Nurse on 12/3/24 at 2:25 PM, confirmed that section K was not completed accurately to reflect Resident #6's weight loss. She revealed the Dietary Manager (DM) was responsible for completing that section of the MDS and confirmed that it was missed. An interview with the DM on 12/3/24 at 3:06 PM revealed, she made a mistake completing Resident #6's section K and explained that she did not go back and look at the weights like she should have. She confirmed if the MDS was not completed accurately, it would not reveal the complete needs of the resident's health status. An interview with the Director of Nursing (DON) on 12/3/24 at 3:20 PM revealed her expectations were for all sections of the MDS to be completed accurately. Record review of the Admission Record revealed the facility admitted Resident #6 on 7/2/24 with medical diagnoses that included Unspecified Dementia and Heart Failure.

Based on staff interviews, record reviews, and facility policy reviews, the facility failed to develop and implement an Activities of Daily Living (ADL) comprehensive care plan for residents' hygiene, grooming, and nail care for two (2) of 19 sampled residents. Resident #38 and Resident #147 Findings include: Record review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #38 Record review revealed a care plan revised on 9/26/24 for Resident #38 with a focus on ADL's/Falls/Pain: I have impaired physical functioning and require assistance with ADL's related to chronic pain and (Right) R-sided Hemiplegia. The care plan for the resident with impairments has no personal hygiene, grooming, or nail care interventions. On 12/02/24 at 2:10 PM, an observation of Resident #38's nails revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged with a brown substance under the nails. On 12/03/24 at 10:45 AM, an observation and interview with Certified Nurse Aide (CNA) #1 revealed the CNAs were responsible for doing Resident #38's nail care. CNA #1 confirmed that Resident #38's fingernails were long and had a brown substance under them, revealing they needed to be cleaned and trimmed. During an interview on 12/04/24 at 11:35 AM, the Director of Nurses (DON) revealed that the purpose of the care plan is to indicate the resident's individualized care that is needed for that resident, so the staff will know the resident's needs. She confirmed that the care plan was not developed to reflect Resident #38's hygiene or grooming needs, which included nail care. Record review of Resident #38's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Vascular Dementia, Depressive disorders, and Hemiplegia and Hemiparesis following Cerebral infarction. 41878 Resident #147 Record review of the care plan for Resident #147 date initiated 11/25/24 revealed, Focus: ADLs .I have impaired physical functioning and require assistance with ADLs . This care plan did not address bathing, hygiene, grooming, or nail care. On 12/02/24 at 10:25 AM, during an observation and interview, Resident #147 revealed she would like her nails to be trimmed. She stated she had never had long nails, and she preferred her nails to be kept short. Observation of her nails revealed seven (7) of her 10 nails were long with the thumb nails approximately 3/4 inch long and some of her nails were jagged and rough. During an interview on 12/3/24 at 11:20 AM, the DON stated the purpose of the care plan was to drive the resident's individualized plan of care and to inform staff of the care that was needed. She confirmed the facility failed to develop an ADL care plan for this resident's nail care. During an interview on 12/3/24 at 3:30 PM, the Minimum Data Set (MDS) Coordinator Registered Nurse revealed she was responsible for the development of the care plans and the purpose of the care plan was to give the staff information on the needed care and preferences for each resident. She confirmed the facility failed to develop the care plan for ADL nail care for Resident #147. Record review of Resident #147's Admission Record revealed the facility admitted the resident on 11/12/24 with diagnoses of Stress Fracture to right ankle and Hypertension. Record review of Resident #147's MDS with Assessment Reference Date (ARD) of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had a moderate cognitive impairment.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene, as evidenced by the failure to provide nail care for two (2) of nineteen sampled residents. Resident #38 and Resident #147 Findings include: A review of the facility policy titled Fingernails/Toenails, Care Of revised 09/08 revealed Purpose: . To clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care cleaning should be done daily. Resident #38 An observation on 12/02/24 at 2:10 PM of Resident #38's nails revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged with a brown substance under the nails. An observation on 12/03/24 at 9:03 AM and again at 10:30 AM revealed Resident #38's fingernails on bilateral hands remained long and jagged with a brown substance under the nails. An observation and interview on 12/03/24 at 10:45 AM, Certified Nurse Aide (CNA) #1 revealed the CNAs are responsible for doing Resident #38's nail care. She revealed we do the nail care when we see that it needs to be done and confirmed that the resident's fingernails were long and had a brown substance under them, revealing they needed to be cleaned and trimmed. An observation and interview on 12/03/24 at 11:05 AM, the Director of Nurses (DON) confirmed that Resident #38's fingernails needed cleaning and trimming and revealed that this could cause skin concerns for the resident. Record review of Resident #38's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Vascular Dementia, Depressive disorders, and Hemiplegia and Hemiparesis following Cerebral infarction affecting right dominant side. 41878 Resident #147 During an observation and interview on 12/02/24 at 10:25 AM, Resident #147 revealed she would like her nails to be trimmed. She stated she had never had long nails and she preferred her nails to be kept short. Observation of her nails revealed seven (7) of her 10 nails were long with thumb nails approximately 3/4 inch long and some of her nails were jagged and rough. An interview with Registered Nurse (RN) #1 with an observation of Resident #147's nails on 12/3/24 at 10:25 AM, revealed the resident's long and rough nails. The resident informed RN #1 that she preferred to have short nails. During an interview on 12/3/24 at 11:20 AM, the DON revealed each resident's nails should be maintained as the resident preferred and since this resident preferred short nails, the staff should ensure they are kept clean and short. Record review of Resident #147's Admission Record revealed the facility admitted the resident on 11/12/24 with a diagnosis of Stress Fracture to right ankle. Record review of Resident #147's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had a moderate cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to properly secure medications as evidenced by leaving a medication cart unlocked for one (1) of four (4) medication administration observations. Findings include: Record review of the facility policy, Storage of Medications with revision date of 09/08 revealed, Purpose: Is to ensure that medications are stored in a safe, secure, and orderly manner .Compartments containing medications are locked when not in use. Carts used to transport such items are not left unattended. (Compartments include .drawers, cabinets, rooms, refrigerators, carts . An observation on 12/03/24 at 9:45 AM, with Licensed Practical Nurse (LPN) #1 revealed an unlocked medication cart left unattended on A-Hall during administration of a resident's medications. At 9:48 AM, LPN #1 revealed that she was assigned to the medication cart on A-Hall and confirmed that she did not lock the medication cart and stated, I don't usually lock it. LPN #1 confirmed that she should have locked the medication cart prior to walking away to prevent others from taking medications out of the cart. An interview on 12/03/24 at 9:53 AM, with LPN Supervisor, revealed that the medication carts should always be locked when unattended to prevent others from opening the drawers and taking the medications. She stated, It's always a given to lock the carts .and they all know this. An interview on 12/03/24 at 10:03 AM, with Director of Nursing (DON), revealed that the medication carts should always be locked when unattended to keep the medications secure and for safety reasons. She revealed that LPN #1 should have locked the medication cart before she walked away from it to keep the medications secure.

