Every finding on record at The Pines Nursing and Rehabilitation Center

Based on observations, interviews, facility document review, the facility failed to ensure a sanitary homelike environment for one of one dining area for all residents that occupy the dining area. Based on observations, interviews, and facility document review, the facility failed to ensure a sanitary homelike environment for one of one dining area for all residents that occupy the dining area. The findings include: During the Resident Council session on 07/29/2026 at 9:30 AM, Resident # 50 stated to this surveyor the air intake vent in the dining area was gross and molded. During an observation on 07/29/2026 at 9:32 AM, the referenced air intake vent, located in the center of the ceiling in the dining area above dining tables, was noted to have an accumulation of a black, green, and gray substance on the grate. In addition, a piece of gray-brown substance (approximately 1-2 inches in length) was suspended and moving in the breeze near the air intake. Two tiles over, a clear hard plastic string with an accumulation of a gray substance was noted. During an observation and concurrent interview on 07/29/2026 at 4:22 PM, the Dietary Manager (DM) took a white paper towel and wiped the grate and pulled down the gray-brown substance dangling nearby the air intake vent, referenced above. The piece hanging down transferred to the paper towel (gray, brownish black particles) and another paper towel was rubbed over the grate which resulted in the transferring of a grayish color. The DM also pulled down the hard plastic string, two tiles over, that had the grayish particles, as referenced above. The DM described the black, green, and gray substance on the grate, the piece of gray-brown substance, and the substance on the plastic string as dust and dirt. The DM indicated that it [the substances noted] did not help to create a sanitary homelike environment and that if the substances were to fall into the residents' food, it might cause them to get sick. The DM also indicated they were not aware if there was anyone responsible for cleaning the vent and ceiling areas. During an interview on 07/29/2026 at 4:40 PM, the Director of Housekeeping Services stated that Housekeeping Services were responsible for cleaning the areas referenced above, and that it was put onto the project calendar, 28 days ago, for the employee responsible for cleaning the floors. The Director of Housekeeping Services indicated that their company was a new service to the facility, having started on July 1, 2026. The surveyor requested a policy for cleaning vents/ceilings, and cleaning schedules. On 07/29/2026 at 4:47 PM, the Director of Housekeeping Services provided the housekeeping cleaning schedule and indicated that air vents used to be on the Projects calendar for every Wednesday, but when windowsills and blinds were added, the spacing of the calendar took off the word air vents. No policy was provided. During an interview on 07/30/2026 at 11:00 AM, the Assistant Director of Nursing (ADON) indicated that the condition of the air vent and the particles hanging from the ceiling in the dining area did not make for a sanitary, homelike environment. The ADON also indicated that the air vent and particles referenced above could be a respiratory irritant or ruin a resident's appetite if it fell into their food. During an interview on 7/30/2026 at 05:39 PM, the Administrator indicated that he did see what transferred to the paper towel and observe the air intake (as referenced above) and described what he saw as a chunk of lint and black particles. The Administrator also indicated that if it fell into a resident's food, it would be unsightly, families might complain, and it could possibly cause an illness. A review of the monthly housekeeping cleaning schedule, provided by the Director of Housekeeping Services, did not include air vent or ceiling cleaning.

Based on observation, record review and interview, the facility failed to ensure enteral feeding bags were labeled appropriately for two (Resident #41 and Resident #81) of three residents reviewed.The findings include:Resident #41:During an observation on 07/27/2026 at 11:55 AM, Resident #41 was sitting in a [brand name] chair, awake, with the head leaned back at an angle. Licensed Practical Nurse (LPN) #3 pushed a feeding pump into the room that was covered with a white pillowcase. LPN #3 was asked to remove the pillowcase. There a was an enteral feeding bag with a brown liquid inside. The enteral bag had, 50/ml) (per/milliliters) [LPN #4 initials] written on the posterior side of the bag. The bag did not have Resident #41's name, room number, name of enteral feeding inside the bag, the date or time indicated anywhere. The feeding pump screen displayed 50 ml/hr (hour) and the word hold was displayed on the screen. LPN #3 stated, It's supposed to be [brand name] but the night shift didn't put that [name of product] on there [the enteral feeding bag], referring to the enteral feeding bag.Review of Resident #41's admission Record revealed the facility admitted the resident on 06/30/2026 with diagnoses of dysphagia and encounter for attention to gastrostomy.Review of Resident #41's Physician Order's revealed and order to admit to skilled care as of 6/30/26 with anoxic brain damage. The Physician's Orders also indicated enteral feed with a start date of 6/30/2026 and an NPO (nothing by mouth) diet with a start date of 6/30/2026.Review of Resident #41's electronic medication administration record (eMAR) revealed an enteral feed order for every shift related to anoxic brain damage. The order was for Isosource 1.5 at 50 milliliters (ml) with 45 ml of water every three hours. The start date was 06/30/2026 at 10:00 PM.During an interview with LPN #4 on 07/30/2026 at 9:09 AM, she stated she hung the enteral feeding bag for Resident #41 on her shift, the night of 07/26/2026. She stated she did not label the enteral bag with the type of feeding because in her head she thought the bag was already labeled since it was the type of bag that she had to fill up. She stated she was trained at the facility to put the patient identifier, the time, the date, the product she was giving, the flow rate, and her initials on the feeding /flush bags. At 9:22 AM, this surveyor showed LPN #4 a picture of the anterior and posterior sides of the enteral feeding bag, and she stated those were her initials on the bag and she did not see the type of feeding Resident #41 was to receive on the bag. She stated she had worked at this facility since May or June of 2026 and had been a licensed nurse for the same length of time. She stated the importance of labeling the enteral feeding bag was to know what the resident was being given.Resident #76:During an observation on 07/27/2026 at 10:51 AM, Resident #76 was sitting up in bed awake. There was an enteral bag hanging on a feeding pump that was off. Written on the enteral feeding bag was LPN #4's initials and 60/ml. There was no other information written on the enteral feeding bag.During a second observation on 07/28/2026 at 1:56 PM, the enteral feeding bag hanging at Resident #76's bedside did not have any information written on the anterior or posterior side. The flush bag was labeled with LPN #5's initials.Review of the admission Record for Resident #76 revealed the facility admitted the resident on 08/04/2025 with diagnoses of dysphagia and tracheostomy status.Review of Resident #76's Physician's Orders revealed an order for enteral feed with a start date of 04/30/2026. The Physician's orders also included an order for NPO diet with a start date of 08/05/2025.Review of Resident #76's eMAR revealed an enteral feed order for every shift related to dysphagia for Isosource 1.5 at 60 ml/hr, 35 ml water flush every hour via continuous pump. Initiation date was 04/30/2026.During an interview with LPN #5 on 07/30/2026 at 9:45 AM, she stated she did hang the enteral feeding bag for Resident #76 on 07/27/2026. She was asked if the enteral feeding bag was already labeled with the type of feeding Resident #76 was to receive and she stated, Yes. It says Isosource on it. She was asked if she had checked the enteral feeding bag to see if the label indicated the type of feeding Resident #76 was to receive. LPN #5 stated she could not specifically say she saw Isosource on the enteral feeding bag. She stated the facility was out of the bags she would normally use and she had to cut the enteral feeding bag that was labeled Isosource and pour the liquid into a bag that was not labeled. She stated she was trained on how to label the enteral feeding bag, but she never had to do that before, referring to cutting open the bag that was labeled with the feeding type and pouring the contents into a bag that was not labeled.During an interview with Assistant Director of Nursing (ADON) #1 and ADON #2 on 07/30/2026 at 7:00 PM, ADON #1 stated the nurses were trained on how to use both sets of enteral feeding bags, but the facility has had two Director of Nurses (DON) before the current DON in place now and have been unable to locate any skills checkoffs for the nurses.The Administrator was asked to provide a policy / guideline for nurses to follow for enteral feedings and how to label the bags. As of 07/30/2026 at 8:46 PM, no policy or guidelines for enteral feeding bags regarding the labeling of the bags were provided to the survey team from the facility.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview and facility policy review, the facility failed to ensure the medication error rate was less than five percent during the medication administration observation of one (Residents #20) of five residents. This surveyor observed 37 opportunities for medication administration and two of the 37 medications were not administered in accordance with the Physician's Orders, resulting in a medication error rate in excess of five percent. The findings include: During a medication administration observation on 07/29/2026 for the 8:00 AM time, Licensed Practical Nurse (LPN) #3 prepared Resident #20's medications. At 8:08 AM, she administered a [brand name laxative] mixture to the resident. At 8:10 AM, after shaking [prescription inhaler containing fluticasone (a steroid) and salmeterol (a long-acting bronchodilator)], she administered one puff to Resident #20. As this surveyor was looking at the time, within 15 seconds of the first inhalation, LPN #3 administered a second puff of the inhaler to Resident #20. She immediately offered a cup of water for the resident to swish and spit, and the resident accepted. Review of Resident #20's admission Record indicated the facility admitted to the resident on 02/10/2024 and diagnoses included chronic obstructive pulmonary disease. Review of Resident #20's Physician Orders indicated admit to long term care with a revision date of 07/21/2026. The Physician's Order for a laxative indicated Polyethylene Glycol 1450 was to have been administered, with a start date of 12/15/2025. The Physician's Order for the prescription inhaler indicated two inhalations, inhale orally, with a start date of 12/12/2025. Review of the electronic medication administration record (eMAR) revealed the prescription inhaler order directed two inhalations to be administered orally, with a wait time of 1-2 minutes after inhalation, then rinse and spit. Review of Resident #20's quarterly Minimum Data Set with an Assessment Reference Date of 05/12/2026 indicated a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. During an interview with LPN #3 on 07/29/2026 at 11:56 AM, she was asked to look at Resident #20's instructions on the physician's order for the wait time between doses for the inhaler and she stated, One to two minutes, and I did not [wait]. LPN #3 was asked to produce the bottle of laxative administered to Resident #20, and she produced a bottle of [name brand laxative] 3350. She was asked to look at the resident's physician order and state what the strength indicated. She looked at the order and stated polyethylene glycol 1450 was prescribed. She stated before giving a resident medication, she should make sure she has the right resident, right dose, and right medication. She stated if she makes a medication error during medication pass, she was supposed to report this error to the provider. She stated she would also let the Director of Nursing (DON) know so a form could be filled out. She stated she as the nurse does not fill out the form when a medication error has occurred. She stated it was important to check the resident's medication orders before giving medication because the error could cause problems such as an adverse reaction or death. She stated letting the provider know of a medication error was important so the nurse could get orders to assess the resident and so the provider could assess the resident. She stated she had completed a skill checkoff on medication administration at the facility, and she also shadowed another nurse during medication administration, but she was unable to give names or dates. The Director of Nursing was unavailable for interview during the survey. During an interview on 07/30/2026 at 7:00 PM, Assistant Director of Nursing (ADON)#1 was asked to provide skills checkoffs for LPN #3 but stated they were unable to locate the information at this time for any of the nurses due to the changeovers of DONs. ADON #1 and ADON #2 both agreed medications should be administered as prescribed by the provider. ADON #1 was asked to provide a policy or guidelines on medication errors. As of 07/30/2026 at 8:46 PM, the facility had not provided a policy or protocol for nursing when a medication error occurs. Review of a Preparation and General Guidelines policy, with a revision date of 05/01/19, revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy indicated the five rights were right resident, right drug, right dose, right route and right time and applied for each medication being administered.

Number of residents sampled: Number of residents cited: Based on observation, interviews, record review, and package directions, it was determined that the facility failed to discard food items that were beyond the use by date in the facility kitchen, affecting one (Resident #17) of three residents reviewed. The findings include: During an observation on 07/27/26 at 10:04 AM in the facility kitchen, this surveyor observed a pitcher in the refrigerator, labeled as CIB with a date of 07/24/26. The container looked to contain a milk-based liquid. During a concurrent observation and interview on 07/27/26 at 10:16 AM, this surveyor questioned Assistant Dietary Manager #4 what the CIB on container meant. She indicated it was, [a nutritional drink that comes in powder packets meant to be mixed with milk providing essential protein, vitamins, and minerals]. When asked to describe the meaning of the date on the label, she indicated the drink was made on 07/24/26, and that the product was good for 3 to 4 days. She said stated pitcher was used to serve residents who required the supplement, and it was made up in advance. The original product container was produced for review, and the label indicated the product was to be mixed and consumed within two hours, with any unused product to be covered, refrigerated, and consumed within 24 hours. Review of an admission Record, indicated the facility admitted Resident #17 on 01/01/2018 with diagnoses that included unspecified dementia, other specified nutritional anemias, and abnormal weight loss. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2026, revealed a Brief Interview Mental Status score of 15, which indicated the Resident #17 was cognitively intact. A review of Physician Orders for Resident #17 revealed an order for a supercal diet, regular texture, thin consistency. Liquid protein twice day: CIB 8 oz with breakfast, initiated 09/16/25. During an interview on 07/28/26 at 1:30PM, the drink powder package was reviewed by the Dietary Manager, who confirmed the product directions were to refrigerate unused product and discard after 24 hours if not consumed.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure hand hygiene was performed and sterile technique was maintained during tracheostomy (trach) suctioning for one (Resident #76) of three residents reviewed. The facility also failed to ensure hand hygiene was performed during a glucometer check for one (Resident #23) of one resident reviewed. The findings include: During an observation on 07/28/2026 at 2:03 PM by this surveyor and a second surveyor, Licensed Practical Nurse (LPN) #3 entered Resident #76's room to perform tracheostomy suctioning. She placed items that would be used during the procedure on the overbed table. Without sanitizing her hands, she opened the top of a sterile water bottle. She then opened the sterile kit and put on the sterile gloves from the package. She used the thumb on her right hand to puncture the seal on top of the sterile bottle of water. She picked up the sterile suction tubing with her left hand and as she inserted the suction tubing into Resident #76's trach, the resident's beard hairs made contact with her left gloved hand. LPN #3 continued with the suctioning procedure by suctioning Resident #76's trach as she removed the tubing. She paused for a few seconds and then with the same left gloved hand, she inserted the suction tubing in Resident #76's trach a second time and beard hairs again made contact with her left gloved hand. Review of Resident #76's admission Record indicated the facility admitted the resident on 08/04/2025 with diagnoses that included tracheostomy status. Review of Resident #76's Physician Orders indicated trach care/suctioning via (by way of) sterile technique with a start date of 07/02/2026. Review of Resident #76's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/27/2026 indicated a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. During an interview with LPN #3 on 07/29/2026 at 11:56 AM, she stated that she did not wash or sanitize her hands before she put on the sterile gloves. She stated she should have washed or sanitized her hands to prevent infection. She was asked if she moved Resident #76's beard hairs out of the way before using the suctioning tubing in the resident's trach and she stated, I guess I didn't. She stated she asked the resident to hold their head up as a way to try to get the beard hairs out of the way. During an interview with Assistant Director of Nursing (ADON) #1 and ADON #2 on 07/30/2026 at 7:00 PM, ADON #1 stated LPN #3 should have attempted to reposition Resident #76's beard hairs away from the trach opening to keep the beard hairs from touching her sterile glove during the suctioning of Resident #76's trach. ADON #1 and ADON #2 also stated LPN #3 should have performed hand hygiene before putting on the sterile gloves and after removing the sterile gloves. Review of a Tracheostomy Care-Suctioning policy with no revision date indicated for the procedure, to wash hands and put on personal protective equipment as appropriate. Review of a Hand Hygiene policy not dated indicated hand hygiene was any method that removes or destroys microorganisms on hands that include handwashing and alcohol-based hand rubs. This policy indicated hand hygiene should be performed before having directed contact with patients. During an observation on 07/30/2026 at 11:54 AM by this surveyor and a second surveyor, LPN #6 took a blue pair of clean gloves, a lancet, an alcohol preparation (prep) pad, and a glucometer into Resident #23's room and placed the items on an overbed table. Without sanitizing her hands, she put on the blue pair of gloves and proceeded with using the items to test Resident #23's blood glucose level. After she performed the test and received the results, which showed 199 on the glucometer machine, she removed the pair of blue gloves, discarded the used items, and then used an alcohol-based gel to sanitize her hands. Review of Resident #23's admission Record indicated the facility admitted Resident #23 to the facility on [DATE] with diagnoses that included type two diabetes mellitus with diabetic neuropathy, unspecified. Review of Resident #23's Physician's Orders indicated Humalog injection solution 100 unit/ml (insulin lispro) inject as per sliding scale, and the order start date was 07/16/2026. Review of Resident #23's electronic medication administration record (eMAR) indicated Humalog injection solution 100 unit/ml (Insulin Lispro) inject as per sliding scale: if 60 – [to] 199= (equals) 0 The order start date was 07/16/2026. The 11:30 AM time for the bs (blood sugar) indicated 199 and LPN #6's initials were in the box. LPN #6 was not available later in the day on 07/30/2026 to be interviewed. The Director of Nursing was unavailable for interview during the survey. During an interview with ADON #1 and ADON #2 on 07/30/2026 at 7:00 PM, both ADON's indicated LPN #6 should have performed hand hygiene before and after putting on gloves. Review of a Glucose Monitoring form indicated in the procedural steps after knocking on the door, to perform hand hygiene, provide privacy, explain the procedure and put on clean gloves. The procedural steps also indicate to remove gloves and wash hands.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a resident/resident representative was informed in advance of the risk versus benefits of a psychotropic medication and given treatment alternatives or options of his or her choice for one (Resident #53) of one resident reviewed. The findings include: Review of an admission Record indicated the facility admitted Resident #53 on 06/23/2026 with diagnoses that included dementia with unspecified severity and other behavioral disturbance. The admission record also revealed the resident's family member was the responsible party/power of attorney for care and financials. Review of Physician's Orders indicated Resident #53 had been prescribed a prescription for a selective serotonin reuptake inhibitor (SSRI) used to treat major depression, obsessive-compulsive disorder (OCD), panic disorder, and post-traumatic stress disorder (PTSD), with a route and dosage of oral tablet 25 milligrams (mg), and a start date of 07/25/2026. Review of Resident #53's admission Minimum Data Set with as Assessment Reference Date of 06/29/2026, revealed a Brief Interview for Mental Status score of 04, which indicated Resident #53 had severe cognitive impairment. Review of Resident #53's Psychotropic Med [medication] Consent/Disclosure/BlackBox form dated 06/23/2026 listed four other prescribed medications, but not the prescription SSRI. There was no consent form for the SSRI. Review of Resident #53's nursing note dated 07/24/2026 at 12:01 PM, revealed, New order rec'd [received] per (provider name) to start [SSRI] 25 mg PO (orally) daily.[responsible party name] notified and voiced understanding. During a telephone interview on 07/30/2026 at 12:31 PM, Resident #53's responsible party stated she did receive a phone call from someone [at the facility], but she could not remember the name of the person and did not recall the date of the phone call. She stated the person talked to her about [Resident #53's] increase in depression and that the provider wanted to start an [SSRI]. She stated she was asked how she felt and she stated if the medication would help [Resident #53's] mood she was okay with starting the medication. Resident #53's responsible party reported the risks of initiating the medication were not provided. She added, But to say they said this would cause tremors or blood clots or things that you would discuss with your pharmacist, we did not talk about that. On 07/30/2026 at 1:15 PM, the Assistant Director of Nursing (ADON) #1 provided a Psychotropic Med Consent/Disclosure/BlackBox form for Resident #53 with Zoloft included in the list of medications. The form was dated 07/30/2026 at 1:54 PM EDT (Eastern Daylight Time). During an interview with the ADON #1 on 07/30/2026 at 1:16 PM, he was asked who was responsible for talking to the resident/resident representative regarding starting psychotropic medications and he stated himself or ADON #2 would. He was asked if he or ADON #2 spoke with Resident #53's responsible party and he stated ADON #2 would have notified her of the change. He stated, When we do our electronic admission process, we use [program name]. It [program name] collects their [responsible party] text and email preferences and that way they can sign forms like this (psychotropic consent form) remotely. He added that he updated the [program name] for Resident #53 this morning, 07/30/2026, and [responsible party name] just signed the consent form today. At 1:24 PM, ADON #1 came back to the conference room and stated he needed to clarify a prior statement. He stated the nurse on the hall [LPN #3] notified Resident #53's responsible party, and not ADON #2. During an interview with ADON #1 and ADON #2 on 07/30/2026 at 6:47 PM, ADON #2 stated the facility's process for providing information to the resident/resident representative regarding the risks versus benefits when the provider wants to start a psychotropic medication for a resident was that one of the ADONs would call the family and notify the family when a resident was started on the [psychotropic] medication and of the side effects of that medication. ADON #2 was asked if the provider's responsibility was to speak with the resident /resident representative about the risk vs benefits before starting a psychotropic medication and she stated, I wouldn't say solely. It would be the nurse also. ADON #2 stated the nurses had been educated on calling the responsible party about the risk versus benefits. ADON #1 was asked to provide the skills checkoffs and education the nurses had received, he stated due to change over in the Director of Nurses twice, he did not know where this information was and was unable to provide it at this time. ADON #1 was asked to provide a policy for Psychotropic consents. As of 07/30/2026 at 8:46 PM, this document was not provided to the survey team.

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, the facility failed to develop and implement dementia care needs on a person-centered comprehensive care plan for one (Resident #53) of one resident reviewed. The findings include: Review of Resident #53's admission Record revealed the facility admitted Resident #53 on 06/23/2026 with diagnoses that included unspecified dementia with other behavioral disturbance with an onset date of 05/26/2026. Review of Resident #53's Physician Orders revealed Resident #53 was admitted to long-term care with an order date of 06/23/2026. Review of Resident #53's admission Minimum Data Set (MDS) with an Assessment Reference Date of 06/29/2026, revealed Resident #53 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. The MDS also revealed active diagnoses in the last seven days that included non-Alzheimer's dementia. Review of Resident #53's Care Plan, with a review date of 06/23/2026, revealed the care plan did not indicate a focus or interventions for dementia care. During an interview on 07/30/2026 at 6:05 PM, the MDS Coordinator reviewed Resident #53's admission MDS with an ARD of 06/29/2026 and confirmed there was an active diagnosis for non-Alzheimer's dementia. The MDS Coordinator reviewed the Care Plan for a focus problem of dementia and stated, Impaired cognitive function related to dementia was placed on the care plan 07/30 [2026] when it was realized. She stated dementia care should have been added to the care plan as soon as it [dementia diagnosis] was seen. She stated she did complete section I of the MDS [which covered active diagnoses] and she also added information to Resident #53's care plan. She stated she was trying to catch up on MDS assessments and could not state why she did not add dementia care to Resident #53's care plan. She stated staff knows how to care for residents from the information on their [computer program report name] but she stated the report did not contain any specific information related to dementia care for Resident #53. She printed off a copy of Resident #53's [electronic care plan] report that Certified Nursing Assistants (CNAs) review regarding resident care. She stated the importance of having dementia care on the resident's care plan was so everybody would know if the resident was receiving any special care for dementia. The Director of Nursing was not available to be interviewed during the survey on dementia care. The Administrator was asked to provide a policy for Dementia care. On 07/30/2026, the Administrator provided a document titled, The Well-Being Model For Dementia Care In The Long-Term Care Setting. There were no signature page or certificates of completion provided for any employees related to the dementia care model. As of 07/30/2026 at 8:46 PM, no policy on dementia care was provided to the survey team.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items and leftover food items were promptly removed and/or discarded on or before the expiration or use by date, dietary staff washed their hands between dirty and clean tasks and before handling clean equipment, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting meal service for 1 of 1 meals observed. The findings are: 1. On [DATE] at 10:34 AM, Dietary [NAME] (DC) #4 was wearing gloves on his hands when he deboned seven (7) servings of chicken thighs and emptied them into a blender to ground. He brushed spilled pieces of meat crumbs from the counter into his gloved hands, contaminating the gloves. He then removed the gloves from his hands and placed new gloves contaminating them by not washing his hands. He used his contaminated gloved hands to push ground chicken into a pan to be served to the residents who received mechanical soft diets for lunch. 2. On [DATE] at 11:27 AM, one packet of turkey slices was on a shelf in the refrigerator with an expiration date of [DATE]. 3. On [DATE] at 11:31 AM, there was an open box of biscuits on a shelf in the freezer. The box was not covered or sealed. The Dietary Manager was interviewed and asked what the concerns were if food was kept open in the freezer. She stated it would cause freezer burn. 4. On [DATE] at 11:40 AM, Dietary Aide (DA) #5 turned on the hand washing sink and washed his hands. DA #5 turned off the faucet with his bare hands, contaminating his hands. DA #5 used his contaminated bare hands to pick up glasses by their rims and poured fortified milk, then placed them on the trays to be served to the residents for lunch. 5. During an interview on [DATE] 12:45 PM, DA #5 was asked what should have been done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands. 6. On [DATE] at 11:52 AM, the temperatures of food items were checked and read on the steam table by DC #6 with the following results: a. Pureed cut green beans -120 degrees Fahrenheit. b. Pureed meat -125 degrees Fahrenheit. c. Ground chicken-120 degrees Fahrenheit. d. Pureed bread with milk -100 degrees Fahrenheit. The above food items were not reheated before they were served to the residents. During an interview on [DATE] at 12:36 PM, DC #6 was asked what she should have done when the foods were not hot enough to be served to the residents, to which she replied, reheat the food. 7. On [DATE] at 12:15 PM, DC #6, who was on the tray line serving the lunch meal service, picked up tray cards and placed them on the trays. Without washing her hands, she picked up plates and placed them on the trays with her fingers inside the plates and bowls. She was interviewed and asked what she should have done after touching dirty objects and before handling clean equipment, she stated it was cross contamination, and she should have washed her hands. 8. The review of facility policy titled, Handwashing/Hand Hygiene, initiated 2001, provided by the Dietary Manager on [DATE], indicated all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5% for two (Resident #5, #29) of five sampled residents observed during medication pass. Two (2) errors in medications were observed during thirty-eight (38) opportunities for errors in medication administration. This resulted in a medication error rate of 5.26%. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) 02/26/2025, revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. a. A review of the Care Plan Report for Resident #29 (revision date 11/26/2024), revealed that Resident #29 had altered respiratory status/difficulty breathing related to (r/t) Congestive Heart Failure (CHF), Obstructive Sleep Apnea (OSA), and asthma. Administer medication/treatment as ordered and observe for effectiveness. b. A review of the Medication Administration Record (MAR) revealed that Resident #29 had an order for a [Name brand Bronchodilator] (medication used to relax the muscles in the lungs) inhalation aerosol solution 108 Micrograms per Activated Clotting Time (MCG/ACT) 2 inhalation inhale orally three times a day for increased cough, shortness of breath (SOB), and/or wheezing, wait one minute between puffs. c. On 04/01/25 at 08:10 AM, this surveyor observed Medication Administration Certified (MAC) #1 give Resident #29 the inhaler. Resident #29 self-administered two puffs, then inhaled. d. On 04/01/25 at 11:20 AM, during an interview, Resident #29 stated the way the inhaler was given by self was, the medication was shaken, puff, puff, then inhaled. Resident #29 asked this surveyor Did I do something wrong? Because I do not want to get any of my people in trouble. I like my people. e. On 04/01/25 at 11:30 AM, during an interview, MAC #1 stated Resident #29 administered the inhaler by giving two [puffs] back-to-back. f. On 04/02/25 at 11:32 AM, during an interview, Licensed Practical Nurse (LPN) #3 stated according to the Physician's Order, [Name Brand Bronchodilator] should be administered by waiting one minute between puffs to give the medicine time to open the lungs. 2. A review of the quarterly MDS with the ARD of 03/04/2025 revealed Resident #5 had a BIMS score of 03, indicating severely impaired cognition. a. A review of the Care Plan Report for Resident #5 (initiated date 08/11/2020) revealed that Resident #5's vision was adequate with aides. b. A review of the MAR revealed that Resident #5 had an order for a [Name Brand Optic Beta-Blocker] (medication used to reduce eye pressure) 0.25 % instill 1 drop in both eyes, two times a day for pressure in the eye, wait 3-5 minutes between drops in the same eye; and a [Name Brand Optic Alpha Agonist] (medication used to reduce eye pressure) 0.2 % instill 1 drop in both eyes, three times a day related to unspecified glaucoma, wait 3-5 minutes between drops in the same eye. c. On 04/01/25 at 8:25 AM, this surveyor observed MAC #1 administer the [Name Brand Optic Alpha Agonist], 1 drop to each eye, then the [Name Brand Optic Beta-Blocker] 1 drop to each eye. There was no wait time between the two medications. This surveyor did not see MAC #1 with a watch in place or observe her look at a clock. d. On 04/01/25 at 9:05 AM, during an interview, MAC #1 stated she did not wait 3-5 minutes between administrating the two eye drops. e. On 04/01/25 at 11:30 AM, during an interview, MAC #1 confirmed she did not have a watch in place, and stated I am not sure when asked how time was kept up with between drops. f. On 04/02/25 at 11:32 AM, during an interview, LPN #3 stated according to the Physician's Order, the eye drops (Beta-blocker and Alpha Agonist) should be administered by waiting 3-5 minutes between administrating drops in the same eye, to allow the medication time to work. g. On 04/02/25 at 11:38 AM, during an interview, the Director of Nursing (DON) stated eye drops (Beta-Blocker and Alpha Agonist) should be administered 3-5 minutes apart, according to the Physician's Order. The DON stated a [Name brand Bronchodilator] should be administered by waiting 1 minute between puffs according to the Physician's Order. h. A review of a policy titled Medication Administration-General Guidelines effective date 01/01/15, noted medications are administered as prescribed.

Based on observation, interview, and review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of the 2 meals observed. The findings are: 1. During the observation of noon meal preparation in the kitchen on 03/30/25 at 10:34 AM, Dietary [NAME] (DC) #4 deboned seven (7) pieces of chicken thighs into a blender, of which one chicken thigh weighed 1.7 ounces, ground, and placed into a pan to serve 14 residents who received mechanical soft diets. 2. During an observation of noon meal service on 03/30/25 at 12:11 AM, DC # 4 used a #8 scoop (4 oz) to serve ground fried chicken. He gave half a portion (2 oz or 1/2 cup) per serving. DC #6, who observed DC #4, stated she should have given full serving to the residents, instead of half servings. 3. During an interview on 03/30/25 at 12:41 PM, DC #4, who prepared lunch meals, was asked how many residents were on mechanical soft diets. He stated about seven (7) residents. He was also asked how many servings of fried chicken he prepared for the residents on mechanical soft diets. He stated about seven (7) pieces of chicken thighs. DC #4 was informed by DC #6 there were 14 residents on mechanical diets. DC #6 stated she observed DC #4 serving half a portion of a #8 scoop, instead of full portion. DC #4 stated he would start giving full portions. DC#4 was interviewed was asked if he reviewed the menu before serving the noon meal. He stated he did not. 4. During the noon meal service on 03/30/25 at 12:15 PM, DC #6 served one fried chicken thigh to some residents, two chicken thighs were served to seven (7) residents who received a large portion, one (1) resident received one chicken leg and a wing, another resident received three (3) chicken wings, and another resident received one chicken thigh. The remaining residents received two chicken wings. 5. During an interview on 03/30/25 at 12:32 PM, DC #6, who assisted in serving the noon meal, was asked if she would weigh the same amount of chicken served to the resident. She did and stated one thigh weighed 1.7, one wing weighed 0.7ounce, 2 wings weighed 1.1 ounce, 3 wings weighed 1.4 ounce, one leg and 1 one wing weighed 2.1 ounces. DC #6 stated not enough protein was served. DC #6 was asked if she reviewed the menu before serving the noon meal. She stated she did not. All residents on regular diets, mechanical soft diets, and pureed diets were served less than 4 ounces of fried chicken for lunch. 6. During an interview on 03/30/25 at 12:35 PM, the Dietary Manager was asked what the concerns would be of the residents not getting enough meat with their meal. She stated they may not get enough protein. In the kitchen the staff had a menu, and each diet count was posted on the wall. 7. During an interview on 03/31/25 at 12:04 PM, the Administrator was asked what the concerns would be of the residents not getting enough meat with their meal. He stated it would be not getting sufficient protein. 8. During an interview on 03/31/25 at 12:06 PM, the Director of Nursing (DON) was asked what the concerns would be of the residents not getting enough meat with their meal. She stated they would not be getting protein.

Based on observations, interviews, facility document review, and policy review, the facility failed to ensure Enhanced Barrier Precautions were implemented for 1 (Resident #64) of 2 Residents reviewed for Enhanced Barrier Precautions. The findings are: 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/2025, indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of 14 (indicating the resident was cognitively intact), and had diagnoses including anemia, heart failure, pneumonia, and Multidrug-Resistant Organism (MDRO). The resident was receiving intravenous (IV) antibiotics. 2. On 04/01/2025 at 3:19 PM, Licensed Practical Nurse (LPN) #2 was observed administering an IV antibiotic solution to Resident #64. The resident's room was observed to have signage on the door indicating the resident needed Enhanced Barrier Precautions (EBP) for high-contact care. The EBP sign indicated staff should wear Personal Protective Equipment (PPE), that included both a gown and gloves. a. LPN #2 took medication and pump to the resident's room, performed hand hygiene, and put on a gown and gloves. LPN #2 entered the room and began attempting to find an available electrical outlet for the medication pump, then attempted to move the resident's bed with gloved hands. LPN #2 sat on the floor, with the gown touching the floor, and reached under the bed to access the surge protector using both gloved hands. LPN #2 then stood up and began the process of medication administration by touching the alcohol pads, flushes, and manipulating the Peripherally Inserted Central Catheter (PICC line) without re-performing hand hygiene or putting on a new gown and gloves 3. On 04/01/2025, during an interview immediately after the observation, LPN #2 confirmed their gloves should have been changed prior to starting the infusion. 4. The Director of Nursing (DON) provided documents/policies for review. The document titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, from the Centers for Disease Control and Prevention (CDC) indicated, Residents with indwelling medical devices should be placed on EBP, which includes staff performing hand hygiene, and wearing gown/gloves while performing high-contact resident care activities. 5. On 04/02/2025 at 10:18 AM, during an interview with the DON, it was confirmed the gloves should have been changed so that contamination did not occur. 6. On 04/02/2025 at 10:24 AM, during an interview with the Administrator, it was confirmed the nurse should have taken off the original PPE and put on new PPE to avoid introducing possible contamination. 7. On 04/02/25 at 11:35 AM, during an interview with the Advanced Practice Registered Nurse (APRN), it was confirmed that after a staff member touched under the bed it would have been appropriate for them to change gloves and gown, to help not spread infection to patients and staff.

Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to insulin administration for 1 (Resident #1) of 3 residents reviewed for newly admitted residents. Specifically, Resident #1 was admitted to a local hospital on 7/19/2024 due to a fall and left upper extremity pain. While at the hospital, the resident was diagnosed with left upper extremity thrombosis and had a necrotic ulcer on the left elbow, which was debrided at the hospital. On 07/31/2024, Resident #`1 was admitted to the nursing home facility with an order for continued anticoagulation (blood thinner) therapy. The resident's nursing home admission diagnosis was embolism or thrombosis of the arteries in the upper extremity. The physician's order for the blood thinner was not transcribed by the admitting nurse. From 07/31/2024 to 08/07/2024, the resident complained of left arm pain and received medication for the pain. On 08/07/2024, Resident #1 was found unresponsive, cool, clammy to touch, and the resident's left arm was blue and cold to touch. The resident was sent to the local hospital on 08/07/2024 and passed away on 08/09/2024 from a stroke. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Pharmacy Services) at a scope and severity of J. The IJ began on 07/31/2024, when Resident #1 was admitted to the facility with orders for a blood thinning medication. The Administrator was notified of the past noncompliance (PNC) IJ on 08/28/2024 at 9:27 AM. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey, thus it was determined to be a Past Noncompliance citation. The findings include: A review of the Admission Record, indicated the facility admitted Resident #1 on 07/31/2024 with diagnoses that included upper extremity blood clots, muscle wasting, difficulty walking, cognitive communication deficit, pain in the left arm, dementia, heart disease, irregular heart rhythm, and heart failure. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Further review indicated the resident was not on any blood thinning medication. A review of Resident #1's care plan, revised on 08/06/2024, revealed the resident had impairment to skin integrity of the upper, inner left arm. The first goal, initiated on 08/02/2024 indicated the resident had skin impairment but the specific information was left blank. Interventions included evaluating skin concern weekly and as needed, observing the location, size and treatment of the skin injury and to report any abnormalities to the doctor, and to provide treatment to skin concern as ordered. A review of an After Visit Summary indicated Resident #1 was to be discharged from the hospital to the facility on [DATE] and the resident's medication list indicated the resident needed to take a blood thinning medication two times a day. During the resident's hospital stay, the resident was diagnosed with a blood clot in the left arm and a necrotic wound in the left elbow. A review of Clinical Summary, from the local hospital completed on 07/31/2024 indicated Resident #1 was prescribed a blood thinning medication to take twice daily. A computerized tomography (CT) scan of the resident's head was completed on 07/19/2024 with no acute findings. A review of Order Summary Report indicated Resident #1 had a physician's order to treat the wound to the left arm every Tuesday, Thursday, and Saturday, however, there were no orders for a blood thinning medication. A review of an Advanced Practical Registered Nurse (APRN) visit on 07/31/2024 at 9:35 PM indicated APRN #22 visited Resident #1 for extremity pain and the resident was recently hospitalized for a blood clot in the resident's arm and the resident was having significant pain to that arm. There were no indication the resident's physician's orders were reviewed to ensure the resident was taking a blood thinning medication. APRN #22 ordered a pain medication. A review of Drug Regimen Review, with an effective date of 08/01/2024 indicated a drug regimen review was completed to identify clinically significant medications issues. The potential concern indicated was a drug-to-drug interaction. There was no information related to a blood thinning medication. A review of Pharmacy MRRs [medication regimen review] - *New Admit with an effective date of 08/03/2024, completed by Pharmacist #1 indicated the resident's medications had been reviewed with no discrepancies noted. A review of an APRN visit on 08/01/2024 at 11:23 AM indicated APRN #19 visited Resident #1 to review discharge orders and ensure the patient is medically stable post-discharge from the hospital. APRN #19 indicated Resident #1 had an artery blockage that required irrigation and debridement. APRN #19 reviewed 13 different concerns, including the resident's wound, pain in the left arm, and an irregular heart rate, however a blood thinning medication was not addressed or indicated. Resident #1 was seen again by APRN #19 on 08/06/2024 at 11:50 AM and the blood thinning medication was not addressed or indicated. This note was not signed off on until 08/11/2024. A review of Progress Notes indicated on 08/07/2024 at 7:40 AM, Licensed Practical Nurse (LPN) entered Resident #1's room to provide medication and the resident was unresponsive, cool, clammy to touch and the resident's blood sugar was 191. Emergency Medical Services (EMS) was notified to send to the emergency room . Resident #1 left the facility at 8:00 AM. A review of the hospital's ED [Emergency Department] Provider Note indicated on 08/07/2024, Resident #1 presented to the ED with an infected wound to the left inner elbow, had an altered mental status, had a low level of oxygen in their body, and had low blood pressure. An oral blood thinner was listed on the current medication list. Further review indicated it was reported to the hospital that the resident was not taking the oral blood thinner. The History and Physical portion indicated per the resident's family member, on the evening of 08/06/2024, the resident appeared tired and leaning to the right and this morning, staff noted worsening confusion and decreased responsiveness. The Plan indicated the hospital had attempted to transfer the resident to another hospital during the previous stay, but it was not possible, for various reasons. Resident #1 was treated with a blood thinner, which showed clinical improvement and was discharged to the facility on oral blood thinner. Resident #1 had an MRI (Magnetic resonance imaging) on 08/08/2024, which showed the resident had an acute stroke. On 08/09/2024, Resident #1 was pronounced dead at 3:30 PM. During a telephone interview on 08/27/2024 at 1:52 PM, Pharmacist #1 stated for new admission residents, she allows the facility time to put physician's orders in the resident's electronic health record (EHR) before she reviews the resident's medications. Pharmacist #1 stated she looks for significant drug interactions, duplicate therapies, or anything that needs to be addressed before the monthly pharmacy consultant reviews the resident's EHR. Pharmacist #1 stated she does not look at hospital discharge orders because she would not be able to decipher which medications are supposed to be continued from the hospital and if the admitting doctor wanted to make any changes. Pharmacist #1 stated she bases her review on what orders the facility nurse puts into the EHR and she relied on the nursing staff to put in the correct orders. Pharmacist #1 stated if the order was not entered into Resident #1's EHR, then she would not have caught the discrepancy and she only reviewed active orders. During an interview on 08/28/2024 at 1:43 PM, LPN #3 stated on 08/07/2024, she prepared Resident #1's medication and took it to the resident. Upon entering the room, the resident did not look right and looked gray. LPN #3 stated Resident #1 was not responding, and the resident's arm was blue. LPN #3 called the ambulance and sent the resident to the hospital. LPN #3 stated she had sent three residents to the hospital that day. During an interview on 08/28/2024 at 2:15 PM, LPN #6 stated Resident #1 was admitted from the hospital because of the arm issue. LPN #6 stated the resident was complaining of pain, so she called APRN #22, who prescribed a pain medication. LPN #6 stated that Resident #1's family was present one evening and asked LPN #6 if there was anything different with the resident. LPN #6 stated she assessed the resident, who was able to answer all of the nurses' questions. LPN #6 advised the family that they could request for the resident to go to the hospital, but the family declined. LPN #6 stated the resident had a blood clot that the hospital tried to extract. During an interview on 08/29/2024 at 10:10 AM, APRN #19 stated the facility staff go through the resident's discharge summary from the hospital and make sure medications are in the resident's EHR and verify with APRN #19 to make sure everything matches. APRN #19 stated she was not aware Resident #1 should have been on an oral blood thinning medication. APRN #19 stated she reviews all of the medications listed on the resident's EHR and did not have the After Visit Summary available at the time to review. During an interview on 08/29/2024 at 10:51 AM, Registered Nurse (RN) #11 stated the Assistant Director of Nursing (ADON) was responsible for transcribing medications for newly admitted residents. During an interview on 08/29/2024 at 1:15 PM, the ADON stated on the day Resident #1 was admitted to the facility, there were four new admissions total that day and she transcribed the orders for those residents. The ADON stated she did not recall omitting any medication. The ADON stated Resident #1 did have an order for an oral blood thinning medication on the After Visit Summary. The ADON stated the facility called her on the evening of 08/08/2024 and asked if she knew anything about the resident being on the blood thinner. The ADON stated she came back to work the following day and reported the error to the Administrator, and she was placed on unpaid suspension. The ADON was able to return to work the following Thursday 08/15/2024 and was required to be retrained on the admission process, double checking physician orders, having another nurse check the orders, and contacting the physician to go over the resident's medical record. During an interview on 08/29/2024 at 2:39 PM, the Director of Nursing (DON) stated Resident #1 had an incision and draining (I & D) procedure for a blood clot in their left arm. The DON stated Resident #1's family came to the facility and packed the resident's personal items. LPN #3 told the DON the family wanted to know when the last dose of the resident's blood thinner was given and wanted the After Visit Summary from the hospital. The DON stated we started to get everyone on board of a double check of orders. It was so in your face that it was missed. We have to do a checks and balance system on it. People can make errors. We checked all of the new admits to double check to see if anything was missed within the last several months. We brought it to QA [quality assurance] and that's how we developed the plan. During an interview on 08/29/2024 at 3:55 PM, the Administrator stated the missing physician's order for Resident #1 should have been caught within 24 hours of admission. The Administrator stated it was overlooked by the nurse, the nurse practitioner, and the management team during the daily startup meeting. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey, thus it was determined to be a Past Noncompliance citation. The facility has implemented the following actions to correct the deficient practice effective 08/20/2024: RE: Admission Process The following will serve as the admission process for all new admissions to The Pines Nursing and Rehabilitation. After clinical and financial acceptance, the legal admission paperwork will be generated by DON or designee. The signatures of the resident will be captured by the DON or designee. 1. The admitting charge nurse will enter all orders from the discharge summary (AVS) provided by the hospital. 2. The admitting nurse will make a copy of the AVS and tum it over to the Medical Records Nurse or designee. 3. The MR [medical record] Nurse or designee will provide a copy of the AVS to the DON as well as the APRN or MD for review and recommendations. 4. The nurse management team will jointly verify the accuracy of the orders against the hospital AVS at the following morning nurse start up meeting. 5. For late evening Friday or weekend admissions, the Weekend RN supervisor will review the admission AVS and reconcile against entered orders. Any discrepancy will be immediately reported to the DON and [ .] on call provider for clarification and correction. 6. All weekend admissions will be reviewed again on Monday morning by the nurse management team at nurse start up meeting. The facility alleged compliance on 08/20/2024. A review of Inservice Education Report completed on 08/09/2024, indicated 35 staff signatures for education provided on abuse, neglect, and misappropriation of property. A review of Inservice Education Report completed on 08/15/2024 indicated the ADON was provided education related to verification of medications upon admission. A review of Licensed Nurse Orientation Checklist indicated on 08/16/2024, the ADON was re-oriented by the DON on the facilities admission, transfer, and discharge procedure, job description, written and oral communication, diagnostic testing/lab, controlled drugs - location and accountability, ordered drugs, receiving drugs, stop orders, transcribing physician orders, medication administration record, documentation of anticoagulation therapy, and incident and accident documentation. A review of Medication Pass Worksheet was completed for seven licensed nurses with no errors.

Based on observations, interviews, and record review, it was determined that the facility failed to notify the physician and/or the resident's representative of abnormal finger stick blood sugars, elevated white blood cell count, and the identification of a new pressure ulcer for 1 (Resident #3) of 4 residents reviewed for notification of change. Findings include: A review of the facility's undated policy titled Notification of Change, indicated The nursing facility will immediately inform the Resident/Elder and consult with the Resident/Elder's physician, when a significant change occurs. The nursing facility will also notify the Resident/Elder's legal representative or a designated contact person when a significant change occurs. A review of the Admission Record, indicated Resident #3 had diagnoses that included type 2 diabetes, pressure ulcer to the left buttock, heart disease, muscle weakness, difficulty walking, pain, cognitive communication deficit, and a history of falling. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/22/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review indicated the resident had diabetes and the resident was not admitted with any pressure ulcers. A review of Resident #3's plan of care, initiated on 07/20/2024, revealed the resident had diabetes mellitus. Interventions included observing and/or reporting any signs or symptoms of hyperglycemia and notifying the medical practitioner of lab results. The resident's care plan did not include information related to the resident's pressure ulcer. A review of Order Summary Report, revealed Resident #3 had an order to have their blood sugars checked before meals and at bedtime. There were no orders listed on when to notify the physician if the resident's blood sugar was high or low. Resident #3 also had a physician's order for a treatment to an unstageable pressure ulcer to the resident's left buttock, with a start date of 07/25/2024. A review of Blood Sugar Summary for Resident #3 indicated the resident's blood sugar was 443 on 08/06/2024 at 8:15 AM and 456 at 3:33PM, both completed by Licensed Practical Nurse (LPN) #9. A review of Lab Results Report, with a reported date of 08/06/2024 at 7:44 PM, indicated Resident #3 had a white blood cell count of 23.81, when a normal value would be between 4.23 and 9.07. A review of Progress Notes did not indicate the physician and/or designee was notified of the elevated blood sugars on 08/06/2024. There were no progress notes indicating the resident's representative was notified of the pressure ulcer identified on 07/25/2024. There were no progress notes indicating the physician and/or designee addressed the abnormal lab value from 08/06/2024. During an interview on 08/28/2024 at 1:43 PM, the LPN #3 stated if a resident's blood sugar was below 60 or above 400, staff were to notify the resident's physician, and those parameters should be on the resident's physician's orders. LPN #3 stated Resident #3's blood sugar started to increase probably because the resident had an infection. LPN #3 stated she was aware the resident's blood sugars were going up because the resident's normal values were around 200 and she received in a verbal shift change report that the resident's value had gone up to over 400. LPN #3 stated the Advanced Practical Registered Nurse (APRN) was responsible for reviewing lab results and the nurses do not typically review them unless the lab calls with critical values. LPN #3 stated Resident #3 had a pressure ulcer that developed at the facility but did not know much about it and the resident's family should have been notified. During an interview on 08/28/2024 at 2:15PM, the LPN #6 stated blood sugar parameters to notify the physician should be on the Medication Administration Record. LPN #6 stated she was aware of one physician's order that indicated to notify the physician if the resident's blood sugar was below 60 or above 400 but Resident #3 was not on sliding scale insulin, so she was not sure what the order was for Resident #3. LPN #6 stated the APRN was responsible for reviewing resident's labs, which should be done every day. During an interview on 08/28/2024 at 3:13 PM, Registered Nurse (RN) #10, who was the treatment nurse, stated Resident #3 had a facility acquired unstageable pressure ulcer to the left buttock and any time a resident had a newly acquired pressure ulcer, the resident's family should be notified. RN #10 stated she could not remember if she notified Resident #3's family or not. RN #10 stated the resident's labs are reviewed by the APRN, however, she stated she should be reviewing them because they are related to wound care, and it was a very important step. RN #10 stated she was aware Resident #3 had high blood sugars, which could have affected Resident #3's wounds. During an interview on 08/29/2024 at 9:48 AM, Resident #3's Responsible Party (RP) stated he was not notified of the resident's pressure ulcer, the elevated blood sugars, or the abnormal lab values. The RP stated he would call the facility every day and staff would just state Resident #3 was good, and they had more conversations about the resident's diet and physical therapy. During an interview on 08/29/2024 at 10:10 AM, APRN #19 stated if a resident's blood sugar was below 40 or above 400, staff should notify the physician and there should be a physician's order indicating the parameters for notification. APRN #19 stated she could not locate any documentation that she was notified of the resident's blood sugars. APRN #19 stated labs should be reviewed by the APRN that was working the day the labs were received. At this time, APRN #19 reviewed Resident #3's physician's orders and verified there were no parameters indicated. APRN #19 verified the resident's labs were ordered on 08/06/2024 and the resident's white blood cell count was elevated but the labs were not reviewed until 08/09/2024 by herself and she stated she did not know why the labs were not reviewed before then. During an interview on 08/29/2024 at 10:51 AM, RN #11 stated Resident #3's wound was facility acquired but was no aware if the resident's family was notified. RN #11 stated if a resident's blood sugar was greater than 400, staff should notify the physician. During an interview on 08/29/2024 at 1:15 PM, the Assistance Director of Nursing (ADON) stated if a resident has a newly identified pressure ulcer, the resident's family should be notified. The ADON stated if a resident's blood sugar was below 60 or above 400, the resident's physician should be notified and Resident #3's physician should have been notified of the high blood sugar levels. During an interview on 08/29/2024 at 2:39 PM, the Director of Nursing (DON) stated she was not aware if Resident #3's pressure ulcer was facility acquired or not, but family should be notified of any newly acquired pressure ulcers. During an interview on 08/29/2024 at 3:55 PM, the Administrator stated the physician and/or designee should be notified if a resident's blood sugar was below 60 or above 400. LPN #9 was called numerous times throughout the survey and did not return the surveyor's phone call during the survey.

Based on observations, interviews, record review, facility document review, it was determined that the facility failed to ensure physicians orders were followed for wound care treatment for 2 (Resident #2 and Resident #4) of 3 residents reviewed for skin concerns and/or pressure ulcers. Specifically, the facility failed to ensure wound care was provided to residents when the designated wound care nurse was out sick. Findings include: 1. A review of the Admission record, indicated the facility admitted Resident #2 with diagnoses that included liver failure, metabolic disorder, major depression, schizophrenia, and sepsis left buttock stage 4 pressure ulcer. The signification change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #2 had a Staff Assessment of Mental Status (SAMS) score of 2 which indicated the resident was moderately impaired for daily decision making Resident #2 had a stage 4 pressure ulcer. A review of Resident #2's care plan, revealed the resident had a left lluteal stage 4 pressure ulcer. Interventions included to assist the resident to keep skin clean and dry, educate staff on proper technique of removal of dirty brief so as not to damage skin, conduct a body audit weekly, encourage adequate nutrition, and encourage and assist with fluid intake. A review of Order Summary Report, revealed Resident #2 had physician's orders to treat a stage 4 pressure ulcers every day and as needed. A review of Treatment Administration Record, revealed Resident #2 missed wound care treatment on 08/26/2024. During an interview on 08/28/2024 at 1:43 PM, LPN # 3 stated she was assigned to Resident #2 on 08/26/2024. LPN #3 stated Registered Nurse (RN) #10 was the treatment nurse, however, RN #10 was sick on 08/26/2024, so LPN #3 was responsible for all wound care on her assigned hall. LPN #3 stated she was unable to provide wound care treatment on all her assigned residents and she was not able to complete Resident #2's wound care. LPN #3 stated she was told by the Director of Nursing (DON) the treatments that had no been completed would be completed by someone else. LPN #3 stated she did not notify the oncoming shift of which resident's wound care had not been completed. During an interview on 08/28/2024 at 3:13 PM, Registered Nurse (RN) #10 stated she was the treatment nurse for the facility but was out sick for the week. RN #10 stated when she is not at work and there was a scheduled wound care treatment for any resident, the floor nurse assigned to the resident should complete the wound care orders. During an interview on 08/29/2024 at 11:07 AM, Registered Nurse (RN) #11 stated Resident #2 had been sent to the hospital a few times and was readmitted to the facility on antibiotics due to sepsis. RN #11 stated each nurse was responsible for completing treatment orders if the treatment nurse was not on shift when the treatment was due. During an interview on 08/29/2024 at 1:15 PM, the Assistance Director of Nursing (ADON) stated if the treatment nurse was not working when a treatment was due for a resident, the facility would designate a staff member to complete the treatments. and her expectations were that physician's orders were followed. During an interview on 08/29/2024 at 2:41 PM, the DON stated Medication Attendant Certified (MAC)'s could not complete dressing changes for wound care on residents and the nurse on the floor was always aware the treatment nurse was to complete the wound care. The DON stated the nurses on the floor knew to ask her for assistance, if needed. The DON stated she was unaware the nurse needed her assistance on completing wound care on 08/26/2024. During an interview on 08/29/2024 at 3:55 PM, the Administrator stated he expected physician's orders to be followed for wound care and the task should be delegated to the floor nurse if the treatment nurse was not available. 2. A review of the Admission record, indicated the facility admitted Resident #4 with a diagnosis of dementia, bipolar, depression, diabetes, osteoarthritis, and unstageable pressure ulcer of the back, buttock and hip. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #4's care plan, dated, 06/14/2024 revealed the resident had a stage 4 pressure ulcer on their sacrum, and a shear on the left trochanter. Resident #4 also had a deep tissue pressure infection to the left heel. Interventions included to educate the resident to reposition often, offer a wedge, complete treatment as ordered until healed, continue to promote nutrition, reposition every two hours, completed a body audit weekly, and provide a low air mattress. A review of Order Summary Report, revealed Resident #4 had physician's orders to treat an unstageable left hip pressure ulcer on Monday, Wednesday and Friday, a treatment to a healed pressure ulcer on the right hip every five days, and a treatment order for a stage 4 pressure ulcer to the sacrum every day. A review of Treatment Administration Record, revealed Resident #4 was missing wound care treatment on 08/25/2024 and 08/26/2024 for the sacral wound and left heel. Resident #4 was also missing wound care on 08/26/2024 for the left and right hip pressure ulcer. During an interview on 08/29/2024 at 2:15 PM, LPN # 3 stated she was unable to provide wound care treatment on 08/25/2024 and 08/26/2024 on all her assigned residents and Resident #4 was one of them. LPN #3 stated the treatment nurse provided the care, but she was home sick. LPN # 3 stated she was told by the Director of Nursing to finish her assigned tasks and the treatments would get done by someone else. LPN #3 stated she did not complete wound care on Resident #4 and did not relay to the oncoming shift that treatment had not been provided. During interview on 08/29/2024 at 1:07 PM, Advanced Practical Registered Nurse (APRN) #19 stated APRN #21 completed wound care and she did not. During an interview on 08/29/2024 at 1:07 PM APRN #21 stated she had seen Resident #4 a couple of times and visited with the family and the family signed a document that the resident's wounds were unavoidable. During interview on 08/29/2024 at 2:41 PM, the DON stated Medication Attendant Certified (MAC) cannot do dressing changes for wound care on residents and the nurse on the floor was always aware the nurse was responsible for wound care. The DON stated she let the LPN know to come to the DON if she needed help. The DON stated she was aware on 08/26/2024 the LPN assigned to complete wound care treatments needed assistance with wound care.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure the ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles, failed to ensure food items stored in the refrigerator or freezer were sealed, labeled and dated, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, failed to ensure expired food items were promptly remove/discarded by the expiration or use by dates, and failed to ensure kitchen floors and kitchen walls were free of stains and chips. These failed practices had the potential to affect 75 residents who received meals from the kitchen (total census: 76). The findings are: 1. On [DATE] at 10:06 AM, Dietary Employee (DE) #1 took the coffee dispenser to the dining room and walked back into kitchen. Without washing her hands, she picked up glasses by their rims and poured beverages to be served to the residents for noon meal. 2. On [DATE] at 10:07 AM, DE #1 took a can of vegetable juice from the storage room and placed it on the counter. She opened the can of vegetable juice, without washing her hands, she picked up glasses by their rims and poured the juice in them to be served to the residents for noon meal. 3. On [DATE] at 10:09 AM, DE #2 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the plate warmer to be used in serving noon meal to the residents. The Surveyor asked DE #2 immediately, What you should have done after touching dirty objects or before handling clean Equipment? She stated, I should have washed my hands. 4. On [DATE] at 10:12 AM, the wall by the 2- compartment sink and wall leading to the dish washing machine room had black stains on them. The floor in the storage room was chipped, exposing the concrete. 5. On [DATE] at 10:29 AM, the following observations were made in the refrigerator: a. A container of leftover diced pepper was on a shelf in the refrigerator with no opened or received date on it. b. A box of sausage had no received date on it. c. An opened box of nectar thickened tea had no open date on it. d. There was a pan of unidentified red liquid drink on a shelf in the refrigerator. There was no name written on the pan and there was no date when the unidentified red liquid item was prepared in or stored. e. There was a pan of unidentified red liquid drink on a shelf in the refrigerator. There was no name written on the pan and there was no date when the unidentified red liquid item was prepared in or stored. f. A zip lock bag that contained mechanical soft chopped lettuce and one that contained lettuce leaf and sliced tomatoes and carrots were on a shelf in the refrigerator. Both mechanical and regular salad were wilted, have green liquid, and were discolored. The surveyor asked the Dietary Supervisor to describe the appearance of the salad in the bags. She stated, They look terrible. g. Cherry pie filling with open date of [DATE]. The surveyor asked the Dietary Surveyor how long you keep your open food items. She stated, 3 days usually this can keep longer. I will contact our supplier. On [DATE] at 08:03 AM, the surveyor asked the Dietary Supervisor how long should cherry filling be kept once opened? She stated, The company stated 3 days. 6. On [DATE] at 10:43 AM, the following observations made in the second door refrigerator were: a. A container of super calorie pudding with preparation date of [DATE] written on the container. The surveyor asked the Dietary Supervisor how long leftover foods should be kept. She stated, We keep them for 3 days. b. An opened zip lock bag that contained slices of cheese was on a shelf in the refrigerator, exposing them to the air or cross contamination. c. An opened box of sausage was on a shelf on the refrigerator. There was no date as of when it was opened. d. A leftover container of pork roast dated [DATE] was on a shelf in the refrigerator. e. A gallon of French dressing was on a shelf in the refrigerator. There was no date on the gallon to indicate when it was opened. f. An opened bottle of pickles was on a shelf in the refrigerator. There was date on the bottle when it was opened. Another opened gallon of pickles with a received date of ,d+[DATE] was on a shelf in the refrigerator. The container did not indicate the year when food item was received. g. A -5-pound container of cottage cheese was on a shelf in the refrigerator with an expiration date of [DATE]. 7. On [DATE] at 10:59 AM, the following observations made in the freezer were: a. Two of the 2 bags of pancakes were on a shelf in the freezer. Each of the bags contained 18 counts of pancake, and there was no received date on either bag to assure first in and first out. b. A box of dinner rolls on a shelf in the freezer has no date when it was opened. c. On [DATE] at 11:05 AM, a bag that contained 8 hot dog buns was on the counter. One of the buns had a sage color on it. The surveyor asked the Dietary Supervisor to describe what was on the bun. She stated, It was mold on it. d. An opened zip lock that contained an opened box of oatmeal was on the counter by the grill. The box was not covered or sealed. On [DATE] at 11:16 AM, the following observations made in the storage room: a. A gallon of chocolate fudge Icing was on a shelf in the storage room. There was no open date on the gallon. The manufacturer specification on the bottle documented, Keep 7 to 10 days once opened. b. An opened box of coconut was on a shelf in the storage room. There was no opened date on the box. 8. On [DATE] at 11:33 AM, DE #4 removed individual cartons of butter from a box in the refrigerator and placed them in a container. Without washing his hands, he picked up glasses by their rims and placed them on the counter. DE #4 removed gloves from the glove box and placed them on her hands, contaminating the gloves. He removed 3 cartons of milk from the milk refrigerator and emptied them into 3 individual glasses. At 11:35 AM, DE #4 removed 3 packages of dry drink mix from the storage room and emptied a packet in each glass of milk. He used his contaminated gloved hand to hold the glasses by their rims, as he mixed the milk mixture to be served to the residents who required supplement with their noon meal. 9. On [DATE] at 11:53 AM, DE #4 was wearing gloves on her hands when she opened the over door and removed a pan of baked sweet potatoes on placed it on the counter. She removed mittens from her hands and placed them on the counter. Without washing her, used her contaminated hand to touch a few baked sweet potatoes to see if they were done. 10. On [DATE] at 11:54 AM, DE #4 picked up a box of saran wrap and placed it on the counter. Opened a can of vegetable juice. Without washing her hands, she picked up glasses by their rims and poured vegetable juice in them, then opened the door to the room, where lids to cover glasses, and paper dishes were kept, removed lids with her fingers touching inner surface that goes over the glasses and covered the glasses with it. 11 On [DATE] at 11:56 AM, DE #1 took a tea container into the dining room and walked back into the kitchen, contaminating her hands. Without washing her hands, she picked up a coffee filter with her bare and placed it in a coffee basket and attached it to the coffee maker to brew. 12. On [DATE] at 12:00 PM, Dietary Supervisor picked up trays that contained clean glasses from under the counter and placed them on the window. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for lunch. 13. On [DATE] at 12:35 PM, the following observations were made in the storage room: a. A gallon of Worcestershire sauce was on the shelf in the storage room with no open date. b. An opened gallon of distilled vinegar was on a shelf in the storage room. There was no date on the gallon to indicate when it was opened. c. A bag of puff was on a shelf in the storage room with an expiration date of [DATE]. 14. On [DATE] at 12:46 PM, the ice machine in a room on 400 hall had wet black residue around the area where ice forms before dropping in to the ice collector. DE #5 was asked to wipe the black/brown residue on the plane of the ice machine. She did so, and the black/brown residue easily transferred to the tissue. DE #5 was asked, How often do you clean the ice machine. Who uses the ice from the ice machine? She stated, The maintenance man cleaned it on [DATE] and I cleaned it on [DATE]. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it in the kitchen to fill beverages served to the residents at meals. 15. On [DATE] at 01:34 PM, a pan that contained 20 cartons of chocolate leftover ice cream and 3 cartons of vanilla ice from lunch was placed on a shelf in the freezer by the DE #4. The surveyor asked DE #4 to see if the ice cream was still frozen. DE #3 felt the ice cream and stated, It was soft. The surveyor asked DE #4 to open a vanilla ice cream cup, then to describe the appearance of the ice cream. DE #4 did so and stated, It looked like a milk shake. The surveyor asked DE #4 the reason the ice cream was placed in the freezer. DE #4 stated, That was the way it had been done since I started working two weeks ago. The surveyor asked if ice cream should have been refrozen after been thawed. DE #6 stated, No, they should be thrown away, never to them back in the freezer. 16. On [DATE] at 07:55 AM, the following observations were made in the deep freezer in the emergence storage room: a. A bag of California vegetable blend in the freezer had no recovered date on it. b. An opened box of pork chops. The box was not covered or sealed. c. A box of winter vegetables in the freezer has no open date on it. 17 On [DATE] at 08:06 AM, the following observations were made in the refrigerator in the Riser room on the 600 hall: a. A container of chicken spaghetti was on a shelf in the refrigerator. There was no name to show whom it belongs to and there was no to indicate when it was received. b. A container of beef stew was on a shelf in the refrigerator. There was no name or received date on the container. c. A clear sealed wrap that contained bacon cheeseburger was on a shelf in the refrigerator. The bacon and the hamburger meat had dried white film on them. slice of cheese was dried, and the bun was dried. The surveyor asked the Dietary Supervisor to describe the appearance of bacon cheeseburger. She stated, It was gross. e. An opened zip lock bag that contained pepperoni was on a shelf. The bag was not sealed, exposing it to air or cross contamination. f. A zip lock bag of petite carrots was on a shelf in the refrigerator with an expiration date of [DATE]. g. A container of fresh guacamole was on a shelf in the refrigerator. The guacamole was discolored. The surveyor asked the Dietary surveyor to describe the appearance of the guacamole. She did and stated, It was nasty gross. h. An opened bottle of grape jelly was on a shelf in the refrigerator with no open date on it. i. A bottle of peanut butter, bottle of barbeque sauce, bottle of pickle bites, a bottle prune juice on a shelf in the refrigerator have no open date on them. j. A paper plate the contained turkey dressing and cornbread was on a shelf in the refrigerator. The dressing and the meat were discolored. The surveyor asked the Dietary Supervisor to describe the appearance of the food item. She stated, old and gross. It doesn't look good. k. An opened box of pizza was on a shelf in the refrigerator. The slices of pizza were dried. There was no received or opened on the box. The surveyor asked the Dietary Supervisor to describe the appearance of the pizza. She stated, It was very dried. 18. On [DATE] at 08:19 AM, the following observations were made in the freezer in the Riser room on the 600 Hall: a. A cup of ice cream with a straw was on a shelf in the freezer. There was no opened or received date on it. The ice cream was discolored. b. An opened container of vanilla bean ice cream was on shelf in the freezer. There was no received on it. c. A box of chicken pot pie was in the freezer with no received date on it. d. A box of shrimp egg in the freezer has no received date on it. e. An opened vanilla deluxe ice cream in the freezer has no opened or received date on it. The ice cream discolored and had pop cycle on it. The Dietary Supervisor stated, It has frost on it. f. An opened zip lock bag that contained eggs was in the freezer. The bag was not sealed. There was no opened or received date on it. g. An opened box of chicken eggs was in the freezer. The box was not covered or sealed. There was no received or opened date on it. h. A box of neapolitan bar ice cream sandwich was in the freezer, there was no received date on the box. i. A box of big bar ice was in the freezer with no received date on it. j. There were 37 loose pop cycle in the freezer with received date. 19 A facility policy tilted .Hand washing/ wash your hands often to stay healthy documented, a. Before, during and after preparing food. b. After eating food.