Based on record reviews, staff interviews, resident interviews, and policy and procedure review, the facility failed to prevent Resident #1, a vulnerable adult, from being verbally abused by Certified Nursing Assistant (CNA) #1. Resident #1 was one (1) of three (3) residents reviewed for abuse/neglect. Findings include: Review of the facility's policy titled : CMS definition of Abuse and Neglect dated 12/20/23 and signed by the facility's Acting Director of Nursing read: Abuse The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Record Review of the facility's written investigation conducted on 12/19/24 revealed that at approximately 10:30 PM the Director of Nursing (DON) was notified that CNA #1 was assisting resident (Res #1) when Resident #1 fell to the floor during a wheelchair to bed transfer. CNA #1 reported to the nurse supervisor, Licensed Practical Nurse (LPN #1) that he needed assistance and that Resident #1 was on the floor. LPN #1 assessed Resident #1 and found no injuries. Nurses proper name (LPN #2) and another CNA , (CNA #2) went to assist with Resident #1. Resident #1 was upset and began yelling out at the staff as a result of the fall. CNA #1 pointed his finger in the face of Resident #1 and said who do you think you are talking too, it sure ain't me cause I ain't got nothing to lose. CNA #1 was confronted by the nurse supervisor (LPN #1) and was asked to leave the facility until a thorough investigation could be conducted. CNA #1 replied: I quit. The facility attempted to reach CNA #1 several times to no avail. The record review revealed that the facility reported the incident as verbal abuse to the State Agency (SA). The written facility investigation contained 3 witness statements from CNA #2; LPN #1; and LPN #2. All 3 witnesses heard and saw CNA #1 verbally abuse Resident #1, in an intimidating manner. The facility reported to the State Agency on 12/20/23 that verbal abuse had occurred to Resident #1 by CNA #1. Interview on 02/15/24 at 3:09 PM, with LPN #2 revealed that she was the medication nurse on the second shift on the evening of 12/19/23. She was asked to assist with Resident #1 who was on the floor of his room after a fall. She stated that she, LPN #1 (nurse supervisor ), CNA #1 and CNA #2 were in the process of placing the sling for the full body lift, under Resident #1 when CNA #1 accidentally bumped the leg of Resident #1, he then yelled out and was hollering and cursing. CNA #1 then got up in the resident's face, pointed his finger at Resident #1 and in a loud intimidating tone told Resident #1 that he better not be yelling at him. LPN #2 stated that since the incident had happened so long ago, that the exact words of CNA #1 she could not remember. LPN #2 stated that all she could clearly remember was the inappropriate manner that CNA #1 spoke to Resident #1. LPN #2 confirmed that she felt that CNA #1 was verbally abusive to Resident #1. Interview on 02/15/24 at 3:30 PM with CNA #2 revealed that she had been asked to assist in the fall of Resident #1 along with CNA #1, LPN#1 and LPN #2. CNA #2 stated that CNA #1 was verbally abusive to Resident #1 and had yelled up close in the face of Resident #1 as the four (4) of them were assisting to get Resident #1 off the floor after a fall. CNA #2 stated that LPN #1 tried to council with CNA #1 and he got mad and clocked out and did not come back. CNA #2 stated that LPN #1 and LPN #2 along with her had witnessed CNA #1 verbally and in a threatening manner, abuse Resident #1 on 12/19/24. The SA attempted to contact LPN #1 for an interview but was unable to reach her during the investigation on 02/15/24. The SA did obtain copies of the written statements of all three (3) witnesses. The SA attempted to obtain an interview on 02/15/24 with CNA #1 to no avail. Record review of the written statement of LPN #1 dated 12/19/23 read: Reported to this writer of resident fall entered room with (CNA #1; CNA #2; and LPN #2). During placement of sling for use of total lift staff member (CNA #1) grabbed resident left leg, resident hollered out at staff not to hurt his leg, screaming that's my sore leg staff member (CNA #1) moved from resident side and stood over resident and hollered while pointing his finger in resident's face who do you think your talking too, it sure aint me cause I got nothing to lose. This nurse prompted staff to be aware of communication between staff and resident during interaction. Staff member (CNA #1) exited room. Communication for education prepared. Approached staff member (CNA #1) for counseling. Staff member immediately began stating resident was cursing him. Attempted to redirect staff member regarding his actions, his demeanor, and educated that he could sign the information or he needed to clock out for the evening. Staff member continued to become agitated, this nurse walked away at this time and phoned DON for further actions needed. After receiving directions from DON, staff member (CNA #1) was approached and informed he would need to clock out for the evening and reach out to (DON) in the A.M., he became agitated and began hollering at this writer that he quit and I could call and inform them. No further interaction occurred between this writer and (CNA #1). The written statement was signed by LPN #1 and dated 12-19-23. Interview and observation of Resident #1 on 02/15/24 at 4:00 PM, revealed Resident #1 recalled the evening of the incident on 12/19/24 as: He talked to me real ugly and it made me feel bad, he hurt my feelings. Resident #1 stated that CNA #1 yelled at him. Resident #1 stated that CNA #1 had not worked at the facility since that event. Record review of Resident #1's Facesheet revealed that he had been admitted to the facility on [DATE] and readmitted to the facility on [DATE]. He had diagnoses of Personal history of Traumatic Brain injury,Type 2 Diabetics; and Unspecified mood (affective) disorder; among other diagnoses. The record review of Resident #1's (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was not cognitively impaired. The State Agency (SA) identified an isolated incident of verbal abuse to Res #1 by a facility staff (CNA#1) which began on 12/19/23. The facility immediately put in place a corrective action plan and the deficient practice was corrected on 12/21/23. Based on the facility's implementation of corrective actions on 12/19/23-12/21/23 the SA determined that the isolated incident was Past Non Compliance (PNC) and was fully corrected on 12/21/23, prior to the SA's entrance on 02/15/24. Record review of the facility's action plan confirmed and validated through staff interviews, resident interviews, and record reviews that the facility's action plan had been effective and the isolated deficient practice was corrected on 12/21/23 prior to the State Agency entering the facility on 02/15/24. The facility's action plan included the following: 1-Removed the alleged perpetrator from the facility 2-Protected all the residents in the facility 3-Assessed all residents for safety and freedom from abuse/neglect 4-Contacted the facility DON and Administrator 5-Educated and In-Serviced all staff on Abuse and Neglect 6-Conducted a full thorough investigation and obtained statements from witnesses 7-Conducted a Quality Assurance (QA) meeting with the QA committee members including the Medical Director 8-Contacted the appropriate State Agencies and provided a written report of the full investigation's findings in a timely manner. 9-Conducted on-going surveillance and monitoring of all residents for signs and symptoms of Abuse/neglect 10-Updated and reviewed the care plans for all residents on 12/20/23. Through interviews and record reviews the SA determined that all ten (10) aspects of the facility's action plan were validated and the SA determined that the isolated incident of verbal abuse had been corrected on 12/21/23, prior to the SA's entrance to the facility on [DATE]. The isolated deficient practice was cited at F600 S/S=D Past Non Compliance (PNC).

Based on observations, staff interviews, record review and facility policy review, the facility failed to develop a comprehensive care plan to prevent the reoccurrence of a pressure ulcer for a resident with a contracture to a hand on one (1) of three (3) residents care plans reviewed for pressure ulcers. Resident #27. Findings include: Review of the facility policy titled,Nursing Care Plans, with an effective date of 9/2016 revealed, Policy: Care, treatment, and services are planned to ensure that they are individualized to the patients needs. The (name of the facility) shall provide an individualized, interdisciplinary plan of care for all patients that is appropriate to the patient's need, strengths, and results of diagnostic testing, limitations and goals. The activities defined in the plan of care shall be planned to occur in the time frame that meets the healthcare needs of the patient . Procedure: The planning of care, treatment and services will include the following: Care planning is based on data collected from patient assessment. Developing a plan of care, treatment and services that includes patient care goals that are reasonable and measurable . Determining how the planned care, treatment and services will be provided. Documenting the plan of care, treatment and services . Review of Resident #27's care plan revealed a care plan description for Skin/Pressure Ulcers/Incontinence: I have potential for skin breakdown related to (R/T) Impaired Mobility with an intervention start date of 7/20/2023 to evaluate right hand due to wound created by right hand contracture. An observation, on 08/21/23 at 11:30 AM and 3:37 PM revealed Resident #27 with contractures noted to her right hand. The resident's index finger on her right hand was sticking straight up, and the next four fingers were closed tightly against her hand. The resident's thumb was pressing into her palm. There was no pressure relieving devices in Resident #27's right hand. An interview, on 08/22/23 at 03:20 PM with Registered Nurse (RN) #1 revealed that Resident #27 previously had a pressure ulcer to the palm of her right hand but that it had healed on 7/18/23. RN #1 observed Resident #27's hand and confirmed that there was an open area due to pressure from the contracture. An interview on 08/23/23 at 3:35 PM with Licensed Practical Nurse (LPN) #2 confirmed she develops the care plans. She stated the purpose of the care plan is to establish a baseline to show the care the resident needs. She stated that she adds daily to the existing care plan from physician orders written the previous day and if something is discontinued, she resolves the problem. She stated that she was not notified of Resident #27's wound being healed. She stated that if she had known the wound was healed she would have added to the care plan to assess the area for recurrent breakdown. She stated that a care plan for splints or hand rolls would be generated from a physician order. An interview, on 8/23/23 at 3:40 PM with Registered Nurse (RN) #1 revealed changes with the residents are written on the 24 hour report and are discussed in their stand up meetings. An interview, on 8/23/23 at 3:55 PM with RN #2 revealed the Minimum Data Set (MDS) nurses do not get a copy of the 24 hour report. She stated that she did not know how that (the information that the pressure ulcer healed) got missed. She stated it was a lack of communication. An interview, on 8/24/23 at 9:46 AM with the Administrator (ADM) revealed that the information concerning the pressure ulcer on Resident #27's hand healing should have been picked up by the MDS nurses in stand-up and a care plan for prevention should have been done. She stated, We missed it. A review of the facility Face Sheet for Resident #27 revealed she admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Heart Failure, Unspecified Psychosis, Hypothyroidism, Major Depressive Disorder and personal history of Malignant Neoplasm of Breast.

Based on observations, staff interview, record review and facility policy review, the facility failed to prevent the recurrence of a pressure ulcer related to a contracture of a resident's hand for one (1) of three (3) residents reviewed on sample for pressure ulcers. Resident #27. Findings include: A review of the facility policy titled, Decubitus Injuries, Prevention, with an effective date of 9/2016 and a review date of 10/22 revealed, Policy: Prevention of pressure sores is primarily a nursing responsibility. The most effective means of preventing skin breakdown are relief of pressure on the skin, maintenance of adequate circulation, hydration, and an adequate diet . Try to prevent any moisture, diarrhea, urinary incontinence, sweating and the like, because excretions may cause skin maceration . Observations on 08/21/23 at 11:30 AM and 3:37 PM, revealed Resident #27 lying in bed on her back with contractures noted to her right hand. The resident's index finger on her right hand was sticking straight up, and the next four fingers were closed tightly against her hand. The resident's thumb was pressing into her palm. There was no pressure relieving devices in Resident # 27's hand. There was a foul odor noted coming from the right hand. An observation and interview, on 08/22/23 at 03:00 PM, revealed Resident #27 lying in bed with a rolled-up bath cloth in her right hand under her four fingers but not under her thumb. Licensed Practical Nurse (LPN) #1 was present in resident's room and removed the bath cloth from Resident #27's right hand and a small amount of a brown substance was noted on the bath cloth when it was removed. LPN #1 opened the resident's hand and revealed an open area to the palm of the right hand and noted a foul odor. Resident #27 confirmed that her hand hurt when it was opened. LPN #1 confirmed that Resident #27 had previously had an open area to that hand but that it had healed. LPN #1 confirmed that it would be her responsibility as a nurse taking care of Resident #27 to observe the area of any contracture for any skin issues. LPN #1 confirmed there was an open area in the palm of Resident #27's right hand. An interview, on 08/22/23 at 03:20 PM, with Registered Nurse (RN) #1 revealed that Resident #27 previously had a pressure ulcer to the palm of her right hand but that it healed. RN #1 stated that she contacted therapy to assess Resident #27 for something to prevent further breakdown. RN #1 stated that she made therapy aware that Resident #27 had a roll for her hand in the drawer in her room and that it was not being used but RN #1 did not follow up with therapy after that point. RN #1 stated that it was the responsibility of the nurses and nurse aides to complete weekly body audits. RN #1 stated that she checked on Resident #27's hand every other day for about a week after it healed to make sure it did not open back up, but she did not know who was looking at it after that. RN #1 observed Resident # 27's hand and confirmed that there is an open area due to pressure from the contracture. RN #1 measured the pressure injury to the right-hand. The pressure ulcer measurements revealed: Length 1.30 centimeters(cm), Width 1.00 cm, and Depth 0.30 cm. An interview, on 08/23/23 at 09:45 AM, with Certified Nurse Aide (CNA) #1 stated that the nurse aides do skin audits daily when they are bathing the residents. CNA #1 confirmed that the area noted to residents' right hand should have been identified before yesterday. She stated that she identified the area yesterday (08/22/23) when she was providing care for the resident, and she put the rolled-up bath cloth in her right hand. She stated that she worked last Friday (08/18/23) and the pressure area was not present then. She stated that the process would be to notify the nurse of any new skin concerns. CNA #1 stated that if the resident was supposed to have any measures in place such as a hand roll it would be in their activity documentation and that there is no documentation for that. An interview, on 08/23/2023 at 10:20 AM, with Occupational Therapist confirmed that she did not receive an order to evaluate the resident for possible interventions related to the right-hand contracture. An interview, on 08/23/2023 at 10:35 AM, with Director of Nursing (DON) stated that the nurse does a weekly body audit with the nurse aide when bathing and that the nurse aides do body audits when giving baths and report any changes to the nurse. The DON confirmed that the area of skin should have been identified prior to yesterday, 08/22/23. The DON confirmed there was no interventions present to prevent breakdown from the contracture. An interview, on 8/23/23 at 3:40 PM, with RN #1 revealed changes with the residents are written on the 24 hour report and are discussed in their stand up meetings. An interview, on 8/23/23 at 3:55 PM with RN #2 revealed the Minimum Data Set (MDS) nurses do not get a copy of the 24 hour report. She stated that she did not know how that got missed, it was a lack of communication. An interview, on 8/24/23 at 9:46 AM with the Administrator (ADM) revealed that everybody doing care for the resident was responsible for assessing the skin breakdown and something should have been in place to prevent the recurrence of the pressure ulcer. A record review of the Wound Assessment Report revealed Resident # 27 had a stage 2 pressure ulcer to her right palm that was identified on 07/01/23 and received treatment until healed on 07/18/23. A record review of the Wound Assessment Report dated 8/22/23 revealed Resident #27 had a stage 3 pressure ulcer to her right palm identifed on 8/22/23 with treatment ordered. Record review of the Completed Care Task form revealed that from 7/18/23 through 8/22/23 under body audit there were no new skin concerns. A record review of the facility Face Sheet for Resident #27 revealed she admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Heart Failure, Unspecified Psychosis, Hypothyroidism, Major Depressive Disorder and personal history of Malignant Neoplasm of Breast. A review of the MDS with an Assessment Reference Date (ARD) of 06/13/2023 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated that Resident #27 was not interviewable.