Based on record review and interview, the facility failed to send the State Long Term Care Ombudsman a copy of the notice of transfer/discharge to the hospital to ensure protection of Resident Rights for 3 (Resident #12, #24, and #39) sampled residents who were discharged /transferred to the hospital. The findings are: 1. Resident #39 had diagnoses of Metabolic encephalopathy, Diabetes mellitus, and Anemia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/24 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A physician's order dated 12/23/2023 documented, .send resident out to [named organization] emergency room for possible GI bleed . b. Resident #39 was admitted to the hospital on 12/23/2023 and discharged back to the facility on [DATE]. The hospital progress notes documented, .Discharge Summary .12/27/23: Pt (patient) admitted [DATE] for 1. GI (Gastrointestinal) Bleed 2. UTI (Urinary Tract Infection) 3. Acute Metabolic Encephalopathy . c. On 02/22/24 at 1:25PM, the Administrator provided a report titled Action Summary dated Feb (February) 22, 2024 12:58PM that contained information on resident discharges/transfers for October, November, and December 2023. There was no documentation that 12/23/23 transfer to the hospital for Resident #39 had been sent to the State Long Term Care Ombudsman. d. On 02/22/2024 at 01:30 PM, the Administrator said he was not aware that they were supposed to send a list of resident transfers and discharges to the ombudsman. The Administrator said the list of residents they gave to the Surveyors was printed and just faxed to the ombudsman today. The Administrator identified Social Services as the person that will be responsible for reporting to the ombudsman. Social Services agreed that she had not been sending information to the ombudsman, because she did not know that she was supposed to. The Surveyor asked Social Services if they had a process in place now for notifying the ombudsman. Social Services said at the beginning of the month they will report for the previous month. Social Services was asked if they understand why the ombudsman would require resident information and she told the Surveyor, No, I really do not understand why and verbalized that she would reach out to the ombudsman for more information. e. On 2/22/2024 at 3:20PM, the MDS Coordinator was asked for a policy on transfers and discharges. f. On 2/22/2024 at 3:55PM, The policy titled Admission, Transfer, Discharge (undated) provided by the Minimum Data Set (MDS) Coordinator documented, .Notice before discharge .The nursing facility shall send a copy of the notice to a representative of the office of State Long Term Care Ombudsman . 47916 2. Resident #24 had diagnoses of Chronic obstructive pulmonary disease, Major depressive disorder, and Infection and inflammatory reaction due to internal right hip prosthesis. The Annual MDS with an ARD of 10/27/23 noted a BIMS score of 15 (13-15 indicates cognitively intact), and that the Resident required set up assistance for eating, dependent on transfers, personal hygiene, and bathing. Resident #24 required complete to moderate assistance for dressing. Resident #24 required a pressure relieving device for chair and bed and receives surgical wound care. A. Review of Nurses note dated 10/21/2023 at 1:34 PM noted, Resident c/o [complaint of] of being cold; gave resident more blankets and turned off fan . Resident was transferred into [transport provider] vehicle, via stretcher. Will call hospital for a later update . b. On 02/22/2024 at 01:25 PM, the Administrator was asked when was the last time the notice of discharge and transfers was sent to the ombudsman and he stated they did not know they were supposed to notify the ombudsman. 48390 3. Resident #12 was hospitalized on [DATE] and readmitted on [DATE]. Resident #12 was re-hospitalized on [DATE] and readmitted on [DATE]. Notice of Transfer was not sent to Ombudsman when Resident #12 was sent to hospital on either occassion.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. On 02/20/24, the menu for the lunch meal documented residents who received regular were to receive 3oz (ounces) of baked ham; and residents who received pureed diets were to receive a # (number) 8 scoop of pureed ham (4oz) and a #8 scoop (1/2 cup) of pureed cornbread. 2. On 02/20/24 at 01:07 PM, the residents' regular diets were served less than 3 ounces of baked ham, instead of 3 ounces as per the menu. 3. On 02/20/24 at 01:10 PM, the resident on a pureed diet was served pureed dressing, pureed ham, pureed turnip greens and pureed plain cake. There was no pureed cornbread served to the resident on a pureed diet. 4. On 02/20/24 at 01:18 PM, the surveyor asked Dietary Employee (DE) #3 the reason the resident on a puree diet was not served. DE #3 stated, The cornbread or bread were not pureed. The resident received stuffing. Is stuffing not bread? 3. On 02/20/24 at 01:32 PM, the surveyor asked DE #3 to weigh the same amount of ham served to the residents on regular diets and resident on pureed diets. She did so and stated, Regular ham weighed 2.3 ounce and pureed ham weighed 3.1 ounce.'

Based on interview, and record review, the facility failed to ensure the Minimum Data Set [MDS] accurately reflected the residents discharge status for 1(Resident #80) sampled resident who discharged home. The findings are: 1.Resident #80 had diagnoses of Right fractured shaft of humerus, Anxiety, Depression, Gastroesophageal reflux disease (GERD), Hypertension (HTN), and Arthritis. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/23 documented that the resident scored 15 (13-15 indicates cognitively intact) and that the resident's overall goal was to discharge to the community. a. A physician's order dated 12/23/23 documented, .May discharge resident to home with all medications and personal belongings . b. A nurses note dated 12/23/23 at 10:52 documented, .resident signed and acknowledged all discharge paperwork. Signed out narcotics to resident. resident was then escorted out of facility to vehicle by this nurse. all personal belongings and medications sent home with resident . c. The MDS with an ARD of 12/23/23 noted, Discharge -return not anticipated . Short-Term General Hospital . e. On 2/22/24 at 2:45PM, the MDS Coordinator was asked, when was (Resident #80) discharged from the facility? The MDS Coordinator stated, The resident discharged on [DATE]. The MDS Coordinator was asked, where did (Resident #80) discharge to? The MDS Coordinator stated, Home. The MDS Coordinator was asked, where does the MDS document the resident discharged to? The MDS Coordinator stated, It says she discharged to the hospital. The MDS coordinator was asked, is the MDS accurate? The MDS Coordinator stated, No. It is false and it will be modified. The MDS Coordinator was asked, why is it important that the MDS is accurate? The MDS Coordinator stated, The MDS is an assessment tool that helps us provide better care by painting a picture of the resident. It is also used for finances, and it should be accurate. I will make sure it is modified. f. On 2/22/24 at 3:55PM the MDS Coordinator stated, We do not have a policy on accuracy of MDS assessments. We refer to the RAI (Resident Assessment Instrument) Manual.

Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards over which the facility had control and provided supervision to each resident to prevent avoidable accidents for 1 (Resident #32) of 1 sampled resident. This failed practice had the potential to affect 18 residents residing on the 100 Hall who were self-mobile according to a list provided by the Administrator on 12/8/22 at 10:58 am. The findings are: 1. Resident #32 had diagnoses of Heart Failure, Cerebral Infarction, Cerebral Palsy, Abnormal Coagulation Profile, and Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 documented that the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with toileting, totally dependent for transferring, and required set up and supervision with eating. a. The Physicians Order dated 10/21/22 documented, .Resident wishes to not be given any medications prior to noon . b. The Medication Administration Record (MAR) documented the following medications were given at 1:00 pm on 12/06/22 and were signed by Licensed Practical Nurse (LPN) #1's initials: i. Cardizem LA Tablet Extended Release 24 Hour 180 MG [milligram] (dilTIAZem HCL [Hydrochloride] ER [Extended Release] Coated Beads), Give 1 tablet by mouth in the afternoon related to HEART FAILURE, UNSPECIFIED. ii.) Cholecalciferol Tablet 1000 UNIT, Give 3 tablet by mouth in the afternoon for vitamin D deficiency. iii.) Docusate Sodium Tablet 100 MG, Give 1 tablet by mouth in the afternoon related to CONSTIPATION, UNSPECIFIED. iv.) Eliquis Tablet 5 MG (Apixaban), Give 1 tablet by mouth in the afternoon related to CEREBRAL INFARCTION, UNSPECIFIED. v.) Ferrous Sulfate Tablet 325 (65 Fe) MG, Give 1 tablet by mouth in the afternoon related to IRON DEFICIENCY. vi.) Furosemide Tablet 20 MG, Give 1 tablet by mouth in the afternoon related to HEART FAILURE, UNSPECIFIED. vii.) Gabapentin Capsule Give 400 mg by mouth in the afternoon related to CEREBRAL PALSY, UNSPECIFIED viii.) Potassium Chloride ER Tablet Extended Release 20 MEQ [milliequivalent], Give 1 tablet by mouth in the afternoon related to HYPOKALEMIA ix.) Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth in the afternoon related to GASTROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS x.) Requip Tablet 1 MG (rOPINIRole HCl), Give 1 tablet by mouth in the afternoon for RLS [Restless Leg Syndrome]. c. On 12/06/22 at 4:16 pm, Resident #32 was in her room in her bed with her eyes closed. with the over bed table positioned over the resident's abdomen. There were 2 medication cups sitting on the over bed table, one cup contained 10 pills and the other cup contained 2 pills. Resident #32 opened her eyes when the Surveyor walked into the room. The Surveyor asked, Are those your medications that you are to take? Resident #32 replied, I guess, I have been sick. The Surveyor asked, Did the nurse leave the medications for you to take? Do you know when she left them? She replied, I don't know. I have been sick, really sick. d. On 12/07/22 at 1:00 pm, the Surveyor asked LPN #1, Who provided medication administration on the 100 Hall yesterday [12-6-22] for the noon medication pass? LPN #1 stated, I gave those. The Surveyor asked, Did you leave [Resident #32's] medications on the over the bed table in cups for her to take? She replied, Yes, she will not take medications prior to noon, so those were her 1:00 pm medications and since she is so with it, she asks us a lot to leave them, and she will take them later. The Surveyor asked, Where those her 1:00 pm medications that were still in there at 4:16 pm, when I entered her room? LPN #1 stated, Yes, she likes to finish her lunch and I let her, and she asks us to leave them often and she will take them. The Surveyor asked, Do you know if she ever took the medications in the cup? Did you go back and check prior to you leaving for the day? She replied, I don't know, I know they were gone when I came in this morning. e. On 12/07/22 at 2:15 pm, the Administrator came to Surveyor and stated, I know there has been some issues with medications being left in a resident's room by a nurse and I just wanted to let you know that has been addressed and we are in the process of doing an incident report and contacting the physician and the pharmacist. The Surveyor asked, Does anyone know if the resident took the medications or not? She stated, We will be finding out, we are speaking with [LPN #1] now, and we are going to call the nurse that worked the night shift as well to see. She should have never left them in the room, you just don't do that, that is totally unacceptable. f. On 12/09/22 at 08:30 am, the Surveyor asked LPN #2, If you entered a resident's room and the resident was sleeping, or eating is it acceptable to set the medication cup containing medications on the table and leave them? She replied, No not at all. The Surveyor asked, What is the procedure if that occurs? She replied, I would try to get the resident to take them and if they refuse, I will bring them back to my cart and label them and then go back within the hour and attempt to give them to the resident. g. On 12/09/22 at 8:40 am, the Surveyor asked LPN #3, If you entered a resident's room and the resident was sleeping, or eating is it acceptable to set the medication cup containing medications on the table and leave them? She replied, No. The Surveyor asked, What is the procedure if that occurs? She replied, I take it and lock it up on my cart and label it with the residents name and then try again to get them to take them. The Surveyor asked, Is it acceptable to chart the medications were given if the resident did not take them at that time? Stated, No, you don't chart them, till the resident actually takes them. h. The facility's policy and procedure titled, Preparation and General Guidelines, provided by the Assistant Director of Nursing (ADON) on 12/09/22 at 8:15 am documented, .4) when medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared .

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed to prevent a significant medication error for 1 (Resident #32) of 1 sampled resident who had physician orders for Cardizem LA twice a day and 1 (Resident #32) of 4 (Residents #28, #32, #74 and #78) sampled residents who had physician orders for Eliquis twice a day. This failed practice had the potential to effect 1 resident who had physician orders for Cardizem and 10 residents who had physician orders for Eliquis and resided in the facility according to a list provided by the Administrator on 12/08/22 at 1:45 pm. The findings are: 1. Resident # 32 had diagnoses of Heart Failure, Cerebral Infarction, Cerebral Palsy, Abnormal Coagulation Profile and Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with toileting, totally dependent for transferring, and required set up and supervision with eating. a. The December 2022 Physicians Order documented, .Resident wishes to not be given any medications prior to noon . Order Date 10/21/22 .Cardizem LA Tablet Extended Release 24 Hour 180 MG [milligram] Give 1 tablet by mouth in the afternoon . Order Date 8/18/21 . Cardizem LA Tablet Extended Release 24 Hour 180 MG Give 1 tablet by mouth at bedtime . Order Date 8/18/21 . Eliquis Tablet 5 MG Give 1 tablet by mouth in the afternoon . Order Date 7/21/21 and .Eliquis Tablet 5 MG Give 1 tablet by mouth at bedtime . Order Date 7/21/21 . b. The Medication Administration Record (MAR) documented the following medications were given at 1:00 pm on 12/06/22 and were signed by Licensed Practical Nurse (LPN) #1's initials: i.) Cardizem LA Tablet Extended Release 24 Hour 180 MG [milligram] (dilTIAZem HCL [Hydrochloride] ER [Extended Release] Coated Beads), Give 1 tablet by mouth in the afternoon related to HEART FAILURE, UNSPECIFIED. ii.) Cholecalciferol Tablet 1000 UNIT, Give 3 tablet by mouth in the afternoon for vitamin D deficiency. iii.) Docusate Sodium Tablet 100 MG, Give 1 tablet by mouth in the afternoon related to CONSTIPATION, UNSPECIFIED. iv.) Eliquis Tablet 5 MG (Apixaban), Give 1 tablet by mouth in the afternoon related to CEREBRAL INFARCTION, UNSPECIFIED. v.) Ferrous Sulfate Tablet 325 (65 Fe) MG, Give 1 tablet by mouth in the afternoon related to IRON DEFICIENCY. vi.) Furosemide Tablet 20 MG, Give 1 tablet by mouth in the afternoon related to HEART FAILURE, UNSPECIFIED. vii.) Gabapentin Capsule Give 400 mg by mouth in the afternoon related to CEREBRAL PALSY, UNSPECIFIED viii.) Potassium Chloride ER Tablet Extended Release 20 MEQ [milliequivalent], Give 1 tablet by mouth in the afternoon related to HYPOKALEMIA ix.) Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth in the afternoon related to GASTROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS x.) Requip Tablet 1 MG (rOPINIRole HCl), Give 1 tablet by mouth in the afternoon for RLS [Restless Leg Syndrome]. c. On 12/06/22 at 4:16 pm, Resident #32 was in her room in her bed with her eyes closed. with the over bed table positioned over the resident's abdomen. There were 2 medication cups sitting on the over bed table, one cup contained 10 pills and the other cup contained 2 pills. Resident #32 opened her eyes when the Surveyor walked into the room. The Surveyor asked, Are those your medications that you are to take? Resident #32 replied, I guess, I have been sick. The Surveyor asked, Did the nurse leave the medications for you to take? Do you know when she left them? She replied, I don't know. I have been sick, really sick. d. On 12/07/22 at 1:00 pm, the Surveyor asked LPN #1, Who provided medication administration on the 100 Hall yesterday [12-6-22] for the noon medication pass? LPN #1 stated, I gave those. The Surveyor asked, Did you leave [Resident #32's] medications on the over the bed table in cups for her to take? She replied, Yes, she will not take medications prior to noon, so those were her 1:00 pm medications and since she is so with it, she asks us a lot to leave them, and she will take them later. The Surveyor asked, Where those her 1:00 pm medications that were still in there at 4:16 pm, when I entered her room? LPN #1 stated, Yes, she likes to finish her lunch and I let her, and she asks us to leave them often and she will take them. The Surveyor asked, Do you know if she ever took the medications in the cup? Did you go back and check prior to you leaving for the day? She replied, I don't know, I know they were gone when I came in this morning. The Surveyor asked, If those medications in the cup were her 1:00 pm dose and she is to then get her evening doses of her medications that are ordered twice a day at 9:00 pm, could that cause an issue? LPN #1 stated, Well yes, I guess it could but like I said, I don't know if she took them or not. e. On 12/07/22 at 2:15 pm, the Administrator came to Surveyor and stated, I know there has been some issues with medications being left in a resident's room by a nurse and I just wanted to let you know that has been addressed and we are in the process of doing incident report and contacting the physician and the pharmacist. The Surveyor asked, Does anyone know if the resident took the medications or not? She stated, We will be finding out, we are speaking with [LPN#1] now, and we are going to call the nurse that worked the night shift as well to see. The Surveyor asked, Is it a concern that she had not taken the 1:00 pm dosage of her twice a day medications at 4:16 pm and then she had 5 medications, one being a hypertension medication and one being a blood thinner, due again at 9 pm? She stated, Oh yes, that is a big concern, and we are contacting the pharmacist like I said. f. On 12/07/22 at 3:00 pm, the Surveyor asked the Assistant Director of Nursing (ADON), Has it been determined if [Resident #32] took the 1:00 pm medications on 12/6/22 and at what time? She stated, I am not sure. We are trying to figure it out. The Surveyor asked, Do you consider any of those medications a significant medication error? The ADON replied, I don't know. I am a nurse, and I will have to ask the pharmacist about that. g. On 12/08/22 at 8:50 am, the Surveyor asked the ADON, the Director of Nursing (DON) and the Administrator, Has it been determined if [Resident #32] took the medication that was left on her over bed table or not? The ADON stated, We know that the night nurse stated the medications were gone when she entered the room after she started her shift. The Surveyor asked, What time did she go into the resident's room, do you know? She stated, No, we don't know that. Her next dosages were given per the MAR at 9:00 pm. The Administrator stated, The resident was asked but she could not remember when she took them or if she did. The DON stated, She has a boyfriend, and he usually goes in to eat supper with her and I can ask him if the medications where there when they ate supper, and I will let you know what he says. h. On 12/08/22 at 9:30 am, the DON came to Surveyor and stated, [Resident #32's] boyfriend, who is also a resident in the facility states the medications were still there when he went in to eat supper with her and he made her take them then, and she took them. That would have been around 5:00 pm. i. The facility policy titled, Preparation and General Guidelines, provided by the ADON on 12/09/22 at 8:15 AM, documented, .7) The person who prepares the does for administration is the person who administers the does . 13) Medications designed to be administered over a 24-hour period (ex: sustained -release) are scheduled accordingly. In these cases, an order for twice a day, for example, shall be interpreted as every 12 hours .