Based on staff interviews and record review, the facility failed to send a copy of a transfer/discharge notice for a resident to the State Long-Term Care Ombudsman for three (3) of four (4) residents sampled for transfer notification. Resident #1, Resident #14, and Resident #88. Findings include: The facility provided documentation on letter head dated 8/23/23 that read, We do not have a policy that specifically addresses notification of transfers to the Ombudsman. Resident #1 Record review of the Departmental Notes for Resident # 1 revealed the resident was transferred to the hospital on 6/30/23 for fever and wheezing. An interview with the Medical Records Nurse on 8/22/23 at 2:35 PM, revealed she was responsible for sending out the written notification of transfer/discharge to the Responsible Party and the Ombudsman. She confirmed that she did not send a copy of the transfer notification to the State Long-Term Care Ombudsman. She revealed that she had not sent any resident transfer/discharge notifications to the Ombudsman since April or May 2022. She stated, Things have been hectic, and it just slipped my mind. She stated, Honestly, I just thought about it when you asked for it. She acknowledged that she should have been sending out the notifications. An interview with the Ombudsman on 8/22/23 at 2:51 PM, confirmed that she had not received a monthly list of resident transfer/discharges from the facility in a while. She revealed that she was unsure of the last time she had received any notifications. An interview with the Administrator on 8/22/23 at 2:56 PM, confirmed that the facility had not been sending out transfer/discharge notifications to the Ombudsman, and she acknowledged that she was not aware they were not being sent. Record review of the Face Sheet revealed Resident # 1 was admitted to the facility on [DATE] with medical diagnoses of Scoliosis, Quadriplegia, Gastrostomy Status and Epilepsy. Resident #14 Record review of the Departmental Notes revealed that Resident #14 was transferred to the emergency room for Nausea and Vomiting on 6/21/23. On 8/22/23 at 2:40 PM, an interview with the Medical Records Nurse confirmed that she did not send a copy of Resident #14's transfer notification to the State Long-Term Care Ombudsman. She confirmed that she had not sent any resident transfer/discharge notifications to the Ombudsman since April or May 2022. Record review of the Face Sheet revealed that Resident #14 was admitted to the facility on [DATE] with medical diagnoses that included Cerebrovascular Disease, Hemiplegia, Type 2 Diabetes Mellitus, Essential (primary) Hypertension and Chronic Kidney Disease. Resident #88 Record review of the Departmental Notes revealed that Resident #88 was transferred to the emergency room for vomiting and bleeding from the surgical site to the left groin. The resident was transferred to the Emergency Department at the Hospital from the facility on 6/16/23. An interview with the Director of Nursing on 8/23/23 at 3:05 PM, confirmed that the transfer/discharge notification to the State Long -Term Care Ombudsman was not sent; therefore, the Ombudsman was not made aware of the transfer or the later discharge from the facility. Record review of the Face Sheet for Resident #88 revealed Resident #88 was readmitted to the facility on [DATE] with medical diagnoses that included Peripheral Vascular Disease, Atherosclerosis of Unspecified Type Bypass Graft of the Left Leg and Cerebral Infarction.

Based on observation, staff interview, and facility policy review, the facility failed to date and label foods in the walk in refrigerator and dispose of expired foods in the refrigerator for one (1) of two (2) kitchen tours. Findings include: Review of the facility policy, dated ,d+[DATE] and most recently revised on ,d+[DATE], titled, Storage of Refrigerated Food, revealed it is the policy that the facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. Procedure 5. revealed all opened foods are labeled with common name of food, date stored and use-by date. During the initial tour of the dietary department on [DATE] at 10:15 AM, an observation of the walk-in refrigerator revealed the following out of date foods in the refrigerator: Three (3) five (5) pound containers of Tuna salad with an expiration date of [DATE]. Two of the containers were unopened and one was one-fourth (,d+[DATE]) full. Two (2) five pound containers of cottage cheese with an expiration date of [DATE] One (1) plastic container of meat mixture, 1 half quart of yellow liquid, and 1 quart of red liquid unlabeled and with no expiration dates. 1 opened, partially used case of individual packets of sour cream with an expiration date of [DATE] 1 opened partially used case of individual serving cups of Blue cheese dressing expired [DATE]. 1 opened partially used case of Thousand Island packets out of date ,d+[DATE] Six (6) ,d+[DATE] gallon cartons of soy milk out of date on [DATE] ,d+[DATE] full one gallon jug of mayonnaise not labeled /dated for expiration. An interview, on [DATE] at 10:30 AM, with the Dietary Manager (DM), revealed that the yellow and red liquid was chicken soup and tomato soup and it should be labeled and dated. The DM stated that she told her staff that they should be checking the dates and throwing these things (expired items) away. An interview, on [DATE] at 02:20 PM, with the Administrator (ADM) confirmed that out of date foods could cause illness. An interview on [DATE] at 10:35 AM, with the DM confirmed the dietary staff had not been following the facility policy for labeling food in the refrigerator.

Based on observation, staff interview, and facility policy review, the facility failed to administer medications via Percutaneous Endoscopic Gastrostomy (PEG) tube in a manner to prevent potential risks for two (2) of two (2) PEG tube administrations observed, out of 12 residents with feeding tubes, Resident #45 and Resident #70. Findings include: Review of Fundamentals of Nursing, Potter and Perry: Ninth Edition, page 635, revealed special consideration is needed when administering medications to patients with enteral or small-bore feeding tubes. Failing to follow current evidenced-based recommendations from the American Society for Parental and Enteral Nutrition (ASPEN) can result in tube obstruction, reduced medication effectiveness, and increased risk of medication toxicity. When administering more than one (1) medication at a time, give each separately and flush between medications with 15 to 30 milliliters (mL) of water. Review of the facility policy titled, Gastric Tube Medication Administration, effective 2001, revised 9/08, revealed it is the policy to flush the tubing with the amount of water ordered before administering the medication and flush the tubing after administering medication with the amount of water ordered. On 09/17/19 at 08:20 AM, Licensed Practical Nurse (LPN) #1 administered five (5) medications to Resident #70 via Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 did not flush between each medication when administered. Interview with LPN #1, on 9/18/19 at 11:45 AM, confirmed that she did not flush between each medication because the policy had changed. She stated they flushed before and after the medications, but not between the medications. She stated she thought there should be a flush between each medication, because that's what she was taught in school. On 09/17/19 at 8:35 AM, LPN 2 administered seven (7) medications to Resident #45 via PEG tube. LPN #2 failed to flush between each medication when administered. Interview with LPN #2 on 9/18/19 at 1:35 PM, revealed she thought she had flushed between some of the medications she had administered through Resident #45's PEG tube, but realized she didn't. She stated she did flush the tube before giving the medications and after they were all given. Interview with the Director of Nursing (DON) on 9/18/19 at 9:45 AM, revealed that Standards of Practice are to flush with water between medications. She stated that's why the nurses set up and give each medication individually, flushing before and after the medication. The DON confirmed the policy does not instruct to give water between each medication. On 09/18/19 at 3:30 PM, an interview with the Administrator revealed they had discussed the issue about PEG tube medications and she stated their policy was not correct.

Based on observation, staff interview, and facility policy review, the facility failed to ensure appropriate procedures to prevent complications while administering medications via Percutaneous Endoscopic Gastrostomy (PEG) tube. This is evidenced by the failure to flush between each medication administered via PEG tube for two (2) of two (2) PEG tube administrations observed out of 12 residents with PEG tubes, Resident #45 and Resident #70. Findings include: Review of the facility policy titled, Gastric Tube Medication Administration, effective 2001, revised 9/08, revealed it is the policy to flush the tubing with the amount of water ordered before administering the medication and flush the tubing after administering medication with the amount of water ordered. Review of Fundamentals of Nursing, Potter and Perry: Ninth Edition, page 635, revealed when administering more than one (1) medication at a time, give each separately and flush between medications with 15 to 30 milliliters (mL) of water to prevent complications such as tube obstruction, reduced medication effectiveness, and increased risk of medication toxicity. Resident #70 On 09/17/19 at 8:20 AM, Licensed Practical Nurse (LPN) #1 administered five (5) medications to Resident #70 via PEG. LPN #1 did not flush between each medication when administered. On 09/18/19 at 11:45 AM, an interview with LPN #1 revealed she did not flush between each medication when administering by PEG because they had had a big discussion about this a while ago and the policy was changed. She stated they flush before and after meds (medications) but not between each one . LPN #1 stated she thought she should flush between each one because that was what she was taught in school and that is how she did it when she worked at another facility. Resident #45 On 09/17/19 at 08:35 AM, Licensed Practical Nurse (LPN) #2 administered seven (7) medications to Resident #45 via PEG tube. LPN #2 failed to flush between each medication when administered. On 09/18/19 at 1:35 PM, an interview with LPN #2 revealed she thought she flushed between some of them, but realized she didn't. She stated she did flush before giving the medications and after they were all given. On 09/18/19 at 09:45 AM, an interview with the Director of Nursing (DON) revealed that Standards of Practice are to flush with water between medications. She stated they should give each medication separately and add water if needed. The DON confirmed the policy does not instruct to give water in between each medication. She stated this is on her, not the nurses and they will look at the policy. On 09/18/19 at 3:30 PM, an interview with the Administrator revealed they had discussed the issue about PEG tube medications and their policy was not correct.

Based on observation, staff interview , and facility policy review, the facility failed to prevent the spread of infection by contaminating gloves and wound during care for one (1) of two (2) wound care observations, Resident #51. Findings include: Review of the facility policy titled, Infection Control, revealed the staff will protect themselves from infection and simultaneously protect the resident form exposure to additional infectious agents by being knowledgeable regarding diseases and modes of transmission. Review of the facility policy titled, Pressure Ulcer Treatment, effective 4/2010, revealed to position the resident and place a towel next to the resident (under) the wound to serve as a barrier to protect the bed linen and other body sites. On 09/18/19 at 11:20 AM, during an observation of pressure ulcer care, performed by Licensed Practical Nurse (LPN) #3, with the assistance of Registered Nurse (RN) #2, Resident #51 was turned to his right side. His brief was undone and slightly pulled away from his buttocks, but then moved back towards his body touching the wound area. LPN #3 did not place the brief in a manner so that it would not contaminate the wound. LPN #3 placed his gloved hand inside the slightly open brief. The back side of his gloved hand touched the brief while cleaning the wound and while applying the dressing. On 9/18/19 at 11:45 AM, an interview with LPN #3 confirmed he should have positioned the brief away from the wound better to prevent it from touching the wound area and contaminating the wound and gloves. On 09/19/19 at 10:44 AM, an interview with the Director of Nursing (DON) confirmed she felt LPN #3 had contaminated the wound and his gloves by not removing the resident's brief before wound care. On 09/19/19 at 10:46 AM, an interview with RN #1 revealed she had just checked LPN #3 off on wound care about two (2) weeks ago. She stated he had no problems during the check off. She stated LPN #3 knew that would contaminant the wound. On 09/19/19 at 10:50 AM, an interview with RN #2 revealed she started to tell LPN #3 to remove the brief, but she thought she could only assist him with holding the resident over. She confirmed the wound was contaminated by the brief and his gloves touching the brief contaminated them.

Based on observation, staff interview, resident group interview, and employee handbook review, the facility failed to ensure comfortable noise levels were maintained on the B Unit, for one (1) of two (2) units. This deficient practice had the potential to affect the 56 residents residing on the B Unit. Findings include: A review of the facility's Employee Handbook, not dated, revealed employees were expected to refrain from any activity that was disturbing to residents. An observation on 02/28/17 at approximately 5:00 PM, during the initial tour of the facility, revealed a loud rumbling noise in the hallway of the B Unit. Staff were observed pulling barrels down the hallway; that was the source of the noise. A group interview on 03/01/17 at 10:00 AM, with 10 residents in attendance, revealed on the B Unit there were barrels that were used for collecting garbage and dirty linens that made a lot of noise when pushed down the hallway. Eight (8) of the 10 residents, all residing on the B Unit, stated the barrels were excessively loud during the daytime, and at night. The residents described the sound as loud rumbling, thunder inside the building and, a freight train coming through. Two (2) residents stated the sound had awakened them at night. Three (3) of the eight (8) residents stated they had complained about the noise to nursing staff and housekeeping staff on more than one (1) occasion. None could remember any names of staff they had complained to. The residents did not recall complaining to any administrative staff, and the residents who regularly attended resident council meeting could not remember whether or not they had discussed the issue in resident council. All of the residents stated the noise had been present over the past year. Review of the resident's most recent Minimum Data Sets (MDSs) compiled on a list provided by the facility revealed nine of the ten resident's Basic Interview for Mental Status (BIMS) score was 15, which indicated no cognitive impairment. One of the ten resident's BIMS score was an eight (8), which indicated moderate cognitive impairment. An interview and observation on 03/02/17 at approximately 9:20 AM, during an environmental tour with the Housekeeping Manager, the Maintenance Director, and the Administrator, revealed a staff member rolling dirty linen barrels down a hallway on the B Unit. The barrels made a loud rumbling noise that was heard from approximately 15 yards away. When asked about the noise level of the barrels rolling down the hall, the Maintenance Director stated it was louder than it should be. The Administrator commented she thought they had just gotten used to it, and hadn't really noticed it. On 03/02/17 at 3:25 PM, an observation and interview with Registered Nurse (RN) #1, RN #2, and the Ward Clerk seated at the B Unit Nurse's Station, revealed a Certified Nurse Assistant (CNA) pulling two (2) laundry barrels down the hallway. The sound made by the barrels was very loud and thunderous. When asked if residents ever complained about the noise, RN #1 stated she agreed the barrels were loud, and she had heard that residents complained about the noise the barrels made at night. She had not relayed those complaints to anyone. RN #2 stated she thought the barrels were very loud, and had heard residents complain about the noise. She stated she had not relayed the complaints, and thought the noise was a necessary evil because the laundry had to be done, and garbage had to be carried out. The Ward Clerk stated she had heard that residents complained about the barrels making noise at night, and she had not relayed this to anyone.

Based on record review, staff interview, resident interview, and facility policy review, the facility failed to accurately code Resident #3's Minimum Data Set (MDS) assessment related to restraints for one (1) of seven (7) records reviewed. Findings include: Review of the facility's Minimum Data Set (MDS) Coordinator policy, dated 07/15, revealed a MDS Coordinator shall be responsible for the development and completion of the resident assessment. Each individual who completes a portion of the MDS must certify accuracy of that portion of the assessment by signing the section of the electronic MDS. An interview on 03/02/17 at 9:25 AM, with Resident #3, revealed his seatbelt was taken off his wheelchair about two (2) months ago. A review of the most recent quarterly MDS assessment with an Assessment Reference Date (ARD) of 12/09/16, for Resident #3, revealed Section P (Restraints) was checked for a trunk restraint used daily. Further review of the MDS revealed Resident #3 scored 11 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. A review of the physician's orders [REDACTED]. Interview on 03/02/17 at 12:05 PM, with Registered Nurse (RN) #4, confirmed upon review of the quarterly MDS assessment, Section P (Restraints) was checked. RN #4 stated, it should not have been. RN #4 also confirmed an order was written on 09/27/16, to discontinue the restraint. Interview on 03/02/17 at 12:30 PM, with Licensed Practical Nurse (LPN) #2, revealed she completed Section P on the quarterly MDS assessment for Resident #3. LPN #2 was not able to respond why she coded Section P (Restraints) on the assessment. LPN #2 stated, I just missed it. Review of the Face Sheet revealed the facility admitted Resident #3 on 04/20/12, with [DIAGNOSES REDACTED].

Based on observation, staff interview, and facility policy review, the facility failed to ensure garbage and refuse was contained inside garbage dumpsters for one (1) of four (4) dumpster observations. Findings include: A review of the facility's treatment of [REDACTED]. An observation and interviews during an environmental tour on 03/02/17 at approximately 9:40 AM, with the facility's Administrator, the Maintenance Director, and the Housekeeping Manager revealed the following findings: There were a total of six (6) dumpsters; two (2) rows of three (3) dumpsters, located outside on a concrete surface at the east end of the facility. Two (2) 45 gallon bags of garbage were on the concrete outside of the center dumpsters. On the first row of dumpsters, all of the dumpsters had trash and/or cardboard boxes holding the dumpster top lids open. There was a total of five (5) 45 gallon bags of garbage visible at the top of the first row of dumpsters. The dumpsters' side doors were not completely closed. On the second row of dumpsters, two (2) dumpsters had trash and/or cardboard boxes holding the lids open. There was a total of five (5) 45 gallon bags of garbage visible at the top on the second row of dumpsters. On the far right side of the second row of dumpsters, there was a 45 gallon bag of garbage on top of the dumpster lid. During the tour on 3/02/17 at approximately 9:40 AM, the Director of Housekeeping stated it was his responsibility to make sure garbage was contained in the dumpsters. He stated the garbage was picked up two (2) days a week, and was to be picked up on this date. He stated it was unusual for the garbage to be this overflowing, but the facility shared the dumpsters with the hospital and wellness center. He believed some of the problem was the kitchen had not broken the cardboard boxes down adequately prior to placing them in the dumpsters. The Maintenance Director stated there must have been a problem with pick up earlier this week for the dumpsters to be that full. The Administrator stated it was important to contain the trash inside the dumpsters with the lids closed so that animals cannot get into the dumpsters and spread the garbage around. The Administrator further stated the hospital was currently at capacity which would generate more garbage than usual, and that it appeared the amount of garbage generated had outgrown the number of dumpsters to hold it.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the prevention for the potential spread of infection/cross contamination by not washing hands and changing gloves during Resident #1's incontinent care and wound care, for one (1) out of five (5) incontinent care observations, and for one (1) out of three (3) wound care observations. Findings include: A review of the facility's Infection Control - Handwashing policy, dated 09/2014, revealed handwashing is be done after moving from a contaminated body site to a clean body site during patient care. Hands are to be washed after handling used contaminated wound dressings and contaminated linens. Hands are to be washed after removing gloves. An observation of incontinent care on 3/1/17 at 2:45 PM, for Resident #1 provided by Certified Nursing Assistant (CNA) #1 revealed CNA #1 washed her hands and put on gloves. CNA #1 cleaned the resident's peri-area and buttocks. CNA #1 completed the care, but did not wash her hands or change gloves prior to handling clean linens. CNA #1 did not wash her hands after handling the soiled linens. During an interview on 03/01/17 at 3:05 PM, with CNA #1, she confirmed she did not wash her hands or change the contaminated gloves before touching the clean linen during the incontinent care she provided for Resident #1. CNA #1 confirmed that not washing her hands, or changing gloves is an infection control concern. An observation of wound care for Resident #1 on 3/1/17 at 2:55 PM, provided by Licensed Practical Nurse (LPN) #1, revealed LPN #1 removed and discarded the old dressing on the resident's left hip Stage two (2) pressure ulcer. LPN #1 cleaned the wound as ordered. LPN #1 discarded the contaminated gauze into the red bag. LPN #1 did not remove her gloves, and wash her hands after touching and removing the soiled dressing, and prior to cleaning the wound. LPN #1 continued to wear the contaminated gloves as she handled and applied the collagen dressing and a clean bordered gauze over the Stage two (2) pressure ulcer located on the left hip. An interview on 03/01/17 at 3:15 PM, with LPN #1 revealed she confirmed she touched the clean dressings after removing the soiled contaminated dressing from the Stage two (2) pressure ulcer located on Resident #1's left hip. LPN #1 confirmed that not washing her hands, or changing gloves could possibly cause the spread of infection to the wound. During an interview on 03//01/17 at 3:45 PM, the Director of Nursing (DON) confirmed that CNA # 1, after touching the dirty linen, should have washed her hands and put on clean gloves before touching the clean linen. The DON also confirmed that LPN #1 should have washed her hands, and changed her gloves after removing the soiled dressing, and before touching the clean dressing. The DON stated, That is definitely an infection control problem. A review of the Face Sheet revealed Resident #1 was admitted by the facility on 04/28/16, with [DIAGNOSES REDACTED]. A review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/17, revealed the Resident's Brief Interview for Mental Status (BIMS) score was a zero (0), indicating severely impaired cognition. Further review of the MDS revealed Resident #1 was always incontinent of bowel and bladder.