Complaint # (AR 815) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure respiratory support was provided during cardiopulmonary resuscitation (CPR) in order to provide oxygenation for 1 (Resident #2) of 2 (Residents #2 and #4) case mix residents who required CPR in the past 60 days. The facility also failed to ensure measures were in place to assure staff who were certified and competent with the provision of CPR were available on all shifts and that staff were knowledgeable as to the conditions that must be present in order to initiate or stop CPR. The failed practices resulted in immediate jeopardy, which caused or was likely to cause serious harm, injury or death to Resident #2, who was found without pulse or respirations and was not provided with respiratory support during CPR, and had the potential to cause more than minimal harm to 16 residents who were identified as full code status on a list provided by the Director of Nursing (DON) on [DATE]. The Administrator was initially informed of immediate jeopardy-level past noncompliance on [DATE] at 4:10 p.m.; however, based on current failed practices identified during the survey, the Administrator was subsequently informed of a current immediate jeopardy situation on [DATE]. The findings are: 1. The facility's Policy and Procedure for Cardiopulmonary Resuscitation, received from the Administrator on [DATE] at 6:15 p.m., documented, .This Nursing Facility provides basic life support, including CPR, to resident requiring such emergency care prior to arrival of emergency medical personnel and subject to related Physician order [REDACTED]. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on a Brief Interview for Mental Status and had no documented shortness of breath and was always continent of bowel and bladder. a. The Care Plan dated [DATE] documented, .Problem . I have requested that CPR measures be performed. I am a Full Code . Date initiated: [DATE] . Approaches / Tasks: .I need you to initiate CPR if you find me pulseless and breathless and continue CPR until Emergency personnel arrive to take over . Communicate my choice to all appropriate staff members . b. An Advanced Directive form dated [DATE] documented, I do not wish to formulate or issue any advanced directive at this time . c. The (MONTH) 2019 Medication Administration Record [REDACTED] d. Nurses' Progress Notes dated [DATE] at 8:25 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, Went into resident's room at this time. Found resident with teeth out of mouth and lips cyanotic. Palpated right carotid and left wrist, no pulse present. No respirations noted and non-responsive to stimulation. CPR initiated, crash cart in room, back board under resident, O2 (oxygen) @ (at) 15L (liters) via mask placed on resident due to no ambu (artificial manual breathing unit)-bag on crash cart. Called for assistance, RN (Registered Nurse) called (emergency medical transport service) ambulance at 2031 (8:31 p.m.). RN came in and took over CPR compressions. Compressions delivered until EMS (Emergency Medical Services) arrived and took over care. At this time, family notified and aware of resident's time down, family requesting CPR be stopped. Coroner notified via (EMS). e. On [DATE] at 2:24 p.m., Licensed Practical Nurse (LPN) #1 stated she had been employed approximately 4 months and had graduated nursing school in (MONTH) 2019. The LPN was asked if she had been trained in CPR and stated, Yes. The LPN was asked if she had coded (provided CPR to) a resident recently. The LPN stated, Yes, (Resident #2). I was making 8:00 p.m. medication pass and went into the room to get her roommate's blood sugar. I looked and her teeth were out of her mouth and I started CPR. They got the crash cart and (Registered Nurse (RN) #1) called the ambulance and took over compressions and we couldn't get her back. It was very nerve-wracking. The LPN was asked if there was an issue with the ambu-bag. The LPN stated, I didn't know there was an extra ambu-bag in the storage room. I don't recall an ambu-bag on the crash cart, and we just put oxygen on her. The LPN was asked, You were performing CPR and no respirations were done? The LPN stated, No, we didn't do any respirations other than the oxygen on by nasal cannula. The LPN was again asked, Are you are certified in CPR? The LPN stated, Yes. The LPN was asked, what is the ratio of compressions to respirations (during CPR)? The LPN stated, I don't know. f. On [DATE] at 3:30 p.m., LPN #1's employee file was reviewed. The American Heart Association, Basic Life Support documentation indicated LPN #1 had successfully completed the cognitive and skills evaluation for Basic Life Support (CPR and AED) (Automated External Defibrillator) program. The form was dated [DATE] and had a recommended renewal date of ,[DATE]. g. On [DATE] at 6:33 p.m., Registered Nurse (RN) #1 stated she had been employed by the facility for approximately 2 years and 2 months. The RN was asked if she was aware of the criteria for withholding CPR from a full code resident and stated, No. The RN was asked, are you certified in CPR? The RN stated, Yes. The RN was asked where the crash cart was located and stated, In the 600 hall storage room. The RN was asked if there was an ambu-bag and if so, where it was located. The RN stated. There's one on the crash cart and one on the shelf in the 600 hall storage room. The RN was asked if she knew how to assemble an ambu-bag and stated, Yes. The RN was asked, what is the ratio of breaths to compressions when performing CPR? The RN stated, Compression is 100. I can't remember the respirations. The RN was asked, have you had to perform CPR recently? The RN stated, Yes, (Resident #2). I got in the room and they said there wasn't an ambu-bag on the crash cart. The RN was asked, did you check to see if the ambu-bag was on the crash cart? The RN stated, No, I didn't look. The RN was asked, did anyone go to the storage room to get an ambu-bag? The RN stated, No, they said there wasn't an ambu-bag. The RN was asked, you didn't check or have someone check the storage room? The RN stated, No. The RN was asked can you explain what happened during the code and how respirations were performed during the CPR? The RN stated, She (resident) had a re-breather mask on. The RN was asked if this provided the resident with oxygen, since the resident was not breathing. The RN stated, We didn't have an ambu-bag. The RN was asked, So during the CPR, there were no respirations administered? Just oxygen applied to the resident's face? The RN stated, Yes, only the oxygen was on the resident. h. On [DATE] at 3:05 p.m., the DON stated she had been employed as the DON since (MONTH) 2019 and had been employed by the facility for approximately 1 year. The DON was asked, when the staff are performing CPR, should respirations be provided? The DON stated, Yes. i. On [DATE] at 6:35 p.m., the DON was asked, how do you ensure there is a CPR-certified Nurse working each shift? The DON stated, I don't. The DON was asked if the staff had been evaluated for knowledge / competency with CPR. The DON stated, No. The DON was asked, have you had any issues regarding CPR being performed prior to the incident that involved (Resident #2)? The DON stated, No. The DON was asked if she was aware of the criteria for withholding CPR from a full code resident. The DON stated, No. The DON was asked if there had been a recent issue regarding an ambu-bag not being available. The DON stated, No, the crash cart is checked by the night shift. The day of the code on [DATE], the ambu-bag was on the crash cart and there was an extra ambu-bag in the storage room. j. The facility provided the following evidence of efforts to correct failed practices related to CPR: 1.) A Record of In-Service dated [DATE] documented, .In-Service Title: Crash Cart . Objectives of the In-Service: Any time you use the crash cart, it is your responsibility to IMMEDIATELY replace the items used. In the event that there is not an ambu-bag on the crash cart, there is an extra one located on the shelf beside the crash cart . The signature sheet documented the signatures of 29 facility nurses who attended this in-service. 2.) An Action Plan dated as developed [DATE] documented the following: i.) .Problem identified: Ambu-bag was on supply shelf and not on crash cart . Action Plan: Begin in-servicing nursing staff to remind them to immediately replace crash cart supplies from replacement supplies maintained in supply closet . Date Resolved: [DATE] and ongoing . ii.) .Problem identified: Crash cart monitoring checklist is responsibility of night shift nurses, and was not part of daily clinical start-up focus rounds by Department Heads . Action Plan: Added crash cart checklist and back-up supply monitoring to DON Daily start-up checklist . Date Resolved: [DATE] and ongoing . iii.) . Problem identified: Current CPR certifications not current in employee files or internal tracking system . Action Plan: Begin verifying and collecting CPR certification cards and entering information into (tracking system) . Date Resolved: Ongoing . iv.) .Problem identified: Nurse schedule not verified consistently to ensure CPR Certified Staff working each shift . Action Plan: Reviewed (MONTH) and (MONTH) schedules, and identified every shift covered with CPR Certified Staff . CPR Certification classes scheduled for nurses with expired CPR Certification and extended training to additional staff such as CNAs and Department Heads . Begin [DATE] and ongoing . Date Resolved: Ongoing . 100% of licensed nurses will have current CPR certification after final class scheduled [DATE] (at) 2:00 p.m. v.) .Problem identified: Staff not monitored for competency or compliance . Action Plan: Staff in-servicing began on [DATE] for all licensed nursing staff . 4 Licensed nurses not scheduled, or unable to attend in person by end of week [DATE] were in-serviced via phone call by DON and ADON prior to beginning of shift. This in-service was also posted to the PCC Bulletin to reinforce education . Beginning [DATE] staff were educated where the extra ambu bag was located. Beginning [DATE], the ambu bag in-service was updated with additional training to include CPR Pocket Resuscitators added to med cart; when to initiate CPR; and the CPR compression ratio . Resolved: Ongoing daily for 2 weeks; 5 x week for 2 weeks; 3 x week for 3 weeks . ongoing until compliance is achieved using the Competency of Cardiopulmonary Resuscitation form and filed in the Respiratory Support Documentation Binder . 3.) Crash Cart Checklists documented daily checks of the crash cart inventory beginning on [DATE]. A monitoring sheet titled, Reviewed Crash Cart Log Checklist and Supplies documented daily checks for, All Items on Crash Cart and Compliance beginning on [DATE]. The checklists included verifying the availability of an ambu-bag. 4.) On [DATE] at 2:10 p.m., the crash cart was checked with the Director of Nursing (DON). The crash cart was stored on the 600 Hall in the storage room. There was a small ambu-bag in a plastic bag on top of the crash cart and a large ambu-bag in a plastic bag on the shelf in the storage room. The DON stated that they keep one ambu-bag on the crash cart and one extra in the storage room on the shelf and the crash cart is checked by the night shift. The cart had a log for checking the crash cart and was initialed that the crash cart was checked each night. 5.) A Record of In-Service dated [DATE] documented, .How to provide respiratory support when unable to locate ambu-bag. The ambu-bag is located on the crash cart. If the back-up ambu-bag is not located on the shelf next to the crash cart, there is a CPR pocket resuscitator located on each med cart . How to know when to initiate CPR. A resident is a full code & (and) is found without signs of life i.e. - no pulse, no respirations . Compression ratio: 30 compressions to 2 breaths . 6.) A Competency of Cardiopulmonary Resuscitation monitoring sheet documented daily staff interviews to determine if the nursing staff were able to verbalize where the ambu-bag was located, where the CPR pocket resuscitator was located, when to initiate CPR, and what the ratio of compressions to breaths should be during the provision of CPR. There were no negative findings documented on monitoring dated as conducted on [DATE] and [DATE]. k. The facility removed the immediate jeopardy and reduced the scope / severity to G on [DATE] by implementing the following plan of removal: How to provide respiratory support when unable to locate ambu-bag, when to initiate CPR, who should receive CPR and the compression, breath ratio. This education includes: When unable to locate an ambu-bag: -there is an extra one located on the shelf beside the crash cart -there is a CPR pocket resuscitator on each med cart CPR should be initiated when: -resident is found with no signs of life. i.e. (that is) no pulse, no respirations and if a full code Compression/breath ratio: 30:2 IMMEDIATE ACTION: .Began re-educating all licensed nurses on current shift, re-educated all ,[DATE] pm (2:00 p.m. to 10:00 p.m.) licensed nursing staff prior to beginning their shift. Will re-educate 10pm-6am (10:00 to 6:00 a.m.) licensed nursing staff prior to beginning their shift. We will continue to educate all licensed nursing staff until 100% have been educated, including PRN (as needed) and any staff that is currently on leave, vacation, etc. (et cetera). .Monitoring to ensure staff competency and compliance will be completed daily for 2 weeks, 5x/week (times per week) for 2 weeks, 3x/week for 3 weeks and 1x/week for 1 week, 1x/month (one time monthly) for 6 months or until compliance is achieved. IMMEDIATE ACTION: .Initiated monitoring plan to include staff interviews and ambu-bag / CPR pocket resuscitator availability. .Monitoring expiration dates of CPR for all licensed nursing staff. IMMEDIATE ACTION: .Human Resources Director began auditing all licensed nursing staff for current CPR certification. .Began developing a CPR binder, to include all licensed nursing staff current status and expiration dates, including copies of CPR documentation. PLAN: Human Resources will alert staff and administration the month prior to expiration via (electronic health record software) dashboard, morning meeting whiteboard and (electronic scheduling software) system in order to keep certifications current. .Ensure there is a licensed nurse, who is CPR certified, on all shifts. IMMEDIATE ACTION: .Human Resources Director began auditing all licensed nursing staff for current CPR certification. It is verified, on the date, that every shift has a licensed nurse with a current CPR certification. PLAN: Any nursing staff that is not currently CPR certified will be, prior to (MONTH) 31, 2020. On [DATE] at 1:30 p.m. the Director of Nursing audited schedules to ensure that there is at least one CPR certified licensed nurse on each shift in both buildings, to which there were not negative findings. The Director of Nursing/Designee will monitor schedules daily, via the (scheduling software) schedule to ensure that no shift goes without a CPR certified licensed nurse in either building. This monitoring will continue until all licensed nursing staff is CPR certified. A certification course has been scheduled through (local community college) for: Thursday, (MONTH) 19, 2019 Friday, (MONTH) 20, 2019 Monday, (MONTH) 23, 2019 in order for the 12 remaining staff members to obtain certification .

Complaint # (AR 654) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure physician orders [REDACTED].#1. The facility failed to ensure the resident, who had a [DIAGNOSES REDACTED].#1) of 3 (Residents #1, #2 and #3) case mix residents who had physician orders [REDACTED].#1, who did not receive anticonvulsant medication and subsequently experienced a [MEDICAL CONDITION], requiring emergency transport to the hospital. This failed practice also had the potential to cause more than minimal harm to 10 residents who had physician orders [REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/15/2019 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required supervision with 1 person assistance for bed mobility and transfer and had a [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION]. a. A physician's orders [REDACTED].[MEDICATION NAME] - XR Tablet Extended Release 12 Hour 400 MG (milligrams) ([MEDICATION NAME] ER) give 1 tablet by mouth every 12 hours related to [MEDICAL CONDITION]. A physician's orders [REDACTED]. b. A Care Plan dated 7/12/18 documented, Self care performance deficit r/t [MEDICAL CONDITION] activity and weakness . 11/11/18 (Resident #1) refuses his medications at times .Nurse to encourage resident to take his medications .Psychiatric consult as indicated .When the resident becomes agitated. Attempt to intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . c. A Laboratory (Lab) Report dated 7/9/2019 documented the resident's Levetiracetam ([MEDICATION NAME]) level was 8.70. The therapeutic reference range was documented as 5.0 to 30.0. d. The (MONTH) 2019 Medication Administration Record [REDACTED]. Give 2 tablets by mouth two times a day related to Unspecified Convulsions .Start Date 09/12/2019. The form documented the medication was scheduled to be administered at 0800 (8:00 a.m.), 1700 (5:00 p.m.) and 1700 (5:00 p.m.). The following signatures and codes were documented: The form documented on 9/14/19 at 0800 and 9/15/19 at 0800, a signature with the number 5 above the signature. The signature space for the 15th at 1700 had a signature with the number 6 above the signature. The MAR indicated [REDACTED]. e. A Progress Note dated 9/12/19 by the Advanced Practice Registered Nurse (APRN) documented, .Interval History 9/12/19: (Resident #1) is seen in the clinic in follow-up. He is accompanied by a nursing home attendant. [MEDICATION NAME] was decreased to 500 mg (Milligrams) BID (twice daily) (was taking 1500 mg BID), the attendant tells me it was decreased due to abnormal labs ([MEDICATION NAME] level 4/17 (4/17/19) of 47.6, recheck on 4/25 (4/25/19) with level of 15). There is a documented ED (Emergency Department) visit 7/5 (7/5/19) for [MEDICAL CONDITION] where he was given [MEDICATION NAME] at the NH (Nursing Home). He was post-ictal in the ED. His [MEDICATION NAME] level at that time was 3.6 but medications were continued unchanged. He is also taking [MEDICATION NAME] 400 mg bid and [MEDICATION NAME] 400 mg at HS (bedtime). No side effects from medications. No headaches. Does walk some in his room but is in a wheelchair most of the time, chronic weakness on the right side after GSW (gunshot wound) to the head . Assessment and Plan . Partial symptomatic [MEDICAL CONDITION] (GSW with Left Temporal Encephalomalacia) . Increase [MEDICATION NAME] back to 1500 mg BID, no need to check [MEDICATION NAME] levels . Continue [MEDICATION NAME] 400 mg bid and [MEDICATION NAME] 400 mg at bedtime . [MEDICAL CONDITION] precautions . return to clinic in 6 months . f. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 750 MG (Levetiracetam) Give 2 tablets by mouth two times a day related to Unspecified Convulsions. g. A Pharmacy Return Medication Form dated 9/13/19 documented, .Patient Name - (Resident #1) .Levetiracetam 500 mg . Reason for Return - Order changed . h. An Orders Administration Note dated 9/14/19 at 9:03 a.m. documented, .Note Text: [MEDICATION NAME] Tablet 750 MG Give 2 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS (R56.9) . med (medication) not available . An Orders Administration Note dated 9/14/19 at 4:07 p.m. documented, .Note Text: [MEDICATION NAME] Tablet 750 MG Give 2 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS (R56.9) . med not available . An Orders Administration Note Dated 9/15/19 at 8:25 a.m. documented, .Note Text: [MEDICATION NAME] Tablet 750 MG Give 2 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS (R56.9) med not available. Not in e-kit (emergency kit) . i. A physician's orders [REDACTED].[MEDICATION NAME] Solution 2 mg/ml (milliliter) Inject 0.5 milliliter intramuscularly every 15 minutes as needed for [MEDICAL CONDITION] 0.5 ml q (every) 15 for [MEDICAL CONDITION]. j. An ED Provider Note dated 9/15/19 at 1:33 p.m. documented, .History of Present Illness . presents to the ED with a Chief Complaint of [MEDICAL CONDITION] .Patient presents to the emergency department from the nursing home by EMS (emergency medical system) after reportedly having a [MEDICAL CONDITION]. He has well-documented [MEDICAL CONDITION] history. He may have missed some doses of his medication at the nursing home. His MAR (Medication Administration Record) includes [MEDICATION NAME], and this has been confirmed with nursing home staff. It is well known that this decreases [MEDICAL CONDITION] threshold . Patient was given [MEDICATION NAME] 0.5 mg IV (intravenously). Nursing home was contacted and instructed to notify the PCP (Primary Care Physician) to please discontinue [MEDICATION NAME]. Return for any concerns or issues . k. An eInteract SBAR (Situation-Background Assessment Recommendation) Summary Note dated 9/15/2019 at 1:37 p.m. documented, . Situation: The Change In Condition (CIC) is reported on this CIC Evaluation are/were: Loss of consciousness [MEDICAL CONDITIONS] Unresponsiveness At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 126/74 . Pulse: 77 . Regular . RR (Respiratory Rate): 17.0 .Temp: 98.2 . Axilla . Resident/Patient had the following medications changes in the past week: [MEDICATION NAME] changed from 500 mg bid to 750 mg x 2 bid .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Unresponsiveness Other . Nursing observations, evaluation, and recommendations are: resident found to be unresponsive and seizing in bed. Administered IM (Intramuscular) [MEDICATION NAME]. Sent to ED via ambulance. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: [NAME] Recommendations: send to ED . l. A hospital Laboratory Report dated 9/15/19 at 2:00 p.m. documented the Levetiracetam Level was 1.0. The therapeutic reference range was documented as 10.0 to 40.0 ug/ml (micrograms per milliliter). m. A Return from Leave of Absence Summary documented the resident returned from the hospital on [DATE] at 4:52 p.m. n. A Nursing Note dated 9/15/2019 at 8:51 p.m. documented, .Note Text: on 9/14/19 pharmacy was contacted about resident [MEDICATION NAME] order, as medication did not arrive with scheduled cycle change out, as shown on pharmacy manifest. Pharmacy refused to send medication, stating that medication was included with scheduled cycle change out, despite staff stating that med was not in cycle change out containers, facility medication storage room, or either medication cart. On 9/15/19 pharmacy was contacted again in attempt to obtain medication. Instructed at 10 am (10:00 a.m.) that medication would be sent as a stat (immediately) since dosage increase had been ordered on [DATE], and old dosage was shown on pharmacy manifest. At 1253 (12:53 p.m.) resident was found to be in bed convulsing by CNA (Certified Nurse Assistant). Pink sputum on face and linens. 1 mg of [MEDICATION NAME] administered IM in the left ventrogluteal area at 1255 (12:55 p.m.). Life Net (Name) EMS (Emergency Medical Services) contacted by CNA during this time. Resident out the door via ambulance at 1300 (1:00 p.m.). Instructed EMS to take resident to ER (emergency room ). Report called to ER. At 1425 (2:25 p.m.), stat delivery received of resident's [MEDICATION NAME]. Received call from ER at 1545 (3:45 p.m.) stating that resident had been brought to them by EMS and that he would be discharging to facility. Resident returned at 1635 (4:35 p.m.). Drowsy. Vomiting on return. Care assumed by RN supervisor from 1650-1915 (4:50 p.m.-6:15 p.m.). Attempted to administer pm (evening) meds (medications), including [MEDICATION NAME]. Resident difficult to arouse enough to swallow. Currently resting in bed. Respirations even and unlabored . o. A Pharmacy Care Consolidated Delivery Sheet dated 9/16/19 documented, .(Resident #1) . qty (quantity)114 . Tab Levetiracetam 750 mg tabl (tablet) . 6 sent from backup sending remainder of 114 . This delivery sheet was signed as received by LPN #4 on 9/16/19 at 3:35 p.m. p. An OLTC Witness Statement form dated 9/16/19 at 10:00 a.m. and signed by LPN #1 documented, .(LPN #2) called me on 9/12/19 to inform me that (Resident #1) [MEDICATION NAME] level had been increased to 1500 mg BID. I changed the order in the computer printed the order and faxed to pharmacy. On 9/13/19 I used the remaining 0800 (8:00 a.m.) [MEDICATION NAME] which was 1.000 mg and one 500 from the 2000 (8:00 p.m.) card to equal his 1500 mg dose. I was told from the pharmacy the new medication would be delivered on 9/13/ so when trying to help with change out so all (LPN #3) would have to do is place cards in appropriate spots, I pulled his 500 mg dose to send back to pharmacy along with some others that orders had been changed. On the return slip I wrote the reason for return - change in orders and faxed it to pharmacy . On 10/25/19 at 12:04 p.m., LPN #1 was asked about the order changes for Resident #1 on 9/12/19. The LPN stated, He had a doctor's appointment, the (ADON/LPN #2) called to tell me to increase resident's [MEDICATION NAME] to 1500 mg BID. She went to the doctor's appointment with the resident and told me to change the order which I did and faxed it to the pharmacy. The next day on the 6-2 (day) shift 9/13/19 the medication had not arrived from the pharmacy, I popped out 2-500 mg tablets off my a.m. card which emptied that card, 1- 500 mg from the p.m. card. I called the pharmacy and was told it would be here on the night run. We have change out on the 14th, I was trying to help with the change out, I pulled the 500 mg dose, pulled sticker and filled out a return slip, I do not know if the medication was picked up by pharmacy. On Monday when I returned, I was told that the resident had a [MEDICAL CONDITION]. He does not have [MEDICAL CONDITION] very often, 2 since being moved to my side. The resident will try to refuse meds. On Monday I think his [MEDICATION NAME] was in a bottle. q. A Nursing Home Progress Note dated 9/16/2019 at 2:44 p.m. and signed by the APRN documented, .PMH (prior medical history) of [MEDICAL CONDITION], Post Epileptic Paralysis, [MEDICAL CONDITION], and Dementia with Behavioral Disturbance. Today's visit is medically necessary to evaluate pt. (patient) after he was taken to the hospital over the weekend. Staff reported that over the weekend pt. had a grand mal [MEDICAL CONDITION] that would not stop with IM [MEDICATION NAME]. The ambulance was called, and pt. was taken to the ER for evaluation. Pt just saw his neurologist last week and [MEDICATION NAME] level was increased. Staff reports that pt. was not receiving his ordered dose of the medication. Pt was cleared and brought back to the facility. Staff reports that he has a fever, which could have been caused by the [MEDICAL CONDITION]. Pt seen in his room, at bedside. He is not cooperative at this time. He will not let staff take a temperature. He does not want to take his meds. He asked me to, 'leave him alone'. Pt choosing not to participate in ROS (review of symptoms) . r. On 10/25/19 at 12:22 p.m., LPN #2 was asked about the order changes for Resident #1 on 9/12/19 and stated, On 9/12/19, I went to the doctor with (Resident #1), his [MEDICATION NAME] order was changed to 1500 mg BID, and they didn't want his [MEDICATION NAME] levels monitored past increasing the medication. I called (LPN #1) from the doctor's office waiting room. (LPN #1) told me the order was in. On Monday, I discovered the resident had a [MEDICAL CONDITION] over the weekend. Pharmacy said they did not receive the new order. Resident missed 2 doses on Saturday and 1 dose on Sunday; as he was leaving to go to the hospital his medication had arrived from the pharmacy. s. On 10/25/19 at 12:29 p.m., LPN #3 was asked about the order changes for Resident #1 on 9/12/19 and stated, On Saturday when I came to work, he did not have the changed dosage of [MEDICATION NAME], I called the pharmacy and, they said they were not going to send it because it was sent with change out. I searched the facility and could not find it. I searched again for the pm (evening) dose and was unable to find it; another staff member assisted me, and we could not find it. On Sunday it was not available; it had not been delivered by pharmacy. I called the pharmacy and got them to send the stat dose, I searched the facility again, but it was not available. A CNA found the resident having a [MEDICAL CONDITION] and he was sent out to the ER. I did not notify anyone of the medication not being delivered. I did call the pharmacy. Since then we have received an In-service regarding when medication is not available to call the DON. t. On 10/25/19 at 1:15 p.m., the resident was in bed, watching television. He was asked if there were any problems or concerns and stated, that he has not had any problems with [MEDICAL CONDITION] since his medicine was changed out and that it had been a while since he had a [MEDICAL CONDITION]. He also stated that he gets his medicine and has had no problem with getting it. u. The facility removed the immediate jeopardy and corrected the failed practices on 9/16/19, as evidenced by the following: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS (Department of Medical Services)- 762) dated 9/16/19 documented, .While reviewing nursing documentation, it was noted that on Saturday, 9/14/2019 and Sunday 9/15/2019, (Resident #1) did not receive his [MEDICATION NAME], per MD (Medical Doctor) order, due to pharmacy error . Findings and Actions Taken .Began obtaining witness statements from staff with any knowledge of why the medication wasn't given. Began obtaining statements from alert and oriented residents as to having not received medications per doctors' orders, to which there were no negative findings. Began re-educating nursing staff regarding notification to immediate supervisor if medications that have been ordered from the pharmacy are not here in a timely manner. Nurse who were directly involved were re-educated 1:1 (one-on-one) . 9/12/2019 - 11:35 AM. A new order was received per MD to increase (Resident #1) [MEDICATION NAME] from 500 mg twice daily to 750 mg give two tablets to equal 1500 mg twice daily. At 11:38 AM order was sent and received by Pharmacy. (Resident #1) had already received his 8 AM (8:00 a.m.) 500 mg dose of [MEDICATION NAME] on this date. Per Pharmacy's contract, the medication should have arrived at 1700 (5:00 p.m.). The medication did not arrive, therefore, the LPN (Licensed Practical Nurse) (her 2nd day), gave 2-500 mg tablets . 9/13/2019 - The 6 AM (6:00 a.m.) - 2 PM (2:00 p.m.) nurse noted that the correct dosage of [MEDICATION NAME] had still not arrived from pharmacy. She popped the remaining 2-500 mg tabs from the 0800 (8:00 a.m.) card plus 1-500 mg tab from the 1700 card to equal 1500 mg. She phoned pharmacy again who stated that the new medication would be arriving on this date. Change out medications had arrived on 9/9/2019, which contained the 500 mg tablets of [MEDICATION NAME]. Change out is scheduled to be completed on 9/14/2019. The 6-2 (day shift) LPN, in an effort to help the weekend staff, went through the change out container and returned medications to pharmacy that had been changed or discontinued per MD order. This included the 500 mg tablets of [MEDICATION NAME]. The 2 PM-10 PM (evening shift) LPN, gave 3-500 mg tablets of [MEDICATION NAME] to equal 1500 mg at the 1700 medication pass .09/14/2019 - LPN, having no knowledge of the events of the previous 2 days, contacted pharmacy regarding the [MEDICATION NAME] not being delivered. Pharmacy refused to send medication, stating that the medication had been delivered with change out. (Resident #1) did not receive any [MEDICATION NAME] on this date, as there was none in house ordered for him . 9/15/19 - 1000 (10:00 a.m.) LPN contacted pharmacy again in an attempt to obtain medication. Pharmacy stated that the medication would be sent as a stat since dosage increase had been ordered on [DATE]. At 1253 (12:53 p.m.), resident was found to be in bed convulsing with pink sputum on face and linens. He received 1 mg [MEDICATION NAME] IM, per MD order. (Emergency Medical Transport) was contacted at 1255 (12:55 p.m.) and resident exited the facility at 1300 (1:00 p.m.) with EMS. 1425 2:45 p.m.) stat delivery of [MEDICATION NAME] 750 mg arrived from the pharmacy. 1545 (3:45 p.m.) received call from hospital stating that resident was returning to the facility. Returned at 1635 (4:35 p.m.). Attempted to administer 2 tablets 750 mg [MEDICATION NAME] to equal 1500 mg, resident difficult to arouse enough to swallow . 9/16/2019 - 0800 (8:00 a.m.) dosage of [MEDICATION NAME] was refused by resident, however he has taken it since then. Per hospital recommendations, [MEDICATION NAME] was discontinued secondary to drug interaction with [MEDICATION NAME]. Have attempted to obtain [MEDICATION NAME] levels in the past, to which resident refuses and is often non-complaint with medications. (Resident #1) continues at baseline. He participates in self-directed activities of choice and receives meals in his room per preference . An Action Plan has been developed to include: The DON (Director of Nursing) / Designees will monitor daily for 2 weeks, 3 x a week for 2 weeks or until compliance is achieved. Staff education regarding notification of administration when meds (medications) are not received in a timely manner. Staff education on importance of utilizing the 24 - hour report for communication/follow up. Will review all new orders each morning. Check med cart to ensure that new medications are available on cart and that old med's have been removed. Re-educate staff regarding the change out process . 2.) On 10/25/19 at 12:52 p.m., was asked about the facility's corrective actions and monitoring and stated, On 9/16/19, an Action Plan/ Monitoring was put into place . we discovered the concern, we in-serviced the nurses, implemented an Action plan, we are monitoring new orders daily at this time. All anti-[MEDICAL CONDITION] medications are checked for availability. 3.) On 10/25/19 at 1:26 p.m., the Nurse Consultant (NC) was asked about the corrective actions that were taken as a result of the medication issues for Resident #1. The NC stated, After discovery, when I was notified of the incident regarding [MEDICATION NAME], we initiated an investigation. I spoke with the DON and ADON (Assistant DON) to see if the nurses were signing the doses out. It led me to believe they were using the change out cards to administer the medication. The change out medications had not been picked up. We started to in-service the nurses and monitoring. i.) An Action Plan provided by the DON on 10/25/19 at 10:30 a.m. documented, 9/16/19 . Problem Identified - Resident did not receive medication per MD orders . Goal - Residents will receive medications per MD orders in a timely manner .Action Plan - Will review all new orders each morning .Monitor daily for 2 weeks, 3 x week for 2 weeks or until compliance is achieved . Check med cart to ensure that new medications are available on cart and that old meds have been removed . Staff education regarding notification of Administration when meds are not received in a timely manner .Staff education on importance of utilizing the 24-hour report for communication/follow up . Person Responsible - DON/Designee . Completion of Actions - 9/16/19 . ii.) An In-Service titled Medication Notification dated 9/16/19 for LPNs #1 and #2 documented, .Any time that you do not have a medication in your cart that you are scheduled to administer. You must notify your DON/ADON immediately . iii.) The 1:1 retraining forms dated 9/20/2019 for LPN #1 and LPN #3 documented, .If pharmacy has been notified of any new orders and they have not been received at the facility within 24 hours, it is my responsibility to make my supervisor aware in order to find another avenue to receive the medication . Additionally, the 1:1 retraining form dated 9/20/19 for LPN #1 documented, .I understand that I must receive a physician's orders [REDACTED]. iv.) As of 10/25/19, the facility's Action Plan Monitoring tool documented ongoing monitoring had been conducted from 9/16/2019 through 10/11/19 and identified no further issues with medication compliance. v.) On 10/25/19 at 12:30 p.m., the surveyor conducted a reconciliation with LPN @1 of the resident's medication for [MEDICAL CONDITION], [MEDICATION NAME] Capsule 100 milligrams (mg) Capsule, [MEDICATION NAME] Tablet 750 mg, and [MEDICATION NAME] XR tablet Extended Release 400 mg and all medication were available for administration.

Complaint # (AR 652) was substantiated, all or in part, with F689 cited. Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to a resident who was noncompliant with the smoking policy, as evidenced by failure to develop and implement interventions to ensure the resident did not smoke unsupervised and with his oxygen in use, to prevent a serious accident with injury for 1 (Resident #1) of 3 (Residents #1, #2 and #4) case mix residents who smoked and had a physician's orders [REDACTED].#1, who had repeatedly exhibited a behavior of unsupervised smoking while wearing his oxygen, which resulted in the resident experiencing second [MEDICAL CONDITION] his hands, face, mouth, lips and intranasal area. The resident subsequently expired four days after this incident. The failed practice also had the potential to cause more than minimal harm to 5 residents who smoked and had physician orders [REDACTED]. 1. The facility's Smoking Policy documented, It is the policy of (nursing facility) to promote the independence of its residents in all activities of their daily living while ensuring a safe environment for all. Procedure: All residents that wish to smoke while residing at (nursing facility) will be assessed for their ability to smoke safely. If the assessment reveals resident can smoke safely, the resident will not be required to wear a smoking apron unless they so desire. If the assessment reveals resident is unable to smoke safely, the resident will be required to wear a smoking apron for safety. Lighters, matches or any other igniting materials will be maintained by facility staff and lighting of any type of smoke will be provided to those residents during scheduled smoke times by the staff. Residents have the option to smoke with family members or responsible parties during personal visits if so desired. Residents will smoke in designated smoke area only. Resident smoking assessments will be completed upon admission, quarterly and following any significant change in condition . It is the responsibility of all employees to follow the smoking safety and assessment policies, to monitor smoking safety practices of residents and to intervene appropriately to keep residents safe . The facility will attempt to accommodate those residents who desire to smoke; however, the facility's primary obligation is to the safety of the facility. Therefore, any resident or visitor who does not comply with the facility's rules regarding smoking may be asked to restrict or forfeit smoking or visiting privileges. If the danger or lack of compliance is serious enough, it may warrant discharge in accordance with state and federal law . 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 14 (,[DATE] indicates cognitive independence) on the Brief Interview for Mental Status (BIMS), had no behaviors, required only supervision with most activities of daily living, and received oxygen therapy. a. A physician's orders [REDACTED]. b. A Nursing Note dated [DATE] at 10:58 p.m. documented, Resident outside of 5 hall smoking a cigarette with his O2 (oxygen) on at 3 liters via nasal cannula. Informed resident that he could not have O2 on while smoking. Resident stated that oxygen is not flammable. Informed resident that oxygen is flammable and that he has been spoken to before about smoking with O2 on. Resident turned off and stated if something happened to him because he did not have on his oxygen, he would have my job. Informed resident that I was doing my job. Will continue to monitor. c. A Social Note dated [DATE] at 8:38 a.m. documented, Spoke with resident on [DATE]. Has history and current behavior of smoking with oxygen on. Has been redirected and care conferences have been held with resident and brother in law about this issue. Lighters have been confiscated. Resident continues to do this. Social spoke with resident about issue. That oxygen must be removed before he can smoke due to safety of himself and others. Resident stated understanding. Social stressed to resident that if this continued, he would be issued a discharge. Resident stated understanding. d. A Nursing Note dated [DATE] at 4:27 p.m. documented, Resident caught outside once again smoking with O2 on. Resident has been told several times not to smoke with O2 on but continues to do so. e. A Nursing Note dated [DATE] at 4:13 p.m. documented, 0415 (4:15 a.m.) Resident found outside this a.m. in smoking area with small portable O2 concentrator on and smoking. When this nurse confronted resident, states 'Oxygen is not flammable. You people don't know what the (expletive) you are talking about.' Lighter taken from resident and locked up in med (medication) cart. Resident states he will not smoke anymore with it on and states 'this is bull (expletive)you people don't know (expletive).' Administration made aware of this incident. f. An MDS Progress Note dated [DATE] at 2:37 p.m. documented, Care plan meeting with (Resident #1) and the IDT (Interdisciplinary Team). (Resident #1) states that he has no complaints or concerns. He is doing better with smoking, he only smokes occasionally now . g. A Nursing Note dated [DATE] at 2:31 a.m. documented, ,[DATE] on ,[DATE] (6:00 a.m. to 2:00 p.m.) shift, responsible party present, gave this nurse a lighter and stated resident was trying to light cigarette in room. Unaware where resident got lighter and he states he doesn't remember. Re-educated resident that he cannot smoke in room and with oxygen. States I forgot where I was. h. The Care Plan dated as reviewed [DATE] documented in the Problem section, (Resident #1) is a routine smoker. He also uses O2 via cannula . (Resident #1) refuses to be compliant with smoking policy. Refuses to give up his lighter, refuses to remove O2 and becomes aggressive with staff when attempting to remove his O2 and take his lighters. States that he will sue and call the police. He will sneak out and smoke alone and go out with other family members and smoke. The Approaches/Tasks section documented, Continue to encourage to remove O2 prior to smoking. Date initiated: [DATE]. Monitor when smoking. Date initiated: [DATE]. Remind (Resident #1) to remove O2 when smoking. Date initiated: [DATE]. When he is not in his room search for him, and if he is out smoking, turn off his O2 and bring him back inside. If he refuses to come inside, remove his oxygen off the back of his chair. Date initiated: [DATE]. Remind (Resident #1) to smoke in designated smoke area at all times. Date initiated: [DATE]. i. The Quarterly MDS with an ARD of [DATE] documented the resident scored 10 (,[DATE] indicates moderate cognitive impairment) on the BIMS, had verbal behavioral symptoms directed toward others, required extensive assistance from staff for most activities of daily living, and received oxygen therapy. j. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. Resident requires supervision . k. A Behavior Note dated [DATE] at 3:38 p.m. documented, Resident went out to smoke a second time, pushing the door open on his own after coming in from smoking. Resident was wearing his O2 and while attempting to light his cigarette the CNA (Certified Nursing Assistant) assigned to that smoke break said let's turn your O2 off. At that time, resident swung elbow back attempting to hit CNA while saying 'you bastard'. CNA notified head CNA of incident; the head CNA brought resident inside to talk with a staff member. This staff member explained to resident that he is unable to smoke while wearing his oxygen. Resident stated that oxygen was not flammable. Resident remained upset after explanation and education of why oxygen cannot be on while smoking. Resident wanted proof that oxygen is flammable. Resident calmed down somewhat however insisted that oxygen is not flammable. Will continue with current P[NAME] (plan of care) and observation while resident smokes. l. A Behavior Note dated [DATE] at 6:22 p.m. and written by Registered Nurse (RN) #1 documented, Resident caught in room smoking cigarette. Lighter taken from resident at this time. Discussed with resident that he was not allowed to smoke in room at any time and that if behavior continued, he was in jeopardy of being removed from home. Called and discussed situation with POA (Power of Attorney), ADON (Assistant Director of Nursing) and DON (Director of Nursing). m. A Nursing Note dated [DATE] at 6:04 p.m. documented, 1340 (1:40 p.m.) (family member) standing outside 5 hall door and yelled help. Staff began to run out 5 hall and (family member) states he is on fire. Resident was not on fire. Resident sitting bent over in manual wheelchair. I called his name he responded and told me he was hot. I raised his head, soot noted to nasal, mouth, and palm of hands; he was pushed to his room, oxygen at 3 lpm (liters per minute) applied via nasal cannula, updraft administered. Vitals ,[DATE], hr (heart rate)-80, unable to obtain respiration. Resident mumbling, instructed resident to breathe. Removed resident's shirt no lighter found. Cold towels draped over head/facial area, and both hands. 1342 (1:42 p.m.) staff notified 911, 1350 (1:50 p.m.) life net arrived . n. The Hospital Emergency Department (ED) Provider Notes dated [DATE] documented, .presents with a chief complaint [MEDICAL CONDITION] the face and hands. Patient reportedly lit a cigarette while using his nasal cannula and this resulted in flames to the face. This included the mouth and lips as well as the intranasal area. He also [MEDICAL CONDITION] the left side of his face and ear. [MEDICAL CONDITION] to the fingertips of the fingers. Patient is reportedly on outpatient hospice due to [MEDICAL CONDITION] . Patient is complaining of pain to the face as well as shortness of breath. No other history available as patient is not speaking that much . Burn quality: Black, intact blister, red and painful . He appears distressed . Second [MEDICAL CONDITION] the upper lip and lower lip. There is soot that goes into both nostrils with [DIAGNOSES REDACTED]. There is soot and [DIAGNOSES REDACTED] within the oral cavity itself. There are second degree [MEDICAL CONDITION] the left ear and left lateral cheek area . He is in respiratory distress . There is a mixture of first and second [MEDICAL CONDITION] the fingertips of the index and thumb fingers . Summary Statement: . Patient's pH (power of hydrogen) is down to 7.0 and his PCO2 (partial pressure of carbon [MEDICATION NAME]) is over 100. Given this fact, I do think that he will most likely expire if he does not get mechanical ventilation. Both patient and family understand this. Given his injuries and his worsening respiratory status, family has requested in patient hospice care . 3. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitive independence) on the BIMS, had no behaviors and required limited assistance with most activities of daily living. a. The Care Plan with a review date of [DATE] documented in the Problem section, Smoker: Potential for injury R/T (related to) being a smoker . He refuses to give staff his lighter. He is safe to smoke with supervision of family and staff. The Approaches/Tasks section documented, Keep lighter and cigarettes at nurse's station. Date Initiated: [DATE]. Requires supervision when smoking. Date Initiated: [DATE]. Smoke only in designated area. Date Initiated: [DATE]. Redirect when resident is inappropriate in smoking area. Date Initiated: [DATE]. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 2:20 p.m., Resident #2 was observed in a w/c (wheelchair) in his room. He was asked about the incident in the smoking area on [DATE]. He stated, This man (Resident #1) has been lighting his cigarettes for a long time. Several times, and he's got a tank on his chair. And he's been told several times not to do it. I was outside with my daughter under the canopy, and he was by the door. He started screaming, and my daughter ran to him to put it out. I know the rules and I signed the agreement. I know you're not supposed to smoke with O2 on. They have been picking the lighters up, but people keep breaking the rules. People find out the code and go outside. You can't stop people from smoking if they want to smoke. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively independent) on the BIMS, had no behaviors and required extensive assistance with most activities of daily living. a. The Care Plan dated as reviewed [DATE] documented in the Problem section, Smoking Safety. With staff supervision. Date Initiated: [DATE]. Revision on: [DATE]. The Approaches/Tasks section documented, Educate resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: [DATE]. Ensure oxygen canisters/concentrators are not present when resident is smoking. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 1:05 p.m., Resident #3 was asked about the incident that happened out in the smoke area on [DATE] and stated, We were out smoking, and I was sitting next to (Resident #1) talking. I looked over there, and he was lighting a cigarette off another one, and fire shot out his nose. I hollered for help and so did a family member. He was asked, Do you know where (Resident #1) got the cigarette to light his? He stated, He had just smoked one and used that. They have told him a dozen times not to come out there with his O2 on. He was asked, Has the staff informed you and the other smokers not to go out and smoke without staff supervision? He stated, Yes, they have, but some of the people know the codes to get out the door. I used to. He was asked, Who opened the door to let them out last Friday when this happened? He stated, I don't know. Now they make sure a CNA is out there, and no one gets out, because the code changed. He was asked, Could other residents go out and smoke whenever they wanted before this incident? He stated, No, but people did anyway. 5. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 on the BIMS, had no behaviors and required extensive assistance with most activities of daily living. a. The Care Plan dated as reviewed [DATE] documented in the Problem section, Smoking Safety. Date Initiated: [DATE]. The Approaches/Tasks section documented, Assist (Resident #4) as needed for smoking to assist with anxiety control. Date Initiated: [DATE]. Educate resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: [DATE]. Ensure oxygen canisters/concentrators are not present when resident is smoking. Date Initiated: [DATE]. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 1:25 p.m., Resident #4 was asked about the incident that occurred in the smoke area on [DATE] and stated, I didn't see nothing. Me and (Resident #3) were out there, and (Resident #2) and his daughter were sitting around the corner. Next thing I know, I heard someone yelling, 'help, help'. (Resident #2's daughter) jumped up and ran around there and yelled, 'he's on fire'. She beat on the door, and they came out. The man . he was a butt. He would turn his own O2 up or down whenever and do it when he was smoking. You couldn't tell him nothing. What they should have done was not allow anyone out that door who was on O2. He was asked, How did you get out the door? He stated, I don't know. I knew the code. (Resident #1) knew the code. I've seen him kick the door open. Only certain people can go out and smoke whenever. I can. I could before this, anyway. He knew he wasn't supposed to do that. He wasn't stupid. I think when (Resident #1) gets back, I'm gonna beat the hell out of him for this. 6. On [DATE] at 3:15 p.m., LPN #1 was asked what happened with Resident #1 on [DATE] and stated, I was at the nurse's station on the computer. I heard someone yell. I looked down 500 hall and saw (family member) and she said 'help, he's on fire!' I took off running. I went out the door, and (Resident #1) was to my left as I went out. (Resident #3) was to my right. I grabbed him and pushed him back into his room. I yelled to get cold towels and had them call 911, got vital signs . She was asked who was out in the smoking area when this happened and stated, (Resident #2) and his daughter, (Resident #4) and (Resident #3). She was asked why there was no staff in the smoking area at that time and stated, Because smoke break was over. They are taken out at 1, and they have 15 minutes or 2 cigarettes, then they come back in. She was asked if it was okay for any of the residents to go out and smoke unsupervised. She stated, Since I've been here, they've been doing that. It's my understanding that if a resident is capable of letting themselves out and back in, then they can go out and smoke unsupervised. That's how it's always been. For (Resident #3), he cannot get out by himself, so someone had to let him out. (Resident #1) . sometimes he can get out by himself, sometimes he can't. It depends on his strength that day. She was asked if it was okay for Resident #1 to go out and smoke without supervision if he could let himself out. She stated, No, it wasn't, because he knew he wasn't supposed to go out, because he had O2. He had been reprimanded several times about that. She was asked if Resident #1 could comprehend what people were telling him and stated, Yes, he could. She was asked which residents were able to go out whenever they wanted to smoke unsupervised. She stated, (Resident #4) and (Resident #3). Those two can go whenever they want. They're not supposed to have a lighter, but that's been a problem. I asked (Resident #1) at the hospital how he got outside and who lit his cigarette and he wouldn't answer. He could answer any other questions, but not those. She was asked if it was possible that Resident #1 knew the door code. She stated, Now that, I don't know. She was asked if she was ever instructed to increase the monitoring or supervision for Resident #1 because of his behavior of smoking with his O2 on. She stated, Absolutely not. 7. On [DATE] at 12:25 p.m., CNA #1 was asked if she had ever provided care to Resident #1 and stated, Yes. I took care of him last Thursday night on 10 to 6 (10:00 p.m. to 6:00 a.m. shift). (Resident #1) was an easygoing guy. Never complained to me. She was asked about his cognitive status and whether he was capable of understanding what she told him. She stated, To me, yes. He didn't seem confused. She was asked if she had ever taken him out to smoke and stated, Yes. We have assigned smoke breaks. Whenever I would take him out to smoke, I would make sure his O2 was off. She was asked what she meant by that and stated, Like turned off. She was asked, Did his O2 tank still be stay on his wheelchair? She stated, Sometimes, yes. She was asked, Did you if she had ever seen him with a lighter? and she stated, No. She was asked, Did you if she had ever see him outside smoking without staff present? She stated, When he first came, I did, but not lately. She was asked, Do if there were any of the residents here who go out and smoke on their own, without staff supervision? She stated, They're not here anymore. She was asked, Do you know if she knew (Resident #1) had been recently caught in his room smoking? She stated, No. She was asked, Do you know if there had been if she knew of any increased supervision or monitoring done for (Resident #1) due to his behavior of smoking with his O2 on? She stated, Not that I know of. 8. On [DATE] at 12:39 p.m., CNA #2 was asked about Resident #1 and stated, He was as sweet as he wanted to be, but he was gonna do what he wanted to do. He never said an ill word toward me. He wanted to smoke, and he loved his gold. Gold watches, rings, etc (et cetera). She was asked if she had ever taken Resident #1 and the other residents out to smoke and stated, Yes, I have. I took the residents out to smoke last Friday, the 22nd, at the 645 (6:45 a.m.) break. I worked the hall and was (Resident #1's) CNA that day. He did not go out for that smoke break. She was asked, Where were you she was when this incident occurred? She stated, I was changing a resident, and when I came out of the room, I saw everybody running out the door, so I ran too. They grabbed him and pulled him inside. I was holding a cold wet towel on his face while they were giving him oxygen. Now I've quit smoking because of this. Smoking was his joy. She was asked, Did you ever see (Resident #1) outside smoking without staff supervision and with his O2 on? She stated, There are several of them that get out without staff, so we have to go out and bring them back in. They also know they can push on the door for 15 seconds and it will open. She was asked, Did you ever have to go outside and get the residents who were smoking and bring them back in because there was no staff with them? She stated, Yes. She was asked, Was if (Resident #1) one of them? She stated, Yes, he was. She was asked, Was he using his O2 at that time? She stated, Yes, he was. She was asked, What has been done to prevent residents from going out to smoke, unsupervised? She stated, There have been in-services with the residents, we have done lighter round-ups and the door codes are changed. She was asked, Were you ever instructed to increase the monitoring/supervision on (Resident #1), due to his known behavior of smoking with his O2 on? She stated, I personally have never been told to keep a closer eye on him. She was asked, Are there any residents here who go outside and smoke whenever they want, without staff supervision? She stated, (Resident #5) will get the code and his wife will bring him a lighter, even though she knows not to, and he goes out whenever he wants, ,[DATE]. She was asked, Do you know if (Resident #1) had recently been caught smoking in his room? She stated, Yes, I am aware of that. She was asked, Do you know if (Resident #1) understood when he was being told not to smoke with the O2 on? She stated, Yes, he understood. She was asked, Had there been a recent time that you had to go outside and get (Resident #1) to and bring him back inside because there was no staff with him? She stated, It's been in the past month. 9. On [DATE] at 1:41 p.m., CNA #3 was asked about Resident #1 and stated, He was kind of goofy. He joked a lot. He was pretty easygoing to me. She was asked if he liked to go out and smoke and stated, He didn't go out too often, but here lately, he was going out more than normal. She was asked, Have you ever taken the residents out to smoke? She stated, Yes. I have taken them out to smoke, including (Resident #1). I wouldn't let him go smoke with his O2. She was asked if there were any residents who could go out and smoke whenever they wanted, without supervision. She stated, We do have a resident who knew the code, (Resident #4), and he would occasionally let people out. (Resident #5) goes out whenever he wants. Before this incident, (Resident #5) was allowed to keep his own lighter and cigarettes. I've never known (Resident #1) to have his own lighter. She was asked, Did you know if (Resident #1) had been caught smoking in his room a week ago? She stated, No, I didn't. She was asked, Do you know if the facility implemented any increased monitoring for (Resident #1) due to his behavior of smoking with his O2 on? She stated, No. Sorry, but no. 10. On [DATE] at 2:09 p.m., CNA #4 was asked if she had ever known of Resident #1 to smoke in his room. She stated, I've never caught him smoking in his room. I've seen him with a lighter, but we get them as soon as we see it. She was asked, Were you ever instructed to increase the monitoring or supervision for (Resident #1) due to his behavior of smoking with his O2 on? She stated, No. She was asked, Do you know if (Resident #1) was capable of understanding instructions when you told him? She stated, I think so. She was asked, Were there any interventions implemented before this incident to prevent an accident in the smoke area? She stated, There's always someone present on the smoke break. There's a door code and it changes often. Lighters are taken. The family members know not to bring lighters, but they do it anyway. Since the incident, we keep the cigarettes and lighters. They are all veterans, and they say they know their rights and that we are stealing from them and such. 11. On [DATE] at 2:26 p.m., RN #1 was asked about the incident on [DATE] when (Resident #1) was caught smoking in his room. She stated, (CNA #5) was walking down the hall and smelled smoke and she came and told me about it. I went down there and took his stuff and explained to him he could not smoke with O2 in the room or outside with it. She was asked, Did if he still have his cigarette lit when she you went into the room? She stated, I think (CNA #5) had put the cigarette out. She was asked, Was if this was something the (Resident #1) did frequently? She stated, This is a conversation we have with him daily. Not that he's been caught daily, but he's adamant that O2 won't blow up. She was asked, Do you know if the supervision or monitoring for him was increased after that incident, since his behavior of smoking with O2 on placed him at high risk for an accident? She stated, We were doing hourly monitoring on the smokers over the weekend, but on (Resident #1) . Not that I know of. She was asked, What kind of interventions were being done prior to the incident to prevent this kind of thing from happening? She stated, We've taken lighters and cigarettes, we do the smoking assessment, and the door code was changed frequently. She was asked, What type of interventions have been implemented since the incident? She stated, Everything is locked up, cigarettes and lighters. We are doing hourly checks on the smoke area to ensure no one is out there, the door code was changed, and it's not being given out. 12. On [DATE] at 2:46 p.m., CNA #5 was asked about the evening when (Resident #1) was caught smoking in his room. She stated, I was passing by and smelled cigarette smoke and I walked past, and (Resident #1) was smoking. I went in and put his cigarette in a plastic cup and took it to show the nurse. She was asked, Did (Resident #1) have his O2 on when he was doing this? She stated, Yes. That was the first time I'd seen him smoking in his room. I have known him to have lighters, and when he wouldn't give them to me, I would go tell the nurse. She was asked, if she Have you ever taken the residents out to smoke? She stated, Yes, and I have taken (Resident #1) out to smoke, but we would leave his O2 in his room. She was asked, Were you ever instructed to increase the monitoring of (Resident #1) due to his behavior of smoking with his O2 on? She stated, I've been told to watch him because of his smoking, but not like a specific time frame, or to document it. She was asked, Do you know if he was capable of understanding what people were telling him? She stated, Yes. She was asked if there were any residents who went out to smoke on their own and stated, (Resident #4) and (Resident #5). They kept their own smokes and lighters. She was asked what kind of interventions were being done prior to the incident to prevent Resident #1 or other residents from going out to smoke unsupervised. She stated, Just go with them. Since Friday, the code hasn't been given out. 13. On [DATE] at 3:50 p.m., the Director of Nursing (DON) was asked about Resident #1 and stated, I know he was a smoker and that he would demand to go out with his O2 on and we would have to re-educate. She was asked if she knew he had been caught smoking in his room one week prior to the incident on [DATE]. She stated, (RN #1) called me on the 15th. I told her to confiscate the lighter and call his POA and tell him to talk to him and to not be bringing any lighters up here. I told him if he was caught again, he could be removed from the facility, because it violates the rules. She was asked, How to do you prevent a resident who is noncompliant from doing something like this? She stated, Change the door codes, make sure he only goes out with staff. She was asked if the facility had implemented any increased monitoring or supervision due to Resident #1's behavior of smoking with his O2 on. She stated, I'm sure they've probably been told to watch him more closely, but as far as documentation, not that I know of. She was asked if Resident #1 and other smokers' noncompliance with the smoking policy had been discussed in quality assurance (QA) meetings and stated, I've been in one QA meeting since I've been here, and I don't remember that. She was asked if there were any residents who went out to smoke without supervision. She stated, There shouldn't be anybody. Since I've been here, they're supposed to be supervised. 14. On [DATE] at 8:19 a.m., the Social Director was asked, Did you have any interactions with (Resident #1)? She stated, About (MONTH) or so of last year, we had an issue with him going out to smoke with his O2 on. We had a care plan meeting with him and his POA. We tried to find placement for him and couldn't. He stopped smoking for a while, maybe a month or 2, but then started back. She was asked, Had if his smoking been an issue lately? She stated, Since last June, as far as I know, he was easily redirected until recently, when his cognitive status was sort of declining. We have had care plan meetings with his POA but not about smoking, because it had gotten better. She was asked if there were any residents who went out to smoke whenever they wanted, without staff supervision. She stated, Some of the smokers who are more cognitive, it's an ongoing issue. Family members bring lighters, we change the code, they push the door for so long, and it opens . She was asked if the facility had implemented any increased monitoring for Resident #1, due to his behavior of smoking with his O2 on. She stated, Not that I know of. 15. On [DATE] at 9:12 a.m., Maintenance Employee #1 was asked how often he changed the door code for the door that led to the smoking area. He stated, (MONTH) of last year, I came out here and changed it, and then it was changed again within a week. He was asked, Why was it changed again so soon? He stated, My guess is that someone discovered the code, and then this past Friday, ,[DATE], I was on the way to Memphis, and they called me asking how to change it. He was asked, Had if the door code been changed between (MONTH) of last year and [DATE]? He stated, Well, I wasn't over this building until January, so if it was changed after (MONTH) of last year, I wouldn't know about that. He was asked, Do you know who was in charge of maintenance during that time? He provided the name of the previous maintenance employee. He was asked, Who is capable of changing the code? He stated, Before Friday, I was the only one who knew how to change it. That's why they called me