Based on observation, interview, record review and policy review, the facility failed to identify the intensity of pain and monitor the effectiveness of PRN (as needed) medication in order to manage pain to a level of comfort for one (1) of five (5) sampled residents reviewed for pain management (Resident #2). Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), with Assessment Reference Dates (ARD) of 03/07/13 and 07/03/13 revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #2 was cognitively intact. Review of the functional status section of the MDS coded that Resident #2 was totally dependent on staff for all Activities of Daily Living (ADLs) except eating, which requires set up only. The MDS identified that the resident was interviewed and acknowledged the presence of pain, which was almost constant. The pain made it hard to sleep and limited daily activities. The MDS identified the pain as moderate. Review of Resident #2's "Selected Resident Care Plan Problem(s)," documented, "Problem: Resident complains of pain in legs, back and hand. She receives [MEDICATION NAME] Bid (two times a day, and [MEDICATION NAME] prn (as needed). Resident has dx (diagnosis) of [MEDICAL CONDITION] and complains of ear pain and chronic pain daily ...she has dx of [MEDICAL CONDITION] Arthritis. GOAL: Resident will have minimal discomfort and no side effects from meds (medications) by 09/03/13. Approaches included: 1. Administer medication as ordered ...5. Assess characteristics of pain, location, severity on a scale of 1-10, type, frequency." Review of a "Radiology Report," dated 05/14/13, documented, "Left foot: 2 views. Generalized [MEDICAL CONDITION] involving the bones. Moderate [MEDICAL CONDITION] changes involving several joints ..." Review of the "Occupational Therapy (OT)" notes, dated 03/04/13 documented, " OT recently attempted to tx (treat) pt (patient) but pt noncompliant and unwilling to perform and OOB (out of bed) activity. On restorative at this time. Review of the OT notes dated 06/01/13, documented, "Patient still declines skilled OT services. c/o (complains of) of constant/chronic multiple site pain." Review of the LTC (Long Term Care) Social Services notes, dated 06/03/13, documented, "(Name of resident) is alert and oriented to person, place and time. She has independent cognitive skills. Her memory is intact. She refuses to get out of bed stating it hurts too much." Review of the facility's policy entitled "Pain Assessment And Management", effective 7/13, documented, "Purpose: The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. General guidelines: The pain management program is based on a facility-wide commitment to resident comfort. "Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain, Effectively recognizing the presence of pain; Identifying the characteristics of pain...Monitoring for the effectiveness of interventions and modifying approaches as necessary. Assessing Pain:...Characteristics of Pain: Intensity of pain (as measured on a standard pain scale); Descriptor of pain; Pattern of pain (e.g. (for example) constant or intermittent); Location and [MEDICAL CONDITION] of pain. Impact of pain on quality of life. 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Monitoring and Modifying Approaches: 2. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales, etc. (so forth) and relevant criteria for measuring pain management..." Review of the facility's "Pain Assessment" tool, not dated, revealed that pain intensity was determined with a scale of 0 (zero) to 10 (ten) with 0 (zero) being no pain and 10 (ten) being the worst possible pain. The tool has spaces on the form to identify information including Onset/Duration, Location, Quality of Pain, and Pain Treatment. Review of the August 2013 physician's orders [REDACTED]. "PRN (as needed) Medication Orders" included "[MEDICATION NAME] 400 MG (milligrams) 1 (one) PO (by mouth) TID (three times daily) PRN." (Start date 01/11/13). Review of the Medication Record for 07/01/13 to 08/06/13 revealed Resident #2 received 40 doses of [MEDICATION NAME] ([MEDICATION NAME]) 400 MG Tab PRN (as needed) for "pain." The medication record and nurse ' s notes did not identify the location, intensity of pain or the effectiveness of the PRN medication. In an interview on 08/06/13 at 12:30 p.m. revealed Resident #2 stated she didn't get out of bed because of severe pain. Resident #2 stated, "I can't get anybody to understand. I have [MEDICAL CONDITIONS] and [MEDICAL CONDITION] Arthritis. When they touch me; it hurts so bad. That is why I don't want to get up." Resident #2 stated on a scale of 1-10 the pain stays at 10 and the least it goes to is 8 after pain medication. In an interview on 08/08/13 at 4:25 p.m. with the Certified Nurse Aide (CNA) assigned to Resident #2 regarding when Resident #2's complains of pain, revealed the CNA stated "all the time." This CNA was asked how she knew when residents were in pain and she stated by the tone in voice, moody or the resident might tell her. The said RI #2 tells her she is in pain. The CNA stated "She don't holler, just the tone of voice that tells me she is in pain." Review of notes in Resident #2's medical record, dated 08/08/13 and electronically signed by the FNP-C (Family Nurse Practitioner Certified), documented, "Chief Complaint, PT (patient) C/O (complains of) Chronic Severe Generalized Pain, Leg Pain, Left, Foot Pain, Left. Proactive and Palliative Factors: Worsening with Movement, Relieved by Nothing, Improved with Nothing ...Severity, Severe ...Skin/Integumentary ...Stage 2 Decubitus Inner Buttock ..." In an interview on 08/08/13 at 4:45 p.m. with Licensed Practical Nurse (LPN) #1 when asked how residents are assessed for pain, stated "We use a pain scale of 1-10 (one to ten) one is least and ten being greatest." LPN #1 was asked what she looks for in residents with pain, especially Resident #2. LPN #1 stated, "Pain with movement, grimacing. LPN #1 stated Resident #2 has a wound on her bottom and it hurts. Her pain is so bad at times she cries." LPN #1 acknowledged that she had administered PRN [MEDICATION NAME] to Resident #2 and did not identify the intensity of pain or the effectiveness of the medication. LPN #1 stated Resident #2's pain was usually 10. In an interview with the Director of Nursing (DON) on 08/09/13 at 10:45 a.m. regarding how nurses should effectively manage pain to ensure Resident #2 reached a level of comfort, revealed the DON stated to administer medications as ordered, monitor by identifying intensity level on a pain scale using 1-10 with one being least and 10 the worst. The DON was asked how should nurses follow up and she said to go back and ask the resident or observe for effectiveness using the pain scale. The DON was asked where the findings should be maintained and she said in the MAR (Medication Administration Record) or the nurse's notes. The MARs for July 2013 and August 2013 were reviewed with the DON and the lack of evidence of assessing intensity of pain or response or effectiveness to PRN medication. In an interview with Registered Nurse (RN) #4 on 08/09/13 at 10:55 a.m. revealed RN #4 acknowledged that she completed the pain assessment for Resident #2 on the Minimum Data Set with Assessment Reference Dates of 03/07/13 and 06/03/13. RN #4 was asked how she determined pain was "almost constantly" for the resident. RN #4 stated she interviewed the resident and asked her about her pain. RN #4 stated, "She was alert and stated, Honey, I hurt all over constantly moderate to severe. RN #4 was asked if pain medications are not effective what nurses should do, and she said "call the doctor." RN #4 was asked how nurses should assess for effectiveness, and she stated to ask on a level of 1-10 (one to ten) with one being least and ten being worst." In an interview on 08/09/13 at 3:00 p.m. with the Nurse Practitioner (NP) regarding Resident #2's pain revealed the NP stated the resident complained of pain when she saw the resident on 08/08/13. The NP stated the medication was changed and would be re-evaluated in two (2) weeks. The NP stated, "We want to try to get her pain to a 4 (four); may not get to 0 (zero) but to a level of comfort for the resident; enough that the resident can get out of bed." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain and the effectiveness of the PRN. The NP was asked how nurses should monitor for effective pain management and she stated, "Assess the level of pain, where the pain is located, using a scale of 1-10 (one to ten); administer the medication and go back in 45 minutes and assess the effectiveness. If not relieved or to a level of comfort, call. If they don't let me know, I can't act on it."