Complaint # (AR 652) was substantiated, all or in part, with F689 cited. Based on observation, record review and interview, the facility's Quality Assessment and Assurance (QA) Committee failed to identify an ongoing problem with resident noncompliance with the facility smoking policy, which resulted in a failure to develop and implement interventions to ensure a resident did not smoke unsupervised and with his oxygen in use, to prevent a serious accident with injury for 1 (Resident #1) of 3 (Residents #1, #2 and #4) case mix residents who smoked and had a physician's orders [REDACTED].#1, who had repeatedly exhibited a behavior of unsupervised smoking while wearing his oxygen, which resulted in the resident experiencing second [MEDICAL CONDITION] his hands, face, mouth, lips and intranasal area. The resident subsequently expired four days after this incident. The failed practice also had the potential to cause more than minimal harm to 5 residents who smoked and had physician orders [REDACTED]. 1. The facility's Smoking Policy documented, It is the policy of (nursing facility) to promote the independence of its residents in all activities of their daily living while ensuring a safe environment for all. Procedure: All residents that wish to smoke while residing at (nursing facility) will be assessed for their ability to smoke safely. If the assessment reveals resident can smoke safely, the resident will not be required to wear a smoking apron unless they so desire. If the assessment reveals resident is unable to smoke safely, the resident will be required to wear a smoking apron for safety. Lighters, matches or any other igniting materials will be maintained by facility staff and lighting of any type of smoke will be provided to those residents during scheduled smoke times by the staff. Residents have the option to smoke with family members or responsible parties during personal visits if so desired. Residents will smoke in designated smoke area only. Resident smoking assessments will be completed upon admission, quarterly and following any significant change in condition . It is the responsibility of all employees to follow the smoking safety and assessment policies, to monitor smoking safety practices of residents and to intervene appropriately to keep residents safe . The facility will attempt to accommodate those residents who desire to smoke; however, the facility's primary obligation is to the safety of the facility as a whole. Therefore, any resident or visitor who does not comply with the facility's rules regarding smoking may be asked to restrict or forfeit smoking or visiting privileges. If the danger or lack of compliance is serious enough, it may warrant discharge in accordance with state and federal law . 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 14 (,[DATE] indicates cognitive independence) on the Brief Interview for Mental Status (BIMS), had no behaviors, required only supervision with most activities of daily living, and received oxygen therapy. a. A physician's orders [REDACTED]. b. A Nursing Note dated [DATE] at 10:58 p.m. documented, Resident outside of 5 hall smoking a cigarette with his O2 (oxygen) on at 3 liters via nasal cannula. Informed resident that he could not have O2 on while smoking. Resident stated that oxygen is not flammable. Informed resident that oxygen is flammable and that he has been spoken to before about smoking with O2 on. Resident turned off and stated if something happened to him because he did not have on his oxygen, he would have my job. Informed resident that I was doing my job. Will continue to monitor. c. A Social Note dated [DATE] at 8:38 a.m. documented, Spoke with resident on [DATE]. Has history and current behavior of smoking with oxygen on. Has been redirected and care conferences have been held with resident and brother in law about this issue. Lighters have been confiscated. Resident continues to do this. Social spoke with resident about issue. That oxygen must be removed before he can smoke due to safety of himself and others. Resident stated understanding. Social stressed to resident that if this continued, he would be issued a discharge. Resident stated understanding. d. A Nursing Note dated [DATE] at 4:27 p.m. documented, Resident caught outside once again smoking with O2 on. Resident has been told several times not to smoke with O2 on but continues to do so. e. A Nursing Note dated [DATE] at 4:13 p.m. documented, 0415 (4:15 a.m.) Resident found outside this a.m. in smoking area with small portable O2 concentrator on and smoking. When this nurse confronted resident, states 'Oxygen is not flammable. You people don't know what the (expletive) you are talking about.' Lighter taken from resident and locked up in med (medication) cart. Resident states he will not smoke anymore with it on and states 'this is bull (expletive)you people don't know (expletive).' Administration made aware of this incident. f. An MDS Progress Note dated [DATE] at 2:37 p.m. documented, Care plan meeting with (Resident #1) and the IDT (Interdisciplinary Team). (Resident #1) states that he has no complaints or concerns. He is doing better with smoking, he only smokes occasionally now . g. A Nursing Note dated [DATE] at 2:31 a.m. documented, ,[DATE] on ,[DATE] (6:00 a.m. to 2:00 p.m.) shift, responsible party present, gave this nurse a lighter and stated resident was trying to light cigarette in room. Unaware where resident got lighter and he states he doesn't remember. Re-educated resident that he cannot smoke in room and with oxygen. States I forgot where I was. h. The Care Plan dated as reviewed [DATE] documented in the Problem section, (Resident #1) is a routine smoker. He also uses O2 via cannula . (Resident #1) refuses to be compliant with smoking policy. Refuses to give up his lighter, refuses to remove O2 and becomes aggressive with staff when attempting to remove his O2 and take his lighters. States that he will sue and call the police. He will sneak out and smoke alone and go out with other family members and smoke. The Approaches/Tasks section documented, Continue to encourage to remove O2 prior to smoking. Date initiated: [DATE]. Monitor when smoking. Date initiated: [DATE]. Remind (Resident #1) to remove O2 when smoking. Date initiated: [DATE]. When he is not in his room search for him, and if he is out smoking, turn off his O2 and bring him back inside. If he refuses to come inside, remove his oxygen off the back of his chair. Date initiated: [DATE]. Remind (Resident #1) to smoke in designated smoke area at all times. Date initiated: [DATE]. i. The Quarterly MDS with an ARD of [DATE] documented the resident scored 10 (,[DATE] indicates moderate cognitive impairment) on the BIMS, had verbal behavioral symptoms directed toward others, required extensive assistance from staff for most activities of daily living, and received oxygen therapy. j. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. Resident requires supervision . k. A Behavior Note dated [DATE] at 3:38 p.m. documented, Resident went out to smoke a second time, pushing the door open on his own after coming in from smoking. Resident was wearing his O2 and while attempting to light his cigarette the CNA (Certified Nursing Assistant) assigned to that smoke break said let's turn your O2 off. At that time, resident swung elbow back attempting to hit CNA while saying 'you bastard'. CNA notified head CNA of incident; the head CNA brought resident inside to talk with a staff member. This staff member explained to resident that he is unable to smoke while wearing his oxygen. Resident stated that oxygen was not flammable. Resident remained upset after explanation and education of why oxygen cannot be on while smoking. Resident wanted proof that oxygen is flammable. Resident calmed down somewhat however insisted that oxygen is not flammable. Will continue with current P[NAME] (plan of care) and observation while resident smokes. l. A Behavior Note dated [DATE] at 6:22 p.m. and written by Registered Nurse (RN) #1 documented, Resident caught in room smoking cigarette. Lighter taken from resident at this time. Discussed with resident that he was not allowed to smoke in room at any time and that if behavior continued, he was in jeopardy of being removed from home. Called and discussed situation with POA (Power of Attorney), ADON (Assistant Director of Nursing) and DON (Director of Nursing). m. A Nursing Note dated [DATE] at 6:04 p.m. documented, 1340 (1:40 p.m.) (family member) standing outside 5 hall door and yelled help. Staff began to run out 5 hall and (family member) states he is on fire. Resident was not on fire. Resident sitting bent over in manual wheelchair. I called his name he responded and told me he was hot. I raised his head, soot noted to nasal, mouth, and palm of hands; he was pushed to his room, oxygen at 3 lpm (liters per minute) applied via nasal cannula, updraft administered. Vitals ,[DATE], hr (heart rate)-80, unable to obtain respiration. Resident mumbling, instructed resident to breathe. Removed resident's shirt no lighter found. Cold towels draped over head/facial area, and both hands. 1342 (1:42 p.m.) staff notified 911, 1350 (1:50 p.m.) life net arrived . n. The Hospital Emergency Department (ED) Provider Notes dated [DATE] documented, .presents with a chief complaint [MEDICAL CONDITION] the face and hands. Patient reportedly lit a cigarette while using his nasal cannula and this resulted in flames to the face. This included the mouth and lips as well as the intranasal area. He also [MEDICAL CONDITION] the left side of his face and ear. [MEDICAL CONDITION] to the fingertips of the fingers. Patient is reportedly on outpatient hospice due to [MEDICAL CONDITION] . Patient is complaining of pain to the face as well as shortness of breath. No other history available as patient is not speaking that much . Burn quality: Black, intact blister, red and painful . He appears distressed . Second [MEDICAL CONDITION] the upper lip and lower lip. There is soot that goes into both nostrils with [DIAGNOSES REDACTED]. There is soot and [DIAGNOSES REDACTED] within the oral cavity itself. There are second degree [MEDICAL CONDITION] the left ear and left lateral cheek area . He is in respiratory distress . There is a mixture of first and second [MEDICAL CONDITION] the fingertips of the index and thumb fingers . Summary Statement: . Patient's pH (power of hydrogen) is down to 7.0 and his PCO2 (partial pressure of carbon [MEDICATION NAME]) is over 100. Given this fact, I do think that he will most likely expire if he does not get mechanical ventilation. Both patient and family understand this. Given his injuries and his worsening respiratory status, family has requested in patient hospice care . 3. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitive independence) on the BIMS, had no behaviors and required limited assistance with most activities of daily living. a. The Care Plan with a review date of [DATE] documented in the Problem section, Smoker: Potential for injury R/T (related to) being a smoker . He refuses to give staff his lighter. He is safe to smoke with supervision of family and staff. The Approaches/Tasks section documented, Keep lighter and cigarettes at nurse's station. Date Initiated: [DATE]. Requires supervision when smoking. Date Initiated: [DATE]. Smoke only in designated area. Date Initiated: [DATE]. Redirect when resident is inappropriate in smoking area. Date Initiated: [DATE]. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 2:20 p.m., Resident #2 was observed in a w/c (wheelchair) in his room. He was asked about the incident in the smoking area on [DATE]. He stated, This man (Resident #1) has been lighting his cigarettes for a long time. Several times, and he's got a tank on his chair. And he's been told several times not to do it. I was outside with my daughter under the canopy, and he was by the door. He started screaming, and my daughter ran to him to put it out. I know the rules and I signed the agreement. I know you're not supposed to smoke with O2 on. They have been picking the lighters up, but people keep breaking the rules. People find out the code and go outside. You can't stop people from smoking if they want to smoke. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively independent) on the BIMS, had no behaviors and required extensive assistance with most activities of daily living. a. The Care Plan dated as reviewed [DATE] documented in the Problem section, Smoking Safety. With staff supervision. Date Initiated: [DATE]. Revision on: [DATE]. The Approaches/Tasks section documented, Educate resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: [DATE]. Ensure oxygen canisters/concentrators are not present when resident is smoking. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 1:05 p.m., Resident #3 was asked about the incident that happened out in the smoke area on [DATE] and stated, We were out smoking, and I was sitting next to (Resident #1) talking. I looked over there, and he was lighting a cigarette off another one, and fire shot out his nose. I hollered for help and so did a family member. He was asked, Do you know where (Resident #1) got the cigarette to light his? He stated, He had just smoked one and used that. They have told him a dozen times not to come out there with his O2 on. He was asked, Has the staff informed you and the other smokers not to go out and smoke without staff supervision? He stated, Yes, they have, but some of the people know the codes to get out the door. I used to. He was asked, Who opened the door to let them out last Friday when this happened? He stated, I don't know. Now they make sure a CNA is out there, and no one gets out, because the code changed. He was asked, Could other residents go out and smoke whenever they wanted before this incident? He stated, No, but people did anyway. 5. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 15 on the BIMS, had no behaviors and required extensive assistance with most activities of daily living. a. The Care Plan dated as reviewed [DATE] documented in the Problem section, Smoking Safety. Date Initiated: [DATE]. The Approaches/Tasks section documented, Assist (Resident #4) as needed for smoking to assist with anxiety control. Date Initiated: [DATE]. Educate resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: [DATE]. Ensure oxygen canisters/concentrators are not present when resident is smoking. Date Initiated: [DATE]. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: [DATE]. b. The Smoking Safety Screen dated [DATE] documented, Safe to smoke with supervision. c. On [DATE] at 1:25 p.m., Resident #4 was asked about the incident that occurred in the smoke area on [DATE] and stated, I didn't see nothing. Me and (Resident #3) were out there, and (Resident #2) and his daughter were sitting around the corner. Next thing I know, I heard someone yelling, 'help, help'. (Resident #2's daughter) jumped up and ran around there and yelled, 'he's on fire'. She beat on the door, and they came out. The man . he was a butt. He would turn his own O2 up or down whenever and do it when he was smoking. You couldn't tell him nothing. What they should have done was not allow anyone out that door who was on O2. He was asked, How did you get out the door? He stated, I don't know. I knew the code. (Resident #1) knew the code. I've seen him kick the door open. Only certain people can go out and smoke whenever. I can. I could before this, anyway. He knew he wasn't supposed to do that. He wasn't stupid. I think when (Resident #1) gets back, I'm gonna beat the hell out of him for this. 6. On [DATE] at 3:15 p.m., LPN #1 was asked what happened with Resident #1 on [DATE] and stated, I was at the nurse's station on the computer. I heard someone yell. I looked down 500 hall and saw (family member) and she said 'help, he's on fire!' I took off running. I went out the door, and (Resident #1) was to my left as I went out. (Resident #3) was to my right. I grabbed him and pushed him back into his room. I yelled to get cold towels and had them call 911, got vital signs . She was asked who was out in the smoking area when this happened and stated, (Resident #2) and his daughter, (Resident #4) and (Resident #3). She was asked why there was no staff in the smoking area at that time and stated, Because smoke break was over. They are taken out at 1, and they have 15 minutes or 2 cigarettes, then they come back in. She was asked if it was okay for any of the residents to go out and smoke unsupervised. She stated, Since I've been here, they've been doing that. It's my understanding that if a resident is capable of letting themselves out and back in, then they can go out and smoke unsupervised. That's how it's always been. For (Resident #3), he cannot get out by himself, so someone had to let him out. (Resident #1) . sometimes he can get out by himself, sometimes he can't. It depends on his strength that day. She was asked if it was okay for Resident #1 to go out and smoke without supervision if he could let himself out. She stated, No, it wasn't, because he knew he wasn't supposed to go out, because he had O2. He had been reprimanded several times about that. She was asked if Resident #1 could comprehend what people were telling him and stated, Yes, he could. She was asked which residents were able to go out whenever they wanted to smoke unsupervised. She stated, (Resident #4) and (Resident #3). Those two can go whenever they want. They're not supposed to have a lighter, but that's been a problem. I asked (Resident #1) at the hospital how he got outside and who lit his cigarette and he wouldn't answer. He could answer any other questions, but not those. She was asked if it was possible that Resident #1 knew the door code. She stated, Now that, I don't know. She was asked if she was ever instructed to increase the monitoring or supervision for Resident #1 because of his behavior of smoking with his O2 on. She stated, Absolutely not. 7. On [DATE] at 12:25 p.m., CNA #1 was asked if she had ever provided care to Resident #1 and stated, Yes. I took care of him last Thursday night on 10 to 6 (10:00 p.m. to 6:00 a.m. shift). (Resident #1) was an easygoing guy. Never complained to me. She was asked about his cognitive status and whether he was capable of understanding what she told him. She stated, To me, yes. He didn't seem confused. She was asked if she had ever taken him out to smoke and stated, Yes. We have assigned smoke breaks. Whenever I would take him out to smoke, I would make sure his O2 was off. She was asked what she meant by that and stated, Like turned off. She was asked, Did his O2 tank still be stay on his wheelchair? She stated, Sometimes, yes. She was asked, Did you if she had ever seen him with a lighter? and she stated, No. She was asked, Did you if she had ever see him outside smoking without staff present? She stated, When he first came, I did, but not lately. She was asked, Do if there were any of the residents here who go out and smoke on their own, without staff supervision? She stated, They're not here anymore. She was asked, Do you know if she knew (Resident #1) had been recently caught in his room smoking? She stated, No. She was asked, Do you know if there had been if she knew of any increased supervision or monitoring done for (Resident #1) due to his behavior of smoking with his O2 on? She stated, Not that I know of. 8. On [DATE] at 12:39 p.m., CNA #2 was asked about Resident #1 and stated, He was as sweet as he wanted to be, but he was gonna do what he wanted to do. He never said an ill word toward me. He wanted to smoke, and he loved his gold. Gold watches, rings, etc (et cetera). She was asked if she had ever taken Resident #1 and the other residents out to smoke and stated, Yes, I have. I took the residents out to smoke last Friday, the 22nd, at the 645 (6:45 a.m.) break. I worked the hall and was (Resident #1's) CNA that day. He did not go out for that smoke break. She was asked, Where were you she was when this incident occurred? She stated, I was changing a resident, and when I came out of the room, I saw everybody running out the door, so I ran too. They grabbed him and pulled him inside. I was holding a cold wet towel on his face while they were giving him oxygen. Now I've quit smoking because of this. Smoking was his joy. She was asked, Did you ever see (Resident #1) outside smoking without staff supervision and with his O2 on? She stated, There are several of them that get out without staff, so we have to go out and bring them back in. They also know they can push on the door for 15 seconds and it will open. She was asked, Did you ever have to go outside and get the residents who were smoking and bring them back in because there was no staff with them? She stated, Yes. She was asked, Was if (Resident #1) one of them? She stated, Yes, he was. She was asked, Was he using his O2 at that time? She stated, Yes, he was. She was asked, What has been done to prevent residents from going out to smoke, unsupervised? She stated, There have been in-services with the residents, we have done lighter round-ups and the door codes are changed. She was asked, Were you ever instructed to increase the monitoring/supervision on (Resident #1), due to his known behavior of smoking with his O2 on? She stated, I personally have never been told to keep a closer eye on him. She was asked, Are there any residents here who go outside and smoke whenever they want, without staff supervision? She stated, (Resident #5) will get the code and his wife will bring him a lighter, even though she knows not to, and he goes out whenever he wants, ,[DATE]. She was asked, Do you know if (Resident #1) had recently been caught smoking in his room? She stated, Yes, I am aware of that. She was asked, Do you know if (Resident #1) understood when he was being told not to smoke with the O2 on? She stated, Yes, he understood. She was asked, Had there been a recent time that you had to go outside and get (Resident #1) to and bring him back inside because there was no staff with him? She stated, It's been in the past month. 9. On [DATE] at 1:41 p.m., CNA #3 was asked about Resident #1 and stated, He was kind of goofy. He joked a lot. He was pretty easygoing to me. She was asked if he liked to go out and smoke and stated, He didn't go out too often, but here lately, he was going out more than normal. She was asked, Have you ever taken the residents out to smoke? She stated, Yes. I have taken them out to smoke, including (Resident #1). I wouldn't let him go smoke with his O2. She was asked if there were any residents who could go out and smoke whenever they wanted, without supervision. She stated, We do have a resident who knew the code, (Resident #4), and he would occasionally let people out. (Resident #5) goes out whenever he wants. Before this incident, (Resident #5) was allowed to keep his own lighter and cigarettes. I've never known (Resident #1) to have his own lighter. She was asked, Did you know if (Resident #1) had been caught smoking in his room a week ago? She stated, No, I didn't. She was asked, Do you know if the facility implemented any increased monitoring for (Resident #1) due to his behavior of smoking with his O2 on? She stated, No. Sorry, but no. 10. On [DATE] at 2:09 p.m., CNA #4 was asked if she had ever known of Resident #1 to smoke in his room. She stated, I've never caught him smoking in his room. I've seen him with a lighter, but we get them as soon as we see it. She was asked, Were you ever instructed to increase the monitoring or supervision for (Resident #1) due to his behavior of smoking with his O2 on? She stated, No. She was asked, Do you know if (Resident #1) was capable of understanding instructions when you told him? She stated, I think so. She was asked, Were there any interventions implemented before this incident to prevent an accident in the smoke area? She stated, There's always someone present on the smoke break. There's a door code and it changes often. Lighters are taken. The family members know not to bring lighters, but they do it anyway. Since the incident, we keep the cigarettes and lighters. They are all veterans, and they say they know their rights and that we are stealing from them and such. 11. On [DATE] at 2:26 p.m., RN #1 was asked about the incident on [DATE] when (Resident #1) was caught smoking in his room. She stated, (CNA #5) was walking down the hall and smelled smoke and she came and told me about it. I went down there and took his stuff and explained to him he could not smoke with O2 in the room or outside with it. She was asked, Did if he still have his cigarette lit when she you went into the room? She stated, I think (CNA #5) had put the cigarette out. She was asked, Was if this was something the (Resident #1) did frequently? She stated, This is a conversation we have with him daily. Not that he's been caught daily, but he's adamant that O2 won't blow up. She was asked, Do you know if the supervision or monitoring for him was increased after that incident, since his behavior of smoking with O2 on placed him at high risk for an accident? She stated, We were doing hourly monitoring on the smokers over the weekend, but on (Resident #1) . Not that I know of. She was asked, What kind of interventions were being done prior to the incident to prevent this kind of thing from happening? She stated, We've taken lighters and cigarettes, we do the smoking assessment, and the door code was changed frequently. She was asked, What type of interventions have been implemented since the incident? She stated, Everything is locked up, cigarettes and lighters. We are doing hourly checks on the smoke area to ensure no one is out there, the door code was changed, and it's not being given out. 12. On [DATE] at 2:46 p.m., CNA #5 was asked about the evening when (Resident #1) was caught smoking in his room. She stated, I was passing by and smelled cigarette smoke and I walked past, and (Resident #1) was smoking. I went in and put his cigarette in a plastic cup and took it to show the nurse. She was asked, Did (Resident #1) have his O2 on when he was doing this? She stated, Yes. That was the first time I'd seen him smoking in his room. I have known him to have lighters, and when he wouldn't give them to me, I would go tell the nurse. She was asked, if she Have you ever taken the residents out to smoke? She stated, Yes, and I have taken (Resident #1) out to smoke, but we would leave his O2 in his room. She was asked, Were you ever instructed to increase the monitoring of (Resident #1) due to his behavior of smoking with his O2 on? She stated, I've been told to watch him because of his smoking, but not like a specific time frame, or to document it. She was asked, Do you know if he was capable of understanding what people were telling him? She stated, Yes. She was asked if there were any residents who went out to smoke on their own and stated, (Resident #4) and (Resident #5). They kept their own smokes and lighters. She was asked what kind of interventions were being done prior to the incident to prevent Resident #1 or other residents from going out to smoke unsupervised. She stated, Just go with them. Since Friday, the code hasn't been given out. 13. On [DATE] at 3:50 p.m., the Director of Nursing (DON) was asked about Resident #1 and stated, I know he was a smoker and that he would demand to go out with his O2 on and we would have to re-educate. She was asked if she knew he had been caught smoking in his room one week prior to the incident on [DATE]. She stated, (RN #1) called me on the 15th. I told her to confiscate the lighter and call his POA and tell him to talk to him and to not be bringing any lighters up here. I told him if he was caught again, he could be removed from the facility, because it violates the rules. She was asked, How to do you prevent a resident who is noncompliant from doing something like this? She stated, Change the door codes, make sure he only goes out with staff. She was asked if the facility had implemented any increased monitoring or supervision due to Resident #1's behavior of smoking with his O2 on. She stated, I'm sure they've probably been told to watch him more closely, but as far as documentation, not that I know of. She was asked if Resident #1 and other smokers' noncompliance with the smoking policy had been discussed in quality assurance (QA) meetings and stated, I've been in one QA meeting since I've been here, and I don't remember that. She was asked if there were any residents who went out to smoke without supervision. She stated, There shouldn't be anybody. Since I've been here, they're supposed to be supervised. 14. On [DATE] at 8:19 a.m., the Social Director was asked, Did you have any interactions with (Resident #1)? She stated, About (MONTH) or so of last year, we had an issue with him going out to smoke with his O2 on. We had a care plan meeting with him and his POA. We tried to find placement for him and couldn't. He stopped smoking for a while, maybe a month or 2, but then started back. She was asked, Had if his smoking been an issue lately? She stated, Since last June, as far as I know, he was easily redirected until recently, when his cognitive status was sort of declining. We have had care plan meetings with his POA but not about smoking, because it had gotten better. She was asked if there were any residents who went out to smoke whenever they wanted, without staff supervision. She stated, Some of the smokers who are more cognitive, it's an ongoing issue. Family members bring lighters, we change the code, they push the door for so long, and it opens . She was asked if the facility had implemented any increased monitoring for Resident #1, due to his behavior of smoking with his O2 on. She stated, Not that I know of. 15. On [DATE] at 9:12 a.m., Maintenance Employee #1 was asked how often he changed the door code for the door that led to the smoking area. He stated, (MONTH) of last year, I came out here and changed it, and then it was changed again within a week. He was asked, Why was it changed again so soon? He stated, My guess is that someone discovered the code, and then this past Friday, ,[DATE], I was on the way to Memphis, and they called me asking how to change it. He was asked, Had if the door code been changed between (MONTH) of last year and [DATE]? He stated, Well, I wasn't over this building until January, so if it was changed after (MONTH) of last year, I wouldn't know about that. He was asked, Do you know who was in charge of maintenance during that time? He provided the name of the previous maintenance employee. He was asked, Who is capable of changing the code? He stated, Before Friday, I was the only one w

A. Based on record review and interview, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for Resident #8. The facility failed to ensure consistent monitoring of blood pressure, to ensure blood pressure medication ordered as needed was administered within the parameters of the physician's orders [REDACTED].#8) of 2 (Residents #8 and #9) case-mix residents who had [MEDICATION NAME] as needed for elevated blood pressures. The failed practice resulted in Immediate Jeopardy, which could have caused serious harm, injury or death for Resident #8 who had documented systolic blood pressure over 160 and diastolic blood pressure over 100 on at least 9 occasions and was not given medication as ordered and had the potential to cause more than minimal harm for 3 residents who had [MEDICATION NAME] as needed as identified by a list provided by the facility Continuous Quality Improvement (CQI) Consultant on 8/31/12 at 10:20 a.m. The facility was notified of the Immediate Jeopardy condition on 08/29/12 at 5:45 p.m. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/28/12 documented the resident scored 8 (8 - 12 moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). a. The June 2012 E-MAR documented, "Check Blood pressure twice a day Start Date: 2/15/12 Discontinue Date: 6/22/12." 1) The Discharge MDS with an assessment reference date of 6/22/12 documented the resident was discharged from the facility to an acute hospital setting on 6/22/12. 2) The MDS with an entry date of 6/25/12 documented the resident re-entered the facility from an acute hospital on [DATE]. The admission orders ...[DIAGNOSES REDACTED]. A physician order [REDACTED]." The August 2012 Physician order [REDACTED]. b. On 8/28/12 at 5:42 p.m. the resident's June - August 2012 E-Mars (Electronic Medication Administration Records) were reviewed and 8/29/12 at 11:23 a.m. the June-August 2012 Nurse's Notes were reviewed with the following findings: June 2012: One administration of the [MEDICATION NAME] 0.1 mg with one blood pressure (B/P) recorded on the June 2012 E-MAR as 220/110 on 6/15/12 at 12:08 a.m. with a follow up recorded in the Nurse's Notes on 6/15/12 at 1:15 a.m. with a reading of 168/84. July 2012: One administration of the [MEDICATION NAME] 0.1 mg with a one blood pressure recorded on the July 2012 E-MAR as 240/120 on 7/24/12 at 11:27 p.m. with a follow up recorded in the Nurse's Notes on 7/25/12 at 1:27 a.m. with a reading of 150/70. August 2012: One administration of the [MEDICATION NAME] 0.1 mg with one blood pressure recorded on the August 2012 E-MAR as 168/120 on 8/2/12 at 2:52 p.m. with a follow up recorded in the Nurse's Notes on 8/2/12 at 5:02 p.m. with a reading of 148/84. c. On 8/28/12 at 2:40 p.m., Medical Records Licensed Practical Nurse (LPN) #3 provided blood pressure documentation for the resident. On 8/29/12 at 12:50 p.m., the DON (Director of Nursing) provided additional blood pressure recordings from handwritten vital sheets for the resident. 1) After both records were reviewed and compared, the resident did not have at least daily blood pressure recorded: June 2012 there was no recorded blood pressure for 6/26, 6/28, 6/29 and August 2012 there was no recorded blood pressure for 8/16, 8/17, 8/19, 8/20, and 8/21. 2) After both records were reviewed and compared, the following Blood Pressure (B/P) readings required administration of [MEDICATION NAME] per Physician order [REDACTED]. August 2012 - 8/3/12 BP 180/90, 8/7/12 BP 180/70, 8/10/12 BP 194/86, 8/11/12 BP 170/90 (7:06 a.m.), 8/11/12 BP 170/90 (10:36 a.m.) and 8/12/12 BP 170/86 (9:22 p.m.). d. The Care Plan dated 8/6/12 documented, "...DX (diagnosis)/Medical Condition: Goal & Target Date (Resident Name) will not exhibit any unidentified s/s (sign/symptoms) of hypertension thru quarter. Approaches Notify MD of any variation in blood pressure... Administer medications as indicated by MD... Observe for complaints of headache and [MEDICAL CONDITION] Monitor for changes in resident condition... Monitor for generalized [MEDICAL CONDITION] Monitor for neurological changes in resident condition ... Assess for dizziness with position changes... Check vital signs as ordered & prn." e. On 8/29/12, interviews were conducted with staff regarding the monitoring of blood pressure: 1) At 10:31 a.m., the LPNs that were on duty for the 6 to 2 shift: The surveyor asked LPN #2, "Where do you get the information for the residents Blood Pressure?" The CNAs are assigned to who are to have their blood pressure taken. They report to the LPN and write on the clipboard. The vitals are to be done by around 10:00 a.m. in the morning." The surveyor asked LPN #2, "Where do you document or monitor the effectiveness of medication?" LPN #2 said, "I don't if in normal parameter." The surveyor asked, "If it is a prn (as needed) blood pressure medication?" The LPN #2 stated, "Only do it (blood pressure), if it is out of range." The surveyor asked LPN #5, "How do you assign the vital signs for blood pressure?" LPN #5 stated, "The Medicare are daily or if they are on the hot rack, I&A (Incident and Accident), or Antibiotic or any that are ordered daily." The surveyor asked, "Who assigns the list?" LPN #5 stated, "I do." The surveyor asked what are the parameters for Blood Pressure?" LPN #5 said, "Greater than 130 to 140/ 90, if higher I recheck the blood pressure." The surveyor asked, "Where is it documented?" LPN #5 stated, "The CNA documents on the clip board and then I record in the computer." The surveyor asked, "What about a resident who is on prn [MEDICATION NAME] like (Resident #8)?" LPN #5, "Not because of the prn [MEDICATION NAME] but they are on an Antibiotic so it is done daily." The surveyor asked, "When would the blood pressure be checked?" LPN #5 stated, "If the CNA checked and the blood pressure was high or if there were any signs and symptoms." 2) On 8/29/12 at 11:00 a.m., the CNAs were interviewed: CNA #9 was asked, "Do you take blood pressures?" CNA #9 said, "Yes." The surveyor asked, "How do you know whose blood pressures to do and where do you document?" CNA #9 said, "The LPN writes down and then we document on the vital sheet." The surveyor asked, what would be parameters for high blood pressure that you would report to the LPN? CNA #9 said, "150/90 or greater." The surveyor asked, "Who do you report it to?" CNA #9 said, "To the LPN if high, but if not high you document. If high you report it immediately." The surveyor asked CNA #3, "Do you take blood pressures?" The CNA stated, "Yes." The surveyor asked CNA #3, "How do you know whose blood pressures to do and where do you document?" The CNA stated, "I write it on paper then the chart." The surveyor asked what would be parameters for high blood pressure that you would report to the LPN. The CNA stated, "140 to 150/90." The surveyor asked, "Who do you report it to and when?" The CNA stated, "The LPN immediately." The surveyor asked CNA #7, "Do you take blood pressures?" The CNA stated, "Yes." The surveyor asked CNA #3, "How do you know whose blood pressures to do and where do you document?" The CNA stated, "The paper then I put it on the vital sheet chart." The surveyor asked, "What would be parameters for high blood pressure that you would report to the LPN ?" The CNA stated, "160/90 and I would report immediately." 3) On 8/29/12 at 1:12 p.m., the surveyor asked LPN #4, "What are signs and symptoms of high blood pressure?" LPN #4 stated, "Headache, pulse rate, issue with nausea, but mostly headache." The surveyor asked LPN #2, "What are signs and symptoms of high blood pressure?" LPN #2 stated, "Nose bleed, headache, veins bulging, and dizziness." 4) On 29/12 at 10:10 a.m., the surveyor asked the DON, "Who takes blood pressures and how?" The DON, "Normally the CNA, the nurse at times has follow-ups. The information is placed on the clip board and the nurses review throughout the shift. The vitals are taken the first two hours of the shift. Anything over 140/90 the nurse monitors from parameters. The surveyor asked, "How do you or who is monitoring the blood pressures?" The DON stated, "Medical records is monitoring on pain, for blood pressure need to check with medical records." The surveyor asked, "Do you have any reports from the Consultant Pharmacist about the blood pressures and the monitoring of the blood pressure medication that is prn?" The DON said, "I will check." The surveyor asked, "If you have a resident on prn blood pressure medication bid, do you have the blood pressure taken bid and is it documented on the E-MAR?" The DON said, "Only if the physician has requested." The surveyor asked, "Does the facility notify the physician?" The DON said, "At times, if needed." f. A Physician's Telephone Order dated 8/29/12 at 7:10 a.m. documented, "DC (discontinue) the [MEDICATION NAME]" 1) On 8/29/12 at 4:20 p.m., the surveyor called the Physician. The surveyor asked the physician, "On the readmission of the resident to the facility there were no orders to monitor the blood pressure." The Physician stated, "That is hard to believe, they (blood pressure readings) are there for me when I do rounds. Check the progress notes." The surveyor asked, "Did you expect the facility to do blood pressure monitoring twice daily?" The Physician said, "No, once a week or monthly." The surveyor asked the Physician, "Were you notified of any blood pressures over the parameters (specified in the June 25, 2012 orders)?" The Physician stated, "Not that I remember." The surveyor asked, "Why did you DC (discontinue) the [MEDICATION NAME] this morning?" The Physician stated, "I am not aware, it must have been the APN (Advanced Practice Nurse)." 2) On 8/29/12 at 4:33 p.m., the surveyor called the APN. The surveyor asked, "Why did you DC the [MEDICATION NAME] this morning?" The APN stated, "(DON) called and I discontinued because of non-use." The surveyor asked, "Are you aware of the three times, once each in June, July and August, the [MEDICATION NAME] was administered and of the August 2012 readings 8/12- 170/86, 8/11 - 170/90, 8/10 - 194/86, 8/7 - 180/70, 8/3 - 180/90, 8/3 - 200/90?" The APN stated, "No, I will be calling with new orders." g. A Physician telephone order dated 8/29/12 documented, "Check B/P (blood pressure) BID (twice a day). [MEDICATION NAME] 0.1 mg (one) BID prn (as needed) for systolic BP greater than 160 or diastolic BP greater than 100." The Departmental Notes Nursing entry dated 8/29/12 at 11:41 p.m. documented, "[MEDICATION NAME] 0.1 mg tablet Blood Pressure = 200/140... was Administered for increased blood pressure." h. On 8/30/12 at 10:30 a.m., the surveyor asked the Director of Nursing (DON), "The telephone order for 8/29/12, why was the prn [MEDICATION NAME] discontinued?" The DON said, "I discussed with the APN and it had only been used three times in the last three months. At that time, I didn't realize the number of times it should been given and how high it had been. Now, I realize the importance to have all the information." i. The Geriatric Pharmaceutical Care Guidelines 2011 Edition on page 457 documented, "Anti-hypertension therapy also should not be withheld on the basis of age. In fact, results of recently published HYVET (Hypertension in the Very Elderly Trial) strongly suggest that lowering BP in patients at least [AGE] years of age significantly reduces their risk of death from stroke or total mortality." 2. The Immediate Jeopardy was removed and the scope/severity reduced to an "H" on 8/30/12 at 10:00 p.m. when the facility implemented the following plan of removal: a. The Director of Nursing identified all residents with blood pressure medications on an as needed basis. b. For each resident with potential to be affected, blood pressure was taken... The blood pressures were within normal parameters. c. The ADON (Assistant Director of Nursing) has notified the patient's attending physician and medical director for any residents with the potential to be affected. Also the blood pressures outside the parameters without medication administered. Reviewed the current as needed blood pressure medications and parameters. d. The Director of Nursing will identify and assess other residents who may also be at risk due to having the needed blood pressure medication. e. All licensed nursing staff on duty as of 6:34 p.m. have been inserviced by Director of Nursing on the following topic of monitoring residents that have blood pressure medications that should be administered on an as needed basis. They will be inserviced on accurate recording of all blood pressure readings. 1) DON will inservice staff on monitoring blood pressure, medicating as ordered, and documenting as ordered. 2) The monitoring process will include validation of information communicated to facility leadership and documented on the 24-hour report. 3) Residents identified at risk on the 24 hour report will be discussed at the daily stand-up meeting. The DON/designee will monitor weekdays and RN supervisor will monitor on weekends. 4) No other Licensed Nursing staff will be allowed to work until they have received the above noted in-service training. f. The Director of Nursing has scheduled inservice training to be conducted by the CQI Director for 10:00 p.m. tonight (8/29/12) for all available Licensed Nursing staff on the topics noted above under Immediate Response. Inservicing will be conducted utilizing a lecture method and discussion. Any Licensed Nurse who do not receive this training tonight will not be allowed to work. B. Based on observation, record review and interview, the facility failed to recognize and provide measures to minimize or prevent pain for situations where pain could be anticipated for 2 (Resident #2 and #5) of 7 (Residents #1 through #7) case mix residents with orders for wound treatments. This failed practice resulted in a pattern of actual harm for Resident #5, who had experienced significant episodic pain without appropriate interventions implemented to minimize or eliminate the pain which the resident experienced during the performance of a daily complex dressing change, and had the potential to cause more than minimal harm for 19 residents who had orders for wound treatments, according to a list provided by the CQI (Continuous Quality Improvement) Nurse Consultant on 8/31/12. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/12 documented the resident scored 0 (0-7 severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance from staff for toilet use and transfers, had a nephrostomy and [MEDICAL CONDITION], had a surgical wound and experienced pain occasionally with an intensity level of 3. a. The physician's orders [REDACTED]." The physician's orders [REDACTED]." The physician's orders [REDACTED]. The physician's orders [REDACTED]." b. The Plan of Care dated 8/17/12 documented, "Problem: Skin/Pressure Ulcers/Incontinence; (Resident #5) has a surgical incision / wound to his coccyx ...Approaches: Administer (Resident #5)'s pain medication per MD (medical doctor) orders and prior to initiating treatment if indicated / ordered." c. The August 2012 Electronic Treatment Administration Record (eTAR) documented that the resident's surgical wound to the coccyx received the prescribed treatment at 12:00 a.m., 8:00 a.m. and 4:00 p.m. daily. The August 2012 Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. The Administration Record for the eTAR dated 8/20/12 at 2:31 a.m. documented, "(Order #110) Coccyx - Surgical Wound - Cleanse with Saf-Clens A... scheduled for 8/19/12 12:00 a.m. was completed. Tolerated well. Had some discomfort." There was no documentation of the level of the discomfort. There was no documentation that the resident was given any [MEDICATION NAME] for the discomfort. The Non-Pressure Skin Condition Record dated 8/24/12 documented, "Measurements: Length (cm (centimeter)) 7.5 x (by) Width (cm) 3.7 Depth (cm): 1.8. Tunneling: 3.8 cm at 6 o'clock. Undermining 1 cm at (blank) o'clock... Progress Notes Weekly Note: Dressing changed, complaints of pain, nurse notified, surrounding skin noted to be red due to tape use, No odor, copious urine/serosanguinous drainage noted. Will continue to observe." There was no assessment of the type or severity of the pain. There was no documentation that the resident was medicated with the [MEDICATION NAME] for the pain. There was no nurse's note entry for 8/24/12. The August 2012 eMAR documented that no [MEDICATION NAME] was given from 11:24 p.m. 8/13/12 until 10:26 a.m. on 8/28/12, despite documentation that the resident experienced pain on 8/20/12 and 8/24/12. e. The Administration Record for the eMAR dated 8/28/12 at 10:26 a.m. documented, "(Order #119) [MEDICATION NAME] 50 mg tablet was administered for pain related to dressing change." The Administration Record dated 8/28/12 at 11:41 a.m. documented, "Medication Follow-up - ([MEDICATION NAME] 50 mg tablet) - Medication was effective ...pain scale 0." f. On 8/28/12 at 1:35 p.m., the resident was in the bed in the room. Registered Nurse (RN) #2 and RN #3 performed wound care on the resident's coccyx wound. When the dressing to the coccyx was removed and the gauze packing was pulled out of the wound cavity, the resident cried out in pain. The resident cried out, "Ouch! Damn it!" repeatedly during the procedure. The resident was asked, "Did that hurt?" The resident stated, "Of course! Don't ask questions!" RN #2 and RN #3 did not stop the procedure. RN #3 stated, "We're almost done." RN #2 cleaned the wound, and then began to pack the wound with Kerlix gauze moistened with [MEDICATION NAME]. The resident cried out in pain with each packing movement. The Resident stated repeatedly, "Ow! Hurry Up!" RN #2 and RN #3 did not stop the treatment. RN #3 stated, "Just a little longer, we're almost done." The resident was positioned on the right side. The Nephrostomy tube was uncovered with no dressing, and the tubing ran under the resident's right flank to a drainage bag on the right side of the bed. RN #2 was asked, "Does (the resident) get any pain medicine before the treatment?" RN #2 stated, "I believe (LPN #1) gave something right before because we asked her to." The resident was rolled to the left side and RN #2 cleaned a stop-cock port connected to the Nephrostomy tube with alcohol, and then attached a 10 cubic centimeter (cc) pre-filled syringe containing normal saline to the port. RN #2 infused the solution in a rapid manner (less than 3 seconds) into the Nephrostomy tube. The resident began to cry out, "Ow! Ow! It's burning!" RN #2 stopped the irrigation after 8 cc of Normal Saline had been administered." RN #3 brought in the Nephrostomy tube dressing supplies and the dressing was applied to the resident's Nephrostomy. The nurses did not stop the procedures or assess the pain verbalized by the resident. The wound treatment was initiated 3 hours after the administration of the [MEDICATION NAME] at 10:26 a.m. g. On 8/29/12 at 9:45 a.m., Resident #5 was asked, "When they do your dressing, does it cause pain every time?" Resident #5 stated, "Yes." Resident #5 was asked, "Do they give you anything for pain?" Resident #5 stated, "No." Resident #5 was asked, "Does it take a while to get over the pain?" Resident #5 stated, "Not if I get medicine." Resident #5 was asked, "On a level of 1 to 10, what level of pain would you say you experienced?" Resident #5 stated, "A seven." Resident #5 was asked, "When they stop / finish doing the dressing, does the pain stop?" Resident #5 stated, "No. If they give me something for it, it doesn't last very long." h. On 8/29/12 at 10:40 a.m., RN #2 was asked, "How is pain assessed?" RN #2 stated, "People that are doing the PRN (as needed) medicines, they assess the level of pain." RN #2 was asked, "Where is this documented?" RN #2 stated, "In the eMAR. Every shift has a pain assessment." RN #2 was asked, "If a resident does not receive a PRN pain medicine, is the pain assessed?" RN #2 stated, "I don't know." RN #2 was asked, "Does (Resident #5) have pain with every dressing?" RN #2 stated, "Not with every dressing, no." RN #2 was asked, "How do you know ahead of time whether the resident will have pain or not?" RN #2 gave no answer. RN #2 stated, "We went ahead and asked the nurse to go ahead and pre-medicate the resident." RN #2 was asked, "Who did you ask?" RN #2 stated, "(LPN #1)." RN #2 was asked, "When did you ask?" RN #2 stated, "One hour prior to the treatment." RN #2 was asked, "When the resident was expressing pain during the treatment, you continued doing the wound treatment. Is there a reason you didn't stop?" RN #2 stated, "No." RN #2 was asked, "What would you be expected to do?" RN #2 stated, "Stop and ask the nurse if there is anything else he could have." i. The August 2012 eMAR review [REDACTED]. 1) On 8/29/12 at 12:15 p.m., RN #2 was asked, "How do you know if the resident has been medicated before you do the treatment?" RN #2 stated, "I ask the nurse." 2) On 8/30/12 at 12:09 p.m., LPN #1 was asked, "On the 28th (of August) you documented you gave an [MEDICATION NAME] (to the resident). Can you tell me about that?" LPN #1 stated, "(RN #2) came and told me to go ahead and medicate him because he was going to get his treatment soon." LPN #1 was asked, "Did you let her (RN #2) know (it had been given)?" LPN #1 stated, "Yes. I told her he had been medicated." LPN #1 was asked, "After the resident's dressing change that afternoon, did anyone inform you of the resident's pain during the treatment?" LPN #1 stated, "No." On 8/30/12 at 1:05 p.m., LPN #1 was asked, "Typically, does (RN #2) tell you before doing a treatment so the resident can be medicated?" LPN #1 stated, "No." 2. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/9/12 the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, did not speak, was rarely / never understood, rarely / never understood others, was totally dependent on the physical assistance staff for all activities of daily living, had no pain assessment interview conducted because rarely / never understood, was at risk for the development of pressure ulcers and had a [MEDICAL CONDITION]. a. The Physician telephone order dated 8/9/12 at 8:24 a.m. documented, "Cleanse Stage III to right buttock and coccyx area with wound cleanser, pat dry, apply [MEDICATION NAME] wet to dry dressing to wound bed, cover with ABD, secure with tape once daily." b. The Physician telephone order dated 8/12/12 at 2:00 p.m. documented, "[MEDICATION NAME] 5/325 (one) po (by mouth) q (every) 8 (hours)." The resident's August 2012 eMAR documented, "8/13/12... [MEDICATION NAME] 5 / 325 tablet (1) by PEG tube every 8 hours..." c. The Physician telephone order dated 8/14/12 at 10:50 a.m. documented, "[MEDICATION NAME] / APAP ([MEDICATION NAME]) 5/325... (one) tid (three times a day) prn (as needed) before wound treatment." The resident's August 2012 eMAR did not document the [MEDICATION NAME] prn physician order. d. The resident's Care Plan was last updated on 8/23/12 and documented, "(Resident #2) has a Stage III pressure ulcer (right) buttock (7.0 (by) 4.8 (by)3.5) with VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) pseudomonas and requires isolation due to wound infection... Administer (Resident #2)'s pain medication as needed... (Resident #2) is experiencing or is at risk for the presence of occasional pain in associat(ion) with wound buttock. Pain management is effective... Administer (Resident #2)'s pain medication as ordered..." e. On 8/28/12 at 11:05 a.m., RN #2 and RN #3 entered the resident's room and provided [MEDICAL CONDITION], percutaneous endogastrostomy site and pressure ulcer care for the resident. 1) The resident's narcotic log sign-out sheet for the [MEDICATION NAME] 5 / 325 mg documented the resident's 12:00 a.m. and 8:00 a.m. on 8/28/12 doses were signed out for administration at 12:00 a.m. and 7:00 a.m. respectively. 2) The resident's August 2012 eMAR documented the resident's level of pain was documented as "0" on 8/28/12 at 12:00 p.m. and as "6" on 8/28/12 at 8:00 a.m. The resident received her scheduled [MEDICATION NAME] 5 / 325 mg on 8/28/12 at 12:00 a.m. and 8:00 a.m. The eMAR further documented, "(7/2/12) Document signs/symptoms of pain or expresses discomfort. 0=No. 1=Yes, If yes document on pain flow sheet." The eMAR documented the resident's signs and symptoms of pain as "0" at 5:30 a.m. on 8/28/12. There was no documentation the resident's pain was assessed prior to initiation of wound care or that any prn [MEDICATION NAME] was administered to the resident prior to initiation of wound care. C. Based on observation, record review and interview, the facility failed to ensure non-pressure related wounds were not contaminated during care for 1 (Resident #1) of 3 (Residents #1, #4 and #6) case mix residents with non-pressure related sores. This failed practice had the potential to cause more than minimal harm to 5 residents who had non-pressure related wounds, according to a list provided by the CQI Nurse Consultant on 8/31/12. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS Assessment with an ARD of 8/1/12 documented the resident scored 0 (0-7 severe cognitive impairment) on the BIMS, required extensive assistance of two or more staff members for transfers, toileting, personal hygiene and bathing, was incontinent of bowel and bladder, was at risk for developing pressure ulcers and had no Stage I or higher pressure ulcers. a. The Body Audit sheet dated 8/22/12 documented there were no [MEDICAL CONDITION] on the resident's coccyx, hips, buttocks or thighs. The Plan of Care updated on 8/28/12 documented, "Problem Onset: 8/7/12. Skin / Incontinence / Pressure Ulcers: risk for skin impairments related to B/B (bowel and bladder) incontinence, hx (history) of [MEDICAL CONDITION] and falls. BLE (Bilateral Lower Extremity) [MEDICAL CONDITION]. Approaches: Body Audit Weekly ...Monitor skin during ADL (Activities of Daily Living) care and report any skin impairments to nurse..." b. On 8/27/12 at 1:30 p.m., during initial rounds with Licensed Practical Nurse (LPN) #1, the resident was sitting in a Broda chair in the room. There was a strong fecal odor in the room. The resident's pants were wet at the waist area and around the thigh area along the border of the incontinent brief. LPN #1 stated the resident had no skin problems and no skin tears. c. On 8/27/12 at 1:35 p.m., the resident was transferred to the bed by a mechanical lift by Certified Nursing Assistant (CNA) #2 and CNA #7. The resident's pants and brief were removed and incontinent care was performed. The brief was totally saturated with urine and loose tan bowel movement. The resident had scratched areas approximately 3/4-inch long on the right hip. CNA #7 was asked, "What is that?" CNA #7 stated, "That's where he's been scratching himself." CNA #7 placed AloVesta cream into the gloved right hand and applied the cream to the resident's anal area that had just been cleaned of incontinent bowel movement and urine. CNA #7 did not change gloves. The CNA immediately smeared the same AloVesta cream that had contacted the anus on the scratches on the right hip.