Based on observation, record review and staff interview, the facility failed to ensure that Resident #1 had supervision for the prevention of neglect. This is for one (1) of seven (7) residents reviewed, Resident #1. Resident #1 exited the facility on 07/01/11 through a door that had been left unlocked by staff members. The staff member had taken an unauthorized smoke break. Resident #1 traversed 457 feet from the facility over gravel and up a hill. Resident #1 was found at a fence trying to pull himself up with the aid of the fence. His temperature was 103 upon admission to the emergency room . The lack of the implementation of safety measures to ensure that Resident #1, who was assessed as exhibiting wandering behaviors, did not exit the building without staff supervision or staff knowledge was deemed as an Immediate Jeopardy (IJ) on 07/08/11 at 1:45 p.m. The Administrator and Director of Nursing of the facility were notified at that time. The IJ began on 07/01/11 and was determined to be removed on 07/09/11. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 07/09/11 at 01:00 p.m. Based on the verification of the facility's corrective action that was validated, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 07/09/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facilities failure to ensure that Resident #1 did not leave the building without staff knowledge and supervision. "Allegation of Compliance" "On July 1, 2011, at approximately 11:30 a.m., Resident #1 was found outside the facility behind the building with wheelchair overturned and attempting to stand holding onto the fence. Resident #1 was seen by laundry staff #1 and #2 through a window. Certified Nurse's Assistant (CNA) #4 assisted Resident #1 up into the wheelchair and transported resident #1 to the emergency room (ER). Resident #1 was unresponsive with an oral temperature of 103 degrees Fahrenheit (F) at 11:45 a.m.. Resident #1 temperature returned to normal 98 degrees F at 1:05 p.m. on July 1, 2011, and Resident #1 was admitted to acute care hospital for further observation with discharge back to nursing home on July 5, 2011 at 10:40 am. Upon investigation by the Nursing Home Administrator and Maintenance Director between 12:00 p.m. and 12:30 p.m. on July 1, 2011, it was discovered that Resident #1 exited the building through Door #4, which is located on the west end exit on Wing A of the Facility. The point of exit was evidenced by wheelchair tracks on the ground immediately to the south of the outdoor ramp leading to and from Door #4. Cigarette butts on the ground immediately surrounding Door #4 led Nursing Home Administrator and Maintenance Director to conclude that unidentified staff members may have left the building through Door #4 for the purpose of an unauthorized smoke break and failed to ensure the door closed securely behind them upon return. Maintenance Director tested Door #4 and discovered that the door intermittently failed to close completely due to friction or obstruction of the hinge due to the presence of rust and debris within the hinge. On July 1, 2011 at approximately 12:30 p.m., Maintenance Director and Maintenance staff personnel #1 and #2 cleaned door frame and door closure of dirt and debris. Immediately thereafter, Maintenance Director Maintenance staff personnel #1 and #2 oiled the hinges and door closures for Door #4 to ensure smooth closure. Maintenance Director subsequently tested the door on July 1, 2011 at approximately 12:30 p.m. Assistant Director of Nursing (ADON) notified the Nursing Home Administrator of elopement at 11:28 a.m. on July, 2011. Nursing Home Administrator notified Police Department on July 1, 2011 at 11:33 a.m. Registered Nurse (RN) #3 notified Resident #1's attending physician/ER physician on July 1, 2011 at 11:50 a.m. ADON notified responsible party (RP) on July 1, 2911 at 1:26 p.m. The Nursing Home Administrator notified Attorney General's office at 4:22 p.m. on July 1, 2011. At approximately 1:00 p.m. on July 1, 2011 ADON instructed all RNs, License(d) Practical Nurse(s) (LPNs), and CNAs to monitor Wing A Doors 1 through 6 and Wing B Doors 1 through 11 every hour and to check on the residents for which each was responsible every two hours. In-services were held on elopement of Resident #1 for all RNs, LPNs and CNAs at the following times by the following personnel: July 5, 2011 at 7:30 a.m. by ADON July 5, 2011 at 2:00 p.m. by Nursing Home Administrator, DON and ADON July 6, 2011 at 7:30 a.m. by Nursing Home Administrator July 6, 2011 at 1:00 p.m. by DON July 7, 2011 at 10:00 a.m. by Nursing Home Administrator and DON July 7, 2011 at 2:00 p.m. by ADON At each of the foregoing in-services, all RNs, LPNs, and CNAs were instructed to continue hourly door checks and to begin to document on a log for each 24-hour period on Door 1 through 6 and to document the checks in a door check log. If a door is found to be malfunctioning the charge nurse will be notified immediately and the maintenance director will be notified immediately. The door check logs for Wing A were introduced on July 7, 2011 at 3:00 p.m. Identical in-services and instructions for all staff which includes housekeeping, therapy, maintenance & dietary were provided at the following personnel: Beginning at July 8, 2011 at 4:00 p.m. by DON July 8, 2011 at 8:35 p.m. by Hospital Administrator July 8, 2011 at 11 p.m. by DON July 8, 2011 at 7 a.m. by DON July 9, 2011 at 7 a.m. by Nursing Home Administrator Construction staff were inserviced on July 9, 2011 by DON at 10:15 a.m. inservice was on door codes, and inform the charge nurse whenever a door has to be opened for a period of time so that the charge nurse can ensure resident safety. The door check logs for Wing B were introduced on July 8, 2011 at 4:00 p.m. The door check logs for Wing A and Wing B are to be reviewed at the end of the shift by the Charge Nurse. Mag-Locks with key pad release were in place on the date of elopement July 1, 2011. Prior to installation of the Mag-Locks, Doors 2, 3 and 4 to Wing A were fitted with a "Wander Guard" alarm system. The Wander Guard system was disengaged when the Mag-Lock System was installed in 2009. On July 1, 2011, at approximately 3:30 p.m., Nursing Home Administrator and DON discussed re-activating the Wander Guard system, or installing a similar system from another manufacturer, on both Wings A and B as a back-up to the Mag-Lock system. The Director of Purchasing placed calls to Wander Guard distributors on July 5, 7, and 8, 2011 with no return call. On July 8, 2011, at approximately 5:00 p.m., Maintenance Director reached a service representative from Wander Guard and arranged for a service call to evaluate the old Wander Guard system. At approximately 8:30 p.m., on July 8, 2011 the Wander Guard service representative reactivated the alarm to Door #4, the door exited by resident #1. Door #2 was also re-activated on July 8, 2011 at approximately 8:30 p.m. On July 8, 2011 at 8:00 p.m., DON changed the key codes for all doors on Wings A (1-6) and Wing B (-11). At 9:00 p.m., The Nursing Home Administrator implemented a confidentiality agreement that will be required to be signed by all visiting family members before they are provided the new code. The agreements were placed into service at 11:00 p.m. on July 8, 2011 by the Nursing Home Administrator. In-services for both Wing A and Wing B which began on July 8, 2011 provided by the DON on the following topics: abuse and neglect, misappropriation of resident's property, elopement policy and elopement drills, and confidentiality of the new key codes. All RNs, LPNs, CNAs and Ward Clerks are required to participate in the foregoing in-services prior to commencement of their next shift. No staff will be allowed to work before in-serviced. On July 8-9, 2011 between 9:30 p.m. and 1:00 a.m., Social Worker and ADON performed wander and elopement assessments of all residents in Wing A and Wing B. Eleven of eighty-three (11) of (83) residents were identified as at risk for wandering or elopement. All eleven (11) residents had a red arm band placed on their wrist indicting their wandering and elopement risk status. The wandering and elopement risk indicator was placed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The following measures have been taken to ensure the security and function of all exit doors: (1) Doors 1 through 6 on Wing A and Doors 1 through 11 on Wing B are being checked hourly by RNs, LPNs, and/or CNAs; (2) The door checks are being logged every hour by the personnel conducting the check; (3) the door check logs are being checked for completion at the conclusion of each shift by the charge nurse; (4) proper function and security of all doors are being checked and logged weekly by maintenance staff. The Nursing Home Administrator is monitoring the door check logs and maintenance logs. The results of the monitoring information is presented at the Daily Nursing Home Meeting and then to the Quality Assurance Committee. Any negative finding is immediately reported to the Nursing Home Administrator and changes made to the current plan." After verification of the facility's corrective action through observation and Interviews with staff conducted on 07/09/11, to ensure that they had been inserviced on the monitoring of residents and how the door checks would be conducted and documented. Staff interviewed included CNAs, Security Patrol, Maintenance, Housekeeping and LPNs. All staff interviewed provided appropriate responses related to the inservice they attended. The Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 07/09/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm.

Based on observation, record review, staff interview and policy review, the facility failed to ensure that measures were put into place to prevent one (1) of seven (7) Residents reviewed for supervision from exiting the facility unsupervised and without staff knowledge (Resident #1). Resident #1 exited the facility on 07/01/11 and propelled himself in a wheelchair unsupervised 427 feet from the facility. The door that Resident #1 exited from should have been locked to prevent him exiting the building unsupervised. Resident #1 wandered in a wheelchair, unsupervised, out of the facility and was found at the back of the facility grounds near a fence. Resident #1's wheelchair was turned over and he was attempting to use the fence to get himself up. Resident #1 was taken to the emergency room (ER) by facility staff where he was noted to have a temperature of 103 degrees Fahrenheit (F)and was unresponsive. Resident #1 had traveled in his wheelchair down a sloping exit from the facility, over uneven ground, up a hill, and across gravel. The maximum outside temperature on 07/01/11 was 94 degrees Fahrenheit (F). There actions resulted in Resident #1 sustaining harm, and put him at risk for serious harm, impairment or death and was determined as Substandard Quality of Care and an Immediate Jeopardy (IJ) on 07/08/11 at 01:45 p.m. The Administrator and Director of Nursing of the facility were notified at that time. The IJ began on 07/01/11 and was determined to be removed on 07/09/11. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 07/09/11 at 01:00 p.m. Based on the verification of the facility's corrective action that was validated, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 07/09/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm. Findings Include: Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admitting History and Physical to the Nursing Home dated 6/8/11 revealed: "CHIEF COMPLAINT: Confusion, Wandering, some aggressive behavior and difficulty with activities of daily living." "SUBJECTIVE: (Resident #1) is an "84 (actually 96) year old male who is admitted to the special care unit of the nursing home with the above complaints." Record review revealed that Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/11 revealed in the Cognitive Skills for Daily Decision Making score to be "2" which was defined as "Moderately impaired-decisions poor; cues/supervision required. The transfer ability was scored at "3" for extensive assistance with 2+ person physical assist. The Functional Limitation in Range of Motion was scored as a "2" for the lower extremities (hip, knee, ankle, foot) with impairment on both sides. The mobility devices used was a wheelchair. Observation on 07/07/11 at 03:00 p.m. revealed that Resident #1 was in a wheelchair and he had a wander guard bracelet on his left ankle. The resident told me his name and said he was trying to find a way out of the facility Interview with Registered Nurse (RN) #2 on 07/07/11 at 3:00 p.m. confirmed that the wander alarm was an ankle bracelet that had been placed on Resident #1 at the previous facility where he resided. He was admitted at this facility on 06/08/11. Review of Nurses Notes for Resident #1 dated 07/01/11 revealed: "7/01/11 3:25a (a.m.) Res (resident) is a recent readmit to special care unit from senior care. In bed c (with) eyes closed. 0 (no) s/s (signs/symptoms) of discomfort, distress or behavior problems noted. Call light in easy reach." "7/1/11 @ 11:05 a.m. Reported to this nurse per CNA that she could not find resident. This nurse & CNA started looking in rooms over the unit. ADON notified along c staff search teams began looking for resident." "7/1/11 11:35 AM notified per staff that resident had been located on the outside of facility. This nurse observed resident face to be red. O (no) obvious bruises or injuries noted. Resident taken to ER at this time. MD (Medical Doctor) made aware & (and) en route. RP (Responsible Party) made aware. Nursing Home administrator made aware & involved in search. Will continue to monitor." "7/1/11 12:35 pm Resident remains @ ER @ this time. We await return." "7/5/11 @11am Return to unit from hospital. Alert & orient x 1. Skin warm dry & intact. 0 (no) acute distress noted. Able to make needs known. New order received Gentamycin 80 mg (milligrams) IM (Intramuscular) daily x 3 days, KCL (Potassium Chloride) 10 meq (milliequivalents) po (by mouth) daily. Bladder training then d/c (discontinue) foley cath per protocol." Review of a "Resident Abuse Report Form" dated 07/04/11 revealed that an incident occurred on 07/01/11 at 10:40 a.m. to 11:00 a.m. when Resident #1 had an "elopement". "Resident transferred to emergency room , given intravenous fluids, and admitted to acute care for observation. No apparent injuries noted but transferred to emergency room for further evaluation." The incident occurred "Outside facility on campus". Certified Nursing Assistant (CNA) # 5 notified Licensed Practical Nurse (LPN) #1 that she was unable to find resident @ (at) approximately 11:05 a.m." The "Summary of interview with resident "revealed: "Resident confused and did not remember anything when interviewed by ADON (Assistant Director of Nursing) and DON (Director of Nursing). "Summary of investigator's findings: CNA reported @ approximately 11:05 AM not being able to find resident, LPN notified ADON and search for resident began. 11:35 am Police and DON notified at 1135 am. Search included inside facility, outside campus and surrounding neighborhood. Two laundry employees saw resident outside behind building through a window. (CNA #4 ran outside and saw the resident trying to get up by climbing on fence. CNA #4 assisted resident up and transferred to wheelchair and pushed resident straight to emergency room ." "Did the findings indicate the abuse occurred? "No" (was checked with a checkmark). No abuse occurred. Looks like resident went out the west door and down ramp. Staff was able to pick up wheelchair tracks and residents shoe prints where gravel road starts behind building. We are unsure of how resident got out of door as door is a mag-lock door c (with) keypad. While staff was investigating door where it looks as though resident got out when door was open it did not close completely to engage mag locks." "Summary of interview with staff members having contact with the resident during the period of the incident" "(LPN #1) last seen resident sitting and talking to resident in dayroom around 9:50 am." "(CNA #1) last seen resident around 10:00 am and 10:30 am up toward nurse's desk." "(CNA #5) last between 10:20 and 10:30 am she did not see resident in the sitting area." "(CNA #3) last seen resident between 10:30 am and 11:00 am going toward nurses' station." "(LPN #2) seen resident wandering at 10:40 am in wheelchair in hallway talking to housekeeping." "(CNA #4) at approx. 11:30 am (CNA #4) heard some say "There he is" and then ran outside and assisted resident back to wheelchair and went straight to ER." (Laundry Worker #1) and (Laundry Worker #2) were walking down the hall and seen resident outside the building through another resident's window." "Resident in Room #50 told different staff members, "Yeah, I saw that man rolling around out there coming down the hill. I don't know how he got out there but I hope he got enough air." "Corrective action taken: All doors in special care checked and repairs made. Staff will initiate hourly door check in special care. Inservice provided to staff. Will institute back-up security to doors in special care. Maintenance will perform weekly preventive checks to doors." The "Triage/Medical Screening Form" dated on 07/01/11 revealed a triage time of 11:45 AM for Resident #1. The "Chief Complaint: pt (patient) found outside, w/c (wheelchair) turned over. Pt. unresponsive." "Vital Signs: B/P (Blood Pressure) 113/77 Pulse 126 Resp (Respirations) 44 Temp (Temperature 103.1 O2 Sat (Oxygen saturation) 94%" The "Triage Class" coded Resident #1 as "Urgent" In a section on the Triage/Medical Screening Form was a "PHYSICIAN MEDICAL SCREEN FORM". On the left of that form was a section titled "Potential Criteria" with a column to check yes or no. There were two (2) checks in the "yes" column and they were for "Temperature: > (greater than) 103.0 oral and Pulse > 100 ADULT". A statement at the bottom of the "Triage/Medical Screening Form" was "Potential Emergency Medical Condition Exits (exists): "Yes" was checked. Another statement at the bottom of the "Triage/Medical Screening Form" was "Disposition: { } ER" and that selection was made. Review of the "emergency room PHYSICIAN'S RECORD" dated 07/01/11 revealed: "General: Fever, Fatigue GU (Genitourinary): Oliguria (a decreased amount of urine formation) Neuro: Weakness Psych: Confusion Skin: Redness" "HISTORY & PHYSICAL" "96 yo (year old) wm (white male) resident of ECF (Extended Care Facility) brought to ER p (after) being found outside on ground p (pass) w/c turning over, lying in sun. Altered MS (Mental Status), lethargic/obtunded & hyperthermic, red skin; no apparent injury from fall. Skin Hot/Dry.CV RRR (Tachycardia). Treatments in the ER were Chest Xray, Electrocardiogram, Cardiac Panel, Complete Blood Count, Complete Metabolic Panel, CPK (Creatine Phosphokinase test), Blood Test x 2, Urine Myoglobins, Urinalysis, Normal Saline (NS) Bolus 500 cc (Cubic Centimeter), then NS @ 75 cc/hr, Oxygen at 2-3 Liters by nasal cannula, Computerized Tomography (CT) of the head without contrast, X-ray of pelvis and a foley catheter was inserted. "Final Diagnosis: [REDACTED]. 2. Fever/Hyperthermia 3. Dehydration 4. UTI (Urinary Tract Infection) 5. Leukocytosis 6. Altered Mental Status Discharge Condition: Fair -Resident #1 was admitted to the hospital on [DATE] at 02:20 p.m. The "emergency room TREATMENT RECORD" for Resident #1 and dated 07/01/11 revealed that he was admitted at 11:45 a.m.. Vital Signs documented: "Time 1145 BP 113/77 T 103.1 P 126 R 44 GSC (Glascow Coma Scale) 94 02 3 L/M. Time 1215, BP 121/60, T 100.0, P 91, R 28, GSC 94, O2 3 L/M. Time 1305 (01:05 p.m.) BP 104/55, T 98, P85, R24, GSC 97, O2 3 L/M" Numeric Pain Scale with a definition of "0-10, Zero equals no pain, 10 equals worst possible pain." The number 10 was circled indicating that was the level of pain that Resident #1 was experiencing. Nurses Notes: "1145 AM Pt (patient) found outside, w/c turned over. Pt unresponsive 1215 pm pt responsive, oriented to person. Reoriented to place time." "220 (02:20 p.m.) pt admitted to acute. Pt transferred per stretcher, O2 @ 2 L NC (liters per nasal cannula), NS 100cc/hr infusing LFA (left forearm). VSS (vital signs stable) NAD (No apparent distress). " The admission orders [REDACTED] "1. Admit to Acute 2. Dx (diagnosis) a) S/P Fall b) Fever/Hyperthermia c) Dehydration d) UTI e) Leukocytosis f) altered M.S. (mental status) g) BPH (benign prostatic hypertrophy) h) Htn (Hypertension) i) Dementia k) DM (Diabetes Mellitus) l) DJD (Degenerative Joint Disease) "3. Condition-Guarded" A notation in the Progress Notes of the Physician at the hospital revealed: "7/5/11 D/C (discharge) back to SCU (Secure Care Unit)" Interview and observation with the Maintenance Director conducted on 07/07/11:50 a.m. revealed the West Door of the Special Care Unit was locked. The Maintenance Director stated that the West Door of the Special Care Unit was the door that Resident #1 exited on 07/01/11, unsupervised. There was a gate just outside that door that had to be opened. That ramp was 26 steps. Observation of the area that Resident #1 traveled on 07/01/11 was gravel, bushes, and was an uphill slope. It was a total of 457 feet from the exit door to the fence where Resident #1 was found. There were a set of two (2) scrapes in the dirt in front of the fence; and the Maintenance Director stated that he was sure those scrapes were made by Resident #1 because he "does his feet like that." The Maintenance Director stated that one (1) out of three (3) times that the West exit door was opened the door would not close because "the roll pin was not allowing the door to close." Interview with the Administrator on 07/07/11 at 12:50 p.m. revealed that the Residents on the Secure Care Unit (SCU) were residents that have Alzheimer's disease or Dementia and those that require one (1) on one (1) supervision. Wanderers were living on that unit so that the staff can watch more