Based on record review and interviews, Nursing Administration failed to ensure consistent monitoring of blood pressure, to ensure blood pressure medication ordered as needed was administered within the parameters of the physician's orders [REDACTED].#8) of 2 (Residents #8 and #9) case mix residents who had [MEDICATION NAME] as needed for elevated blood pressures. The failed practice resulted in Immediate Jeopardy, which could have caused serious harm, injury or death for Resident #8 who had documented systolic blood pressure over 160 and diastolic blood pressure over 100 on at least 9 occasions and was not given medication as ordered and had the potential to cause more than minimal harm for 3 residents who had [MEDICATION NAME] as needed, according to a list provided by the facility Continuous Quality Improvement (CQI) Consultant on 8/31/12 at 10:20 a.m. The facility was notified of the Immediate Jeopardy condition on 08/29/12 at 5:45 p.m. The findings are: 1. The facility "Position Description" of the Director of Nursing was received on 8/31/12 at 10:20 a.m. and documented the "Accountability Objective" as: "Manages the Department of Nursing in accordance with the policy and procedure, state and federal regulations to promote high quality care and service to the facility and community." Key Responsibilities of the Director of Nursing were documented as: "...2. Implements policies / procedures with follow-up and supervision of staff to ensure compliance... 5. Directs and delegates management of professional and ancillary nursing personnel... 7. Analyzes and evaluates nursing and related services rendered to improve quality of resident care and plan better utilization of staff time and activities... 12. ensures that medical documentation and that the care planning process is interdisciplinary, consistent, timely, and reflective of resident needs and in compliance with regulations at all times... 13. Ensures medical services are provided as required by regulation and that the physician component of the medical record is complete..." 2. Resident #8 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/28/12 documented the resident scored 8 (8 - 12 moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). a. The June 2012 E-MAR documented, "Check Blood pressure twice a day Start Date: 2/15/12 Discontinue Date: 6/22/12." 1) The Discharge MDS with an assessment reference date of 6/22/12 documented the resident was discharged from the facility to an acute hospital setting on 6/22/12. 2) The MDS with an entry date of 6/25/12 documented the resident re-entered the facility from an acute hospital on [DATE]. The admission orders ...[DIAGNOSES REDACTED]. A physician order [REDACTED]." The August 2012 Physician order [REDACTED]. b. On 8/28/12 at 5:42 p.m. the resident's June - August 2012 E-Mars (Electronic Medication Administration Record) were reviewed and 8/29/12 at 11:23 a.m. the June-August 2012 Nurse's Notes were reviewed with the following findings: June 2012: One administration of the [MEDICATION NAME] 0.1 mg with one blood pressure (B/P) recorded on the June 2012 E-MAR as 220/110 on 6/15/12 at 12:08 a.m. with a follow up recorded in the Nurse's Notes on 6/15/12 at 1:15 a.m. with a reading of 168/84. July 2012: One administration of the [MEDICATION NAME] 0.1 mg with a one blood pressure recorded on the July 2012 E-MAR as 240/120 on 7/24/12 at 11:27 p.m. with a follow up recorded in the Nurse's Notes on 7/25/12 at 1:27 a.m. with a reading of 150/70. August 2012: One administration of the [MEDICATION NAME] 0.1 mg with one blood pressure recorded on the August 2012 E-MAR as 168/120 on 8/2/12 at 2:52 p.m. with a follow up recorded in the Nurse's Notes on 8/2/12 at 5:02 p.m. with a reading of 148/84. c. On 8/28/12 at 2:40 p.m., Medical Records Licensed Practical Nurse (LPN) #3 provided blood pressure documentation for the resident. On 8/29/12 at 12:50 p.m., the DON (Director of Nursing) provided additional blood pressure recordings from handwritten vital sheets for the resident. 1) After both records were reviewed and compared, the resident did not have at least daily blood pressure recorded: June 2012 there was no recorded blood pressure for 6/26, 6/28, 6/29 and August 2012 there was no recorded blood pressure for 8/16, 8/17, 8/19, 8/20, and 8/21. 2) After both records were reviewed and compared, the following Blood Pressure (B/P) readings required administration of [MEDICATION NAME] per Physician order [REDACTED]. August 2012 - 8/3/12 BP 180/90, 8/7/12 BP 180/70, 8/10/12 BP 194/86, 8/11/12 BP 170/90 (7:06 a.m.), 8/11/12 BP 170/90 (10:36 a.m.) and 8/12/12 BP 170/86 (9:22 p.m.). d. The Care Plan dated 8/6/12 documented, "...DX (diagnosis)/Medical Condition: Goal & Target Date (Resident Name) will not exhibit any unidentified s/s (sign/symptoms) of hypertension thru quarter. Approaches Notify MD of any variation in blood pressure... Administer medications as indicated by MD... Observe for complaints of headache and [MEDICAL CONDITION] Monitor for changes in resident condition... Monitor for generalized [MEDICAL CONDITION] Monitor for neurological changes in resident condition... Assess for dizziness with position changes... Check vital signs as ordered & prn." e. On 8/29/12, interviews were conducted with staff regarding the monitoring of blood pressure: 1) At 10:31 a.m., the LPNs that were on duty for the 6 to 2 shift: The surveyor asked LPN #2, "Where do you get the information for the residents Blood Pressure?" The CNAs are assigned to who are to have their blood pressure taken. They report to the LPN and write on the clipboard. The vitals are to be done by around 10:00 a.m. in the morning." The surveyor asked LPN #2, "Where do you document or monitor the effectiveness of medication?" LPN #2 said, "I don't if in normal parameter." The surveyor asked, "If it is a prn (as needed) blood pressure medication?" The LPN #2 stated, "Only do it (blood pressure), if it is out of range." The surveyor asked LPN #5, "How do you assign the vital signs for blood pressure?" LPN #5 stated, "The Medicare are daily or if they are on the hot rack, I&A (Incident and Accident), or Antibiotic or any that are ordered daily." The surveyor asked, "Who assigns the list?" LPN #5 stated, "I do." The surveyor asked what are the parameters for Blood Pressure?" LPN #5 said, "Greater than 130 to 140/ 90, if higher I recheck the blood pressure." The surveyor asked, "Where is it documented?" LPN #5 stated, "The CNA documents on the clip board and then I record in the computer." The surveyor asked, "What about a resident who is on prn [MEDICATION NAME] like (Resident #8)?" LPN #5, "Not because of the prn [MEDICATION NAME] but they are on an Antibiotic so it is done daily." The surveyor asked, "When would the blood pressure be checked?" LPN #5 stated, "If the CNA checked and the blood pressure was high or if there were any signs and symptoms." 2) On 8/29/12 at 11:00 a.m., the CNAs were interviewed: CNA #9 was asked, "Do you take blood pressures?" CNA #9 said, "Yes." The surveyor asked, "How do you know whose blood pressures to do and where do you document?" CNA #9 said, "The LPN writes down and then we document on the vital sheet." The surveyor asked, what would be parameters for high blood pressure that you would report to the LPN? CNA #9 said, "150/90 or greater." The surveyor asked, "Who do you report it to?" CNA #9 said, "To the LPN if high, but if not high you document. If high you report it immediately." The surveyor asked CNA #3, "Do you take blood pressures?" The CNA stated, "Yes." The surveyor asked CNA #3, "How do you know whose blood pressures to do and where do you document?" The CNA stated, "I write it on paper then the chart." The surveyor asked what would be parameters for high blood pressure that you would report to the LPN. The CNA stated, "140 to 150/90." The surveyor asked, "Who do you report it to and when?" The CNA stated, "The LPN immediately." The surveyor asked CNA #7, "Do you take blood pressures?" The CNA stated, "Yes." The surveyor asked CNA #3, "How do you know whose blood pressures to do and where do you document?" The CNA stated, "The paper then I put it on the vital sheet chart." The surveyor asked, "What would be parameters for high blood pressure that you would report to the LPN ?" The CNA stated, "160/90 and I would report immediately." 3) On 8/29/12 at 1:12 p.m., the surveyor asked LPN #4, "What are signs and symptoms of high blood pressure?" LPN #4 stated, "Headache, pulse rate, issue with nausea, but mostly headache." The surveyor asked LPN #2, "What are signs and symptoms of high blood pressure?" LPN #2 stated, "Nose bleed, headache, veins bulging, and dizziness." 4) On 29/12 at 10:10 a.m., the surveyor asked the DON, "Who takes blood pressures and how?" The DON, "Normally the CNA, the nurse at times has follow-ups. The information is placed on the clip board and the nurses review throughout the shift. The vitals are taken the first two hours of the shift. Anything over 140/90 the nurse monitors from parameters. The surveyor asked, "How do you or who is monitoring the blood pressures?" The DON stated, "Medical records is monitoring on pain, for blood pressure need to check with medical records." The surveyor asked, "Do you have any reports from the Consultant Pharmacist about the blood pressures and the monitoring of the blood pressure medication that is prn?" The DON said, "I will check." The surveyor asked, "If you have a resident on prn blood pressure medication bid, do you have the blood pressure taken bid and is it documented on the E-MAR?" The DON said, "Only if the physician has requested." The surveyor asked, "Does the facility notify the physician?" The DON said, "At times, if needed." f. A Physician's Telephone Order dated 8/29/12 at 7:10 a.m. documented, "DC (discontinue) the [MEDICATION NAME]" 1) On 8/29/12 at 4:20 p.m., the surveyor called the Physician. The surveyor asked the physician, "On the readmission of the resident to the facility there were no orders to monitor the blood pressure." The Physician stated, "That is hard to believe, they (blood pressure readings) are there for me when I do rounds. Check the progress notes." The surveyor asked, "Did you expect the facility to do blood pressure monitoring twice daily?" The Physician said, "No, once a week or monthly." The surveyor asked the Physician, "Were you notified of any blood pressures over the parameters (specified in the June 25, 2012 orders)?" The Physician stated, "Not that I remember." The surveyor asked, "Why did you DC (discontinue) the [MEDICATION NAME] this morning?" The Physician stated, "I am not aware, it must have been the APN (Advanced Practice Nurse)." 2) On 8/29/12 at 4:33 p.m., the surveyor called the APN. The surveyor asked, "Why did you DC the [MEDICATION NAME] this morning?" The APN stated, "(DON) called and I discontinued because of non-use." The surveyor asked, "Are you aware of the three times, once each in June, July and August, the [MEDICATION NAME] was administered and of the August 2012 readings 8/12- 170/86, 8/11 - 170/90, 8/10 - 194/86, 8/7 - 180/70, 8/3 - 180/90, 8/3 - 200/90?" The APN stated, "No, I will be calling with new orders." g. A Physician telephone order dated 8/29/12 documented, "Check B/P (blood pressure) BID (twice a day). [MEDICATION NAME] 0.1 mg (one) BID prn (as needed) for systolic BP greater than 160 or diastolic BP greater than 100." The Departmental Notes Nursing entry dated 8/29/12 at 11:41 p.m. documented, "[MEDICATION NAME] 0.1 mg tablet Blood Pressure = 200/140... was Administered for increased blood pressure." h. On 8/30/12 at 10:30 a.m., the surveyor asked the Director of Nursing (DON), "The telephone order for 8/29/12, why was the prn [MEDICATION NAME] discontinued?" The DON said, "I discussed with the APN and it had only been used three times in the last three months. At that time, I didn't realize the number of times it should been given and how high it had been. Now, I realize the importance to have all the information." i. The Geriatric Pharmaceutical Care Guidelines 2011 Edition on page 457 documented, "Anti-hypertension therapy also should not be withheld on the basis of age. In fact, results of recently published HYVET (Hypertension in the Very Elderly Trial) strongly suggest that lowering BP in patients at least [AGE] years of age significantly reduces their risk of death from stroke or total mortality." 3. The Immediate Jeopardy was removed and the scope/severity reduced to an "H" on 8/30/12 at 10:00 p.m. when the facility implemented the following plan of removal: a. The Director of Nursing identified all residents with blood pressure medications on an as needed basis. b. For each resident with potential to be affected, blood pressure was taken... The blood pressures were within normal parameters. c. The ADON (Assistant Director of Nursing) has notified the patient's attending physician and medical director for any residents with the potential to be affected. Also the blood pressures outside the parameters without medication administered. Reviewed the current as needed blood pressure medications and parameters. d. The Director of Nursing will identify and assess other residents who may also be at risk due to having the needed blood pressure medication. e. All licensed nursing staff on duty as of 6:34 p.m. have been inserviced by Director of Nursing on the following topic of monitoring residents that have blood pressure medications that should be administered on an as needed basis. They will be inserviced on accurate recording of all blood pressure readings. 1) DON will inservice staff on monitoring blood pressure, medicating as ordered, and documenting as ordered. 2) The monitoring process will include validation of information communicated to facility leadership and documented on the 24-hour report. 3) Residents identified at risk on the 24 hour report will be discussed at the daily stand-up meeting. The DON/designee will monitor weekdays and RN supervisor will monitor on weekends. 4) No other Licensed Nursing staff will be allowed to work until they have received the above noted in-service training. f. The Director of Nursing has scheduled inservice training to be conducted by the CQI Director for 10:00 p.m. tonight (8/29/12) for all available Licensed Nursing staff on the topics noted above under Immediate Response. Inservicing will be conducted utilizing a lecture method and discussion. Any Licensed Nurse who do not receive this training tonight will not be allowed to work.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure that Resident #5 received adequate supervision to prevent elopement. The facility failed to ensure staff supervision was provided to prevent elopement and reduce the risk of injury for 1 (Resident #5) of 3 (Residents #1, #2 and #5) case mix residents who were at risk for elopement. The facility failed to ensure Resident #5's wander guard bracelet was functioning. The failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury or death for Resident #5, who eloped from the facility, crossed a 4-lane road and was found on an interstate access road, 0.3 mile from the facility, and was likely to affect 7 residents at risk for elopement who had wander guard bracelets, according to a list provided by the Director of Nursing (DON) on [DATE]. The Immediate Jeopardy was removed by the facility on [DATE] prior to the survey entrance date, when the facility identified the issue and initiated corrective action. However, the underlying deficient practice was not fully corrected at the time of the survey. The facility was informed of the Immediate Jeopardy on [DATE] at 4:12 p.m. The findings are: 1. The "Wanderer Monitoring System Adult Transmitter User Guide" documented, "...Users must read this Guide before using the Product. Overview: This guide provides important information about the Wanderer Monitoring System Adult Transmitter, a component of the 9450 System. It provides detailed instructions about using the transmitter as well as specific requirements. 9450 System: The 9450 System monitors doors. ...The various transmitters and devices of the system alerts staff if monitored devices in the system are not functioning properly. An alarm also sounds if a transmitter is detected in an Exit Alarm Zone. If the system fails to detect a transmitter within its monitored area, a Check Transmitter alarm is issued. ...The Adult transmitter is a small device placed on the ankle or the wrist of a resident. It sends a signal to be received by Exit Alarm Receivers. Exit Alarm Receivers are low frequency antennas placed on or near a door frame or in an Exit Alarm Zone. They receive signals from transmitters within a monitored zone and send the signals to the Exit Alarm Controller, which triggers the alarm process. ...Required Transmitter Testing: You must test all transmitters prior to use to verify proper operation. This includes every time that the band is replaced. ...NOTE: All of these steps are mandatory. 1. Verify that the warranty expiration date that is stamped on the transmitter is not expired. 2. Visually inspect the transmitter for damage or loose parts. 3. Test the operation of the transmitter using the transmitter tester. The transmitter tester will detect whether or not a transmitter is emitting a signal, but cannot indicate the strength of the signal. ...d. While holding the button in, the indicator light flashes and a tone sounds once per second, wait for at least 3 flashes of the indicator light and 3 tones from the transmitter tester to verify that the transmitter is functioning correctly. ...4. Test the signal strength of the transmitter. a. Physically enter an exit zone with the transmitter and walk through the door. b. An alarm must occur when the transmitter is within 4-feet of the monitored door. ...c. If an alarm does not occur, Do Not Use The Transmitter ...Required weekly testing for transmitters in use: Note: Transmitters in use must be tested at least weekly. 1. Test the operation of transmitters in use weekly using the transmitter tester..." 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 5 (0 - 7 severe impairment) on the brief interview for mental status, had signs of delirium: inattention and disorganized thinking which fluctuated (comes and goes, changes in severity), wandered 4 to 6 days, but less than daily and was at risk for getting to dangerous places. a. The Care Plan dated [DATE] documented, "Problem/Need: Psychosocial / Mood / Behavior. Readmission. ...(History) of agitation (with) family, leaving home on foot, hitchhiking prior to admission to facility. Inattention / disorganized thinking / restlessness / wandering less than daily. ...Approaches: ..XXX[DATE] decreased safety awareness/wanders (with) verbal intent to 'go home' - Wander guard to ankle per (physician) orders." 1) The Risk of Elopement Review dated [DATE] documented the resident was at risk for elopement. 2) A Physician order [REDACTED]. Check placement every shift. Safety Precautions." b. The Departmental Notes dated [DATE] at 9:16 a.m. documented, "...Resident is very confused and continues to voice that she wants to go home. ...Resident does wander but does not intrude on the privacy of others..." c. The Daily Skilled Nurse's Note dated [DATE] at 10:26 p.m. documented, "...Gait steady, uses hand rails when walking in hall way... Wanders thru facility at times while up..." d. The Daily Skilled Nurse's Note dated [DATE] at 10:22 p.m. documented, "...Gait steady, uses hand rails when walking in hall way... Wanders thru facility at times while up..." e. The Departmental Notes dated [DATE] at 10:36 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, "This nurse was in dining room until 12:40 (p.m.), resident was sitting at table talking with residents. (I) came out dining room, administered two medications, returned to desk, received phone call at (approximately) 12:50 (p.m.) from resident's (family member), stating "This is (Resident #5)'s (family member), she is out and headed for the interstate." I hung up phone, yelled to other nurse, ran out of building to retrieve resident. Resident was found with no injuries and returned to facility at 1:05 p.m., body audit ...resident to ...emergency room to be evaluated to treated as indicated, resident was sent back to facility at 5:04 p.m. Resident transferred to another facility by personal auto by Administrator and (Assistant Director of Nursing)..." f. On [DATE] at 10:32 a.m., Certified Nursing Assistant (CNA) #1, who initialed the resident's ADL (Activity of Daily Living) Assistance and Support form on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] during the day shift, was asked: "Do you know of any residents that wander? If so who are they?" The CNA stated: "(Resident #5) would wander and get confused, she was ambulatory." CNA #1 was asked: "Did (Resident #5) wander to the exit doors?" CNA #1 stated, "Yes, she would go to the doors and push the door handles." The CNA was asked, "All exit doors?" CNA #1 stated, "Yes." The CNA was asked, "Did the alert alarm or wander guard sound when she got close to the exit doors?" CNA #1 stated, "I'm not sure. I can't remember ever hearing anyone's wander guard causing alarms at the side doors. They will set off the alarm at the front door. I can't remember if hers went off at the front door." CNA #1 was asked, "Did (Resident #5) ever try to go out any of the doors?" The CNA stated, "No, she'd go stand and look. We would redirect (Resident #5) away from the door. She did state often that she wanted to go home." g. On [DATE] at 10:50 a.m., CNA #2, who initialed the resident's ADL Assistance and Support form on [DATE] for the evening shift, was asked "Did (Resident #5) wander?" The CNA stated, "Yes." CNA #2 was asked, "Did (Resident #5) ever try to exit a door?" The CNA stated, "I've seen her at the main (front) door and she'd say I want to get out, how do I get out." The CNA was asked, "Did the alarm sound when she was at the front door?" CNA #2 stated, "Not that I recall." h. On [DATE] at 1:25 p.m., LPN #2, who was the resident's charge nurse on [DATE], [DATE], [DATE] and [DATE], was asked, "How long have you been checking the functioning of the wander guard alarms?" The LPN stated, "Since Monday ([DATE])." The LPN was asked, "(Resident #5), did she go to the exit doors a lot?" LPN #2 stated, "Yes, she would go to the front door but did not push on the door." LPN #2 was asked, "Did (Resident #5) try and go out the front door?" the LPN stated, "No, not that I ever seen." LPN #2 was asked, "Did the alarm sound when she was at the front door?" LPN # 2 stated, "Not that I recall." i. On [DATE] at 1:35 p.m., CNA #3 who initialed the resident's ADL Assistance and Support form on [DATE] for the day shift, was asked, "Do you remember (Resident #5)?" CNA #3 stated "Yes, she always wandered around like she was lost..." CNA #3 was asked, "On [DATE], how was (Resident #5). The CNA stated, "Same as usual, she was just wandering around then around lunch time we passed room trays first. I did Hall-5, then (Hall) 6 and when I got to Hall-1, the nurses were running towards the front door hollering get (Registered Nurse (RN) #1)." CNA #3 was asked, "Did you hear any alarms going off?" The CNA stated, "No. I went to the dining room and got (RN #1) and another CNA stated they got a call that (Resident #5) was near the bypass, so I ran down there. I got past the gas station and I didn't see anybody so I looked toward the interstate bypass and saw the nurses running onto the interstate. A housekeeper came by with her car and picked me up. We went under the interstate to the stop light below the (interstate) on-ramp toward exit 5 and turned around and came back. That's when I saw the resident. She was standing in between the traffic lanes by the on-ramp and the interstate going toward Malvern. After the fact, (CNA #4) told me she'd seen the resident at the front door and (Resident #5)'s alarm was not going off. (CNA #4) said she told the nurse the day before. She told (LPN #1) that the alarm must not be working." j. On [DATE] at 1:47 p.m., LPN # 1 was asked, "Did (Resident #5) have any behaviors?" The LPN stated, "We had to keep our eyes on her and she liked to wander." LPN #1 was asked, "Did (Resident #5) go to doors and try to exit?" The LPN stated, "No." LPN #1 was asked, "Did (Resident #5) have a wander guard on?" The LPN stated, "Yes." LPN #1 was asked, "Did you check (Resident #5)'s wander guard on Sunday [DATE]?" LPN #1 stated, "Yes, I looked to make sure it was on." The LPN was asked, "Did you test it to see if the alarm was functioning?" LPN #1 stated, "No." LPN #1 was asked, "Did you do anything else to check the resident's wander guard?" The LPN stated, "No, only see if they (wander guards) were on and if it was too loose or too tight." LPN #1 was asked, "When you got the call from the family about (Resident #5), were any alarms going off?" LPN #1 stated "No." LPN #1 was asked, "Do you know what door she exited through?" The LPN stated, "She walked out the front door, according to the residents who were in the lobby. She walked out behind people who were leaving." LPN #1 was asked, "Where was (Resident # 5) when you found her?" The LPN stated, "On the bypass. She walked up the on ramp toward Malvern on the right. We didn't see her because it was on a hill. She was on the opposite side of the street, across from the gas station. She was on the on-ramp." LPN #1 was asked, "What did (Resident #5) say about how she got out?" The LPN stated, "She said she'd gone out the front door." k. On [DATE] at 2:00 p.m., RN #2, who worked on [DATE], was asked "What happened Sunday, [DATE], with (Resident #5)?" The RN stated, "We came out of the dining room and went to the nursing station about 12:40 p.m., and about 12:50 p.m. the phone rang. It was (Resident #5)'s (family member) she said '(Resident #5) is out'. (LPN #1) told me to tell (RN #1), the RN Supervisor, and she went out the door to go get the resident." RN #2 was asked, "Did any of the door alarms go off?" The RN stated, "No, I was right there at the nursing station from 12:40 p.m. to 12:50 p.m. and no alarms went off." RN #2 was asked, "Where was (Resident #5) when you found her? On the bypass (interstate) or not?" The RN stated, "She was on the bypass where the service road (on-ramp) joins the bypass. ...She said she was headed to Malvern." l. On [DATE] at 2:10 p.m., Housekeeper #1 was asked, "How did you find out there was a problem with (Resident #5) on [DATE]?" The Housekeeper stated, "I was on Hall-5 and I was near the activity office and a phone call came in and I heard (LPN #1) on the phone. She hung up the phone, then yelled out 'tell (RN #1) to get out here'. So I jumped in my car and found the nurses on the other side of the beltway. I turned around and went up the ramp toward Malvern. I pulled over on the side and nurses brought her to the car." Housekeeper #1 was asked, "Did you hear any alarms going off?" The Housekeeper stated, "No." On [DATE] at 2:17 p.m., this surveyor drove Housekeeper #1 over the route she had driven on [DATE]. This surveyor then drove from the facility to the on-ramp, where Housekeeper #1 stated she had waited for the nurses and (Resident #5). This was approximately 0.3 miles from the facility. The resident had to cross Carpenter Dam Road, a 4-lane road, and was approximately 15-feet from the ,[DATE] bypass/interstate. m. On [DATE] at 2:47 p.m., CNA #4, who initialed the ADL Assistance and Support form for the resident on [DATE] and [DATE] for the day shift, was asked, "Did (Resident #5) have any behaviors?" The CNA stated, "Dementia, she wandered during meals. We had to go and find her and bring her back to eat." CNA #4 was asked, "Did you ever see (Resident #5) trying to go out the front door?" The CNA stated, "Not until this past Saturday ([DATE]). She was sitting by the door in the chair and she watched me putting in the code in the front door." CNA #4 was asked, "Was (Resident #5) near the front door?" CNA #4 stated, "Yes, she was in the chair by the door." The CNA was asked, "Was the wander guard alarm sounding?" CNA #4 stated, "No, it didn't dawn on me it wasn't going off. I did tell the nurse to keep an eye on the resident because I think she's trying to get out. It didn't dawn on me she had a wander guard on and it wasn't going off and she was sitting close to the door." CNA #4 showed this surveyor the chair in which the resident was sitting on [DATE]. The chair was approximately 2-feet from the key pad panel and 4-feet from the front door. n. On [DATE] at 3:00 p.m., the Director of Nursing (DON) stated, "I just received the wand (tester) for the wander guards." The DON demonstrated the wand/tester worked. The DON stated the facility would be using a spare wander guard to test the front door alarm, instead of taking the residents to the front door and teaching bad behavior. At 3:15 p.m., the DON was asked, "Tell me about (Resident #5)." The DON stated, "I received a phone call on Sunday [DATE] from the Administrator and she said (Resident #5) had gotten out of the building and I had to get up here ASAP (as soon as possible). ...As I was driving, I was on the phone with (LPN #1) and I had (LPN #1) have the resident demonstrate how she got out. (Resident #5) went to the front door and it was locked and (Resident #5) said it was locked. She did not try to put the code to exit. ... The resident could not reenact how she got out, but she was trying to go out the front door. When I got here we checked all the residents with wander guards by taking the resident's to the front door to make sure the wander guards were alarming." The DON was asked, "Was that previously part of your process to check the wander guards for functioning?" The DON stated "No. We also checked each resident who was supposed to have a wander guard to ensure it was on." The DON was asked, "Was that previously part of your process?" The DON stated, "Yes." The DON was asked, "How often was, is, that done?" The DON stated, "Every shift." The DON was asked, "Was checking the expiration date part of your previous process?" The DON stated, "No, that's new and it's on the MAR (Medication Administration Record)." The DON was asked, "Was checking the wander guard transmitter for functioning prior to putting it on a resident part of your previous process?" The DON stated "No." The DON was asked, "Do you know if (Resident #5)'s wander guard was functioning?" The DON stated, "Sadly, no it wasn't. ...We interviewed staff members that were here. I asked the staff if they heard an alarm and I didn't have anyone tell me they heard an alarm. We did an in-service with all staff on residents with Dementia. I did an in-service with the nurses on weekends and weekdays. I will complete the in-services by the end of the week. The DON and ADON (Assistant Director of Nursing) will visually watch three times a day that the system is being done." o. On [DATE] at 3:55 p.m., the DON presented a Strategic Action Plan dated [DATE] which documented, "...Problem: Elopement... Date: [DATE]. Action / Intervention: All residents with Code Alert bracelets were checked to (ensure) bracelets working properly. Person Responsible: DON. Target Date: [DATE]. Date: [DATE]. Action / Intervention: All staff to be inserviced regarding procedures for Dementia patients who wander. Person Responsible: Admin (Administrator) / DON. Target Date: [DATE]. Date: [DATE]. Action / Intervention: Nurses re-educated to facility procedure of checking placement of code alert bracelet each shift and walking resident to front door each day to be sure system is working properly. Person Responsible: DON. Target Date: (Blank). Date: [DATE]. Action / Intervention: DON/ADON to monitor system check by nurses 3 (times) (per) week to (ensure) system is working; being followed by staff. Person Responsible: DON/ADON. Target Date: (Blank). Date: [DATE]. Action / Intervention: Code alert wand (transmitter tester) ordered to check transmitters to prevent having to take residents to front door. Also extra transmitter ordered. Person Responsible: Medical Records. Target Date: (Blank). The Strategic Action Plan documented no action plan for staff education regarding testing of transmitters using the transmitter tester once it was delivered to the facility.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review, and interview Nursing Administration failed to ensure staff members were educated and knowledgeable of the procedures required to ensure wander guard bracelets were functioning to prevent elopement for 1 (Resident #5) of 3 (Residents #1, #2 and #5) case mix residents who were at risk for elopement. The facility failed to ensure Resident #5's wander guard bracelet was functioning. The failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury or death for Resident #5, who eloped from the facility, crossed a 4-lane road and was found on an interstate access road, 0.3 mile from the facility, and was likely to affect 7 residents at risk for elopement who had wander guard bracelets, according to a list provided by the Director of Nursing (DON) on [DATE]. The Immediate Jeopardy was removed by the facility on [DATE] prior to the survey entrance date, when the facility identified the issue and initiated corrective action. However, the underlying deficient practice was not fully corrected at the time of the survey. The facility was informed of the Immediate Jeopardy on [DATE] at 4:12 p.m. The findings are: 1. The "Position Description" for the Director of Nursing documented, "... Key Responsibilities: ...2. Implements policies/procedures with follow-up and supervision of staff to ensure compliance..." 2. The "Wanderer Monitoring System Adult Transmitter User Guide" documented, "...Users must read this Guide before using the Product. Overview: This guide provides important information about the Wanderer Monitoring System Adult Transmitter, a component of the 9450 System. It provides detailed instructions about using the transmitter as well as specific requirements. 9450 System: The 9450 System monitors doors. ...The various transmitters and devices of the system alerts staff if monitored devices in the system are not functioning properly. An alarm also sounds if a transmitter is detected in an Exit Alarm Zone. If the system fails to detect a transmitter within its monitored area, a Check Transmitter alarm is issued. ...The Adult transmitter is a small device placed on the ankle or the wrist of a resident. It sends a signal to be received by Exit Alarm Receivers. Exit Alarm Receivers are low frequency antennas placed on or near a door frame or in an Exit Alarm Zone. They receive signals from transmitters within a monitored zone and send the signals to the Exit Alarm Controller, which triggers the alarm process. ...Required Transmitter Testing: You must test all transmitters prior to use to verify proper operation. This includes every time that the band is replaced. ...NOTE: All of these steps are mandatory. 1. Verify that the warranty expiration date that is stamped on the transmitter is not expired. 2. Visually inspect the transmitter for damage or loose parts. 3. Test the operation of the transmitter using the transmitter tester. The transmitter tester will detect whether or not a transmitter is emitting a signal, but cannot indicate the strength of the signal. ...d. While holding the button in, the indicator light flashes and a tone sounds once per second, wait for at least 3 flashes of the indicator light and 3 tones from the transmitter tester to verify that the transmitter is functioning correctly. ...4. Test the signal strength of the transmitter. a. Physically enter an exit zone with the transmitter and walk through the door. b. An alarm must occur when the transmitter is within 4-feet of the monitored door. ...c. If an alarm does not occur, Do Not Use The Transmitter ...Required weekly testing for transmitters in use: Note: Transmitters in use must be tested at least weekly. 1. Test the operation of transmitters in use weekly using the transmitter tester..." 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 5 (0 - 7 severe impairment) on the brief interview for mental status, had signs of [MEDICAL CONDITION]: inattention and disorganized thinking which fluctuated (comes and goes, changes in severity), wandered 4 to 6 days, but less than daily and was at risk for getting to dangerous places. a. The Care Plan dated [DATE] documented, "Problem/Need: Psychosocial / Mood / Behavior. Readmission. ...(History) of agitation (with) family, leaving home on foot, hitchhiking prior to admission to facility. Inattention / disorganized thinking / restlessness / wandering less than daily. ...Approaches: ..XXX[DATE] decreased safety awareness/wanders (with) verbal intent to 'go home' - Wander guard to ankle per (physician) orders." 1) The Risk of Elopement Review dated [DATE] documented the resident was at risk for elopement. 2) A Physician order [REDACTED]. Check placement every shift. Safety Precautions." b. The Departmental Notes dated [DATE] at 9:16 a.m. documented, "...Resident is very confused and continues to voice that she wants to go home. ...Resident does wander but does not intrude on the privacy of others..." c. The Daily Skilled Nurse's Note dated [DATE] at 10:26 p.m. documented, "...Gait steady, uses hand rails when walking in hall way... Wanders thru facility at times while up..." d. The Daily Skilled Nurse's Note dated [DATE] at 10:22 p.m. documented, "...Gait steady, uses hand rails when walking in hall way... Wanders thru facility at times while up..." e. The Departmental Notes dated [DATE] at 10:36 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, "This nurse was in dining room until 12:40 (p.m.), resident was sitting at table talking with residents. (I) came out dining room, administered two medications, returned to desk, received phone call at (approximately) 12:50 (p.m.) from resident's (family member), stating "This is (Resident #5)'s (family member), she is out and headed for the interstate." I hung up phone, yelled to other nurse, ran out of building to retrieve resident. Resident was found with no injuries and returned to facility at 1:05 p.m., body audit ...resident to ...emergency room to be evaluated to treated as indicated, resident was sent back to facility at 5:04 p.m. Resident transferred to another facility by personal auto by Administrator and (Assistant Director of Nursing)..." f. On [DATE] at 10:32 a.m., Certified Nursing Assistant (CNA) #1, who initialed the resident's ADL (Activity of Daily Living) Assistance and Support form on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] during the day shift, was asked: "Do you know of any residents that wander? If so who are they?" The CNA stated: "(Resident #5) would wander and get confused, she was ambulatory." CNA #1 was asked: "Did (Resident #5) wander to the exit doors?" CNA #1 stated, "Yes, she would go to the doors and push the door handles." The CNA was asked, "All exit doors?" CNA #1 stated, "Yes." The CNA was asked, "Did the alert alarm or wander guard sound when she got close to the exit doors?" CNA #1 stated, "I'm not sure. I can't remember ever hearing anyone's wander guard causing alarms at the side doors. They will set off the alarm at the front door. I can't remember if hers went off at the front door." CNA #1 was asked, "Did (Resident #5) ever try to go out any of the doors?" The CNA stated, "No, she'd go stand and look. We would redirect (Resident #5) away from the door. She did state often that she wanted to go home." g. On [DATE] at 10:50 a.m., CNA #2, who initialed the resident's ADL Assistance and Support form on [DATE] for the evening shift, was asked "Did (Resident #5) wander?" The CNA stated, "Yes." CNA #2 was asked, "Did (Resident #5) ever try to exit a door?" The CNA stated, "I've seen her at the main (front) door and she'd say I want to get out, how do I get out." The CNA was asked, "Did the alarm sound when she was at the front door?" CNA #2 stated, "Not that I recall." h. On [DATE] at 1:25 p.m., LPN #2, who was the resident's charge nurse on [DATE], [DATE], [DATE] and [DATE], was asked, "How long have you been checking the functioning of the wander guard alarms?" The LPN stated, "Since Monday ([DATE])." The LPN was asked, "(Resident #5), did she go to the exit doors a lot?" LPN #2 stated, "Yes, she would go to the front door but did not push on the door." LPN #2 was asked, "Did (Resident #5) try and go out the front door?" the LPN stated, "No, not that I ever seen." LPN #2 was asked, "Did the alarm sound when she was at the front door?" LPN # 2 stated, "Not that I recall." i. On [DATE] at 1:35 p.m., CNA #3 who initialed the resident's ADL Assistance and Support form on [DATE] for the day shift, was asked, "Do you remember (Resident #5)?" CNA #3 stated "Yes, she always wandered around like she was lost..." CNA #3 was asked, "On [DATE], how was (Resident #5). The CNA stated, "Same as usual, she was just wandering around then around lunch time we passed room trays first. I did Hall-5, then (Hall) 6 and when I got to Hall-1, the nurses were running towards the front door hollering get (Registered Nurse (RN) #1)." CNA #3 was asked, "Did you hear any alarms going off?" The CNA stated, "No. I went to the dining room and got (RN #1) and another CNA stated they got a call that (Resident #5) was near the bypass, so I ran down there. I got past the gas station and I didn't see anybody so I looked toward the interstate bypass and saw the nurses running onto the interstate. A housekeeper came by with her car and picked me up. We went under the interstate to the stop light below the (interstate) on-ramp ramp toward exit 5 and turned around and came back. That's when I saw the resident. She was standing in between the traffic lanes by the on-ramp and the interstate going toward Malvern. After the fact, (CNA #4) told me she'd seen the resident at the front door and (Resident #5)'s alarm was not going off. (CNA #4) said she told the nurse the day before. She told (LPN #1) that the alarm must not be working." j. On [DATE] at 1:47 p.m., LPN # 1 was asked, "Did (Resident #5) have any behaviors?" The LPN stated, "We had to keep our eyes on her and she liked to wander." LPN #1 was asked, "Did (Resident #5) go to doors and try to exit?" The LPN stated, "No." LPN #1 was asked, "Did (Resident #5) have a wander guard on?" The LPN stated, "Yes." LPN #1 was asked, "Did you check (Resident #5)'s wander guard on Sunday [DATE]?" LPN #1 stated, "Yes, I looked to make sure it was on." The LPN was asked, "Did you test it to see if the alarm was functioning?" LPN #1 stated, "No." LPN #1 was asked, "Did you do anything else to check the resident's wander guard?" The LPN stated, "No, only see if they (wander guards) were on and if it was too loose or too tight." LPN #1 was asked, "When you got the call from the family about (Resident #5), were any alarms going off?" LPN #1 stated "No." LPN #1 was asked, "Do you know what door she exited through?" The LPN stated, "She walked out the front door, according to the residents who were in the lobby. She walked out behind people who were leaving." LPN #1 was asked, "Where was (Resident # 5) when you found her?" The LPN stated, "On the bypass. She walked up the on ramp toward Malvern on the right. We didn't see her because it was on a hill. She was on the opposite side of the street, across from the gas station. She was on the on-ramp." LPN #1 was asked, "What did (Resident #5) say about how she got out?" The LPN stated, "She said she'd gone out the front door." k. On [DATE] at 2:00 p.m., RN #2, who worked on [DATE], was asked "What happened Sunday, [DATE], with (Resident #5)?" The RN stated, "We came out of the dining room and went to the nursing station about 12:40 p.m., and about 12:50 p.m. the phone rang. It was (Resident #5)'s (family member) she said '(Resident #5) is out'. (LPN #1) told me to tell (RN #1), the RN Supervisor, and she went out the door to go get the resident." RN #2 was asked, "Did any of the door alarms go off?" The RN stated, "No, I was right there at the nursing station from 12:40 p.m. to 12:50 p.m. and no alarms went off." RN #2 was asked, "Where was (Resident #5) when you found her? On the bypass (interstate) or not?" The RN stated, "She was on the bypass where the service road (on-ramp) joins the bypass. ...She said she was headed to Malvern." l. On [DATE] at 2:10 p.m., Housekeeper #1 was asked, "How did you find out there was a problem with (Resident #5) on [DATE]?" The Housekeeper stated, "I was on Hall-5 and I was near the activity office and a phone call came in and I heard (LPN #1) on the phone. She hung up the phone, then yelled out 'tell (RN #1) to get out here'. So I jumped in my car and found the nurses on the other side of the beltway. I turned around and went up the ramp toward Malvern. I pulled over on the side and nurses brought her to the car." Housekeeper #1 was asked, "Did you hear any alarms going off?" The Housekeeper stated, "No." On [DATE] at 2:17 p.m., this surveyor drove Housekeeper #1 over the route she had driven on [DATE]. This surveyor then drove from the facility to the on-ramp, where Housekeeper #1 stated she had waited for the nurses and (Resident #5). This was approximately 0.3 miles from the facility. The resident had to cross Carpenter Dam Road, a 4-lane road, and was approximately 15-feet from the ,[DATE] bypass/interstate. m. On [DATE] at 2:47 p.m., CNA #4, who initialed the ADL Assistance and Support form for the resident on [DATE] and [DATE] for the day shift, was asked, "Did (Resident #5) have any behaviors?" The CNA stated, "Dementia, she wandered during meals. We had to go and find her and bring her back to eat." CNA #4 was asked, "Did you ever see (Resident #5) trying to go out the front door?" The CNA stated, "Not until this past Saturday ([DATE]). She was sitting by the door in the chair and she watched me putting in the code in the front door." CNA #4 was asked, "Was (Resident #5) near the front door?" CNA #4 stated, "Yes, she was in the chair by the door." The CNA was asked, "Was the wander guard alarm sounding?" CNA #4 stated, "No, it didn't dawn on me it wasn't going off. I did tell the nurse to keep an eye on the resident because I think she's trying to get out. It didn't dawn on me she had a wander guard on and it wasn't going off and she was sitting close to the door." CNA #4 showed this surveyor the chair in which the resident was sitting on [DATE]. The chair was approximately 2-feet from the key pad panel and 4-feet from the front door. n. On [DATE] at 3:00 p.m., the Director of Nursing (DON) stated, "I just received the wand (tester) for the wander guards." The DON demonstrated the wand/tester worked. The DON stated the facility would be using a spare wander guard to test the front door alarm, instead of taking the residents to the front door and teaching bad behavior. At 3:15 p.m., the DON was asked, "Tell me about (Resident #5)." The DON stated, "I received a phone call on Sunday [DATE] from the Administrator and she said (Resident #5) had gotten out of the building and I had to get up here ASAP (as soon as possible). ...As I was driving, I was on the phone with (LPN #1) and I had (LPN #1) have the resident demonstrate how she got out. (Resident #5) went to the front door and it was locked and (Resident #5) said it was locked. She did not try to put the code to exit. ... The resident could not reenact how she got out, but she was trying to go out the front door. When I got here we checked all the residents with wander guards by taking the resident's to the front door to make sure the wander guards were alarming." The DON was asked, "Was that previously part of your process to check the wander guards for functioning?" The DON stated "No. We also checked each resident who was supposed to have a wander guard to ensure it was on." The DON was asked, "Was that previously part of your process?" The DON stated, "Yes." The DON was asked, "How often was, is, that done?" The DON stated, "Every shift." The DON was asked, "Was checking the expiration date part of your previous process?" The DON stated, "No, that's new and it's on the MAR (Medication Administration Record)." The DON was asked, "Was checking the wander guard transmitter for functioning prior to putting it on a resident part of your previous process?" The DON stated "No." The DON was asked, "Do you know if (Resident #5