closely. Interview on 07/07/11 at 01:10 p.m. with Certified Nursing Assistant (CNA) #3 revealed that between 10:30 and 11:00 a.m. Resident #1 was asking people if they knew how to get to Interstate 55. CNA #3 stated that around lunch they asked where he was and then could not find him. They checked inside the facility. CNA #3 stated: "I went out down walk and checked behind clinic and did not see him." CNA #3 confirmed that she had received no special training at this facility how to deal with special needs residents. Interview with CNA #4 on 07/07/11 at 01:15 p.m. revealed that he works on the B Wing, and that Resident #1 resides on the A Wing. CNA #4 stated that he heard a lot of commotion in the hallway and found that staff were looking for a missing resident. He started to help and heard someone say "There he is!" CNA #4 stated when he got to Resident #1 the wheelchair was overturned and he was using the fence to pull himself up. CNA #4 stated that he had been all around the building and it was "scorching hot outside, he was red as a lobster." Stated: "Saw no visible injuries. Just had head back like dehydrated never said anything." Interview with CNA #2 on 07/07/11 at 01:30 p.m. revealed that around 10:20 to 10:30 a.m. she got to missing Resident #1 so she looked in his room and the next room and could not find him. She then said out loud "(Resident #1) is missing" so we just searched all the rooms, double searched. "I notified LPN #2 after we had looked in the rooms which was about 10 minutes after we noticed him missing." CNA #3 confirmed that she had not received any training at this facility on how to care for residents with special needs. Interview with Laundry worker #1 on 07/07/11 at 01:40 p.m. revealed that she heard a resident was missing and her partner (Laundry Worker #2) told her "Let's go look." I saw something out by the fence and asked (Laundry Worker #2) "What's out by fence?" "I saw it was him, his chair was turned over. We ran down the hall and someone, told the nurse." Interview with LPN #2 on 07/07/11 at 01:45 p.m. stated that around 10:40 a.m. to 10:45 a.m. she saw Resident #1 talking to housekeeping staff trying to get them to open the door. LPN #2 stated "I took break around 10:50 (a.m.) and I came back five (5) to ten (10) minutes later and they were looking for him (Resident #1) around 11 a.m." "He has been combative, he is very strong, he is a wanderer." Interview with Laundry Worker #2 on 07/07/11 at 01:50 p.m. revealed that when she saw Resident #1, he was stretched out flat on his face. She stated she told the nurse. Interview with LPN #1 on 07/07/11 at 02:15 p.m. revealed that Resident #1 used a wheelchair and propelled himself in the halls. He had been asking people for directions to Corinth, a town where he grew up." Interview with RN #2 on 07/07/11 at 03:05 p.m. revealed that there was no formal assessment to identify residents at risk for wandering and no care plan for elopement/wandering. Interview with the Administrator on 07/07/11 at 03:15 p.m. revealed the facility had not conducted any elopement drills. She stated that Maintenance had repaired the door so that it would close and lock and the purchasing Director was trying to get in touch with a service person for the wanderguard system. She also instructed the CNAs and nurses to check the doors more often on the first (July). She stated that inservices were set up for July 5, 6, and 7, 2011 to address elopement and hourly door checks. She stated that when they did not have a wander/elopement assessment since the wanderguard system was no longer in use. Interview was conducted on 07/08/11 11:10 a.m. with the attending Physician/Medical Director for Resident #1. He stated that when Resident #1 arrived in the emergency room he was "Somewhat obtunded neurologically. Hyperthermic. Found lying in sun, skin red. He responded to some stimuli. Responded to hydration and cooling. admitted to the hospital." "Not sure how (Resident #1) got out- puzzled about that." The facility provided a credible Allegation of Compliance (AoC) on 07/09/11 at 01:00 p.m. The AoC was as follows: "On July 1, 2011, at approximately 11:30 a.m., Resident #1 was found outside the facility behind the building with wheelchair overturned and attempting to stand holding onto the fence. Resident #1 was seen by laundry staff #1 and #2 through a window. Certified Nurse's Assistant (CNA) #4 assisted Resident #1 up into the wheelchair and transported resident #1 to the emergency room (ER). Resident #1 was unresponsive with an oral temperature of 103 degrees Fahrenheit (F) at 11:45 a.m.. Resident #1 temperature returned to normal 98 degrees F at 1:05 p.m. on July 1, 2011, and Resident #1 was admitted to acute care hospital for further observation with discharge back to nursing home on July 5, 2011 at 10:40 am. Upon investigation by the Nursing Home Administrator and Maintenance Director between 12:00 p.m. and 12:30 p.m. on July 1, 2011, it was discovered that Resident #1 exited the building through Door #4, which is located on the west end exit on Wing A of the Facility. The point of exit was evidenced by wheelchair tracks on the ground immediately to the south of the outdoor ramp leading to and from Door #4. Cigarette butts on the ground immediately surrounding Door #4 led Nursing Home Administrator and Maintenance Director to conclude that unidentified staff members may have left the building through Door #4 for the purpose of an unauthorized smoke break and failed to ensure the door closed securely behind them upon return. Maintenance Director tested Door #4 and discovered that the door intermittently failed to close completely due to friction or obstruction of the hinge due to the presence of rust and debris within the hinge. On July 1, 2011 at approximately 12:30 p.m., Maintenance Director and Maintenance staff personnel #1 and #2 cleaned door frame and door closure of dirt and debris. Immediately thereafter, Maintenance Director Maintenance staff personnel #1 and #2 oiled the hinges and door closures for Door #4 to ensure smooth closure. Maintenance Director subsequently tested the door on July 1, 2011 at approximately 12:30 p.m. Assistant Director of Nursing (ADON) notified the Nursing Home Administrator of elopement at 11:28 a.m. on July, 2011. Nursing Home Administrator notified Police Department on July 1, 2011 at 11:33 a.m. Registered Nurse (RN) #3 notified Resident #1's attending physician/ER physician on July 1, 2011 at 11:50 a.m. ADON notified responsible party (RP) on July 1, 2911 at 1:26 p.m. The Nursing Home Administrator notified Attorney General's office at 4:22 p.m. on July 1, 2011. At approximately 1:00 p.m. on July 1, 2011 ADON instructed all RNs, License(d) Practical Nurse(s) (LPNs), and CNAs to monitor Wing A Doors 1 through 6 and Wing B Doors 1 through 11 every hour and to check on the residents for which each was responsible every two hours. In-services were held on elopement of Resident #1 for all RNs, LPNs and CNAs at the following times by the following personnel: July 5, 2011 at 7:30 a.m. by ADON July 5, 2011 at 2:00 p.m. by Nursing Home Administrator, DON and ADON July 6, 2011 at 7:30 a.m. by Nursing Home Administrator July 6, 2011 at 1:00 p.m. by DON July 7, 2011 at 10:00 a.m. by Nursing Home Administrator and DON July 7, 2011 at 2:00 p.m. by ADON At each of the foregoing in-services, all RNs, LPNs, and CNAs were instructed to continue hourly door checks and to begin to document on a log for each 24-hour period on Door 1 through 6 and to document the checks in a door check log. If a door is found to be malfunctioning the charge nurse will be notified immediately and the maintenance director will be notified immediately. The door check logs for Wing A were introduced on July 7, 2011 at 3:00 p.m. Identical in-services and instructions for all staff which includes housekeeping, therapy, maintenance & dietary were provided at the following personnel: Beginning at July 8, 2011 at 4:00 p.m. by DON July 8, 2011 at 8:35 p.m. by Hospital Administrator July 8, 2011 at 11 p.m. by DON July 8, 2011 at 7 a.m. by DON July 9, 2011 at 7 a.m. by Nursing Home Administrator Construction staff were inserviced on July 9, 2011 by DON at 10:15 a.m. inservice was on door codes, and inform the charge nurse whenever a door has to be opened for a period of time so that the charge nurse can ensure resident safety. The door check logs for Wing B were introduced on July 8, 2011 at 4:00 p.m. The door check logs for Wing A and Wing B are to be reviewed at the end of the shift by the Charge Nurse. Mag-Locks with key pad release were in place on the date of elopement July 1, 2011. Prior to installation of the Mag-Locks, Doors 2, 3 and 4 to Wing A were fitted with a "Wander Guard" alarm system. The Wander Guard system was disengaged when the Mag-Lock System was installed in 2009. On July 1, 2011, at approximately 3:30 p.m., Nursing Home Administrator and DON discussed re-activating the Wander Guard system, or installing a similar system from another manufacturer, on both Wings A and B as a back-up to the Mag-Lock system. The Director of Purchasing placed calls to Wander Guard distributors on July 5, 7, and 8, 2011 with no return call. On July 8, 2011, at approximately 5:00 p.m., Maintenance Director reached a service representative from Wander Guard and arranged for a service call to evaluate the old Wander Guard system. At approximately 8:30 p.m., on July 8, 2011 the Wander Guard service representative reactivated the alarm to Door #4, the door exited by resident #1. Door #2 was also re-activated on July 8, 2011 at approximately 8:30 p.m. On July 8, 2011 at 8:00 p.m., DON changed the key codes for all doors on Wings A (1-6) and Wing B (-11). At 9:00 p.m., The Nursing Home Administrator implemented a confidentiality agreement that will be required to be signed by all visiting family members before they are provided the new code. The agreements were placed into service at 11:00 p.m. on July 8, 2011 by the Nursing Home Administrator. In-services for both Wing A and Wing B which began on July 8, 2011 provided by the DON on the following topics: abuse and neglect, misappropriation of resident's property, elopement policy and elopement drills, and confidentiality of the new key codes. All RNs, LPNs, CNAs and Ward Clerks are required to participate in the foregoing in-services prior to commencement of their next shift. No staff will be allowed to work before in-serviced. On July 8-9, 2011 between 9:30 p.m. and 1:00 a.m., Social Worker and ADON performed wander and elopement assessments of all residents in Wing A and Wing B. Eleven of eighty-three (11) of (83) residents were identified as at risk for wandering or elopement. All eleven (11) residents had a red arm band placed on their wrist indicting their wandering and elopement risk status. The wandering and elopement risk indicator was placed on the Medication Administration Record (MAR), the Activities of Daily Living (ADL), and care plan for each resident. The following measures have been taken to ensure the security and function of all exit doors: (1) Doors 1 through 6 on Wing A and Doors 1 through 11 on Wing B are being checked hourly by RNs, LPNs, and/or CNAs; (2) The door checks are being logged every hour by the personnel conducting the check; (3) the door check logs are being checked for completion at the conclusion of each shift by the charge nurse; (4) proper function and security of all doors are being checked and logged weekly by maintenance staff. The Nursing Home Administrator is monitoring the door check logs and maintenance logs. The results of the monitoring information is presented at the Daily Nursing Home Meeting and then to the Quality Assurance Committee. Any negative finding is immediately reported to the Nursing Home Administrator and changes made to the current plan." After verification of the facility's corrective action through observation and Interviews with staff conducted on 07/09/11, to ensure that they had been inserviced on the monitoring of residents and how the door checks would be conducted and documented. Staff interviewed included CNAs, Security Patrol, Maintenance, Housekeeping and LPNs. All staff interviewed provided appropriate responses related to the inservice they attended. The Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 07/09/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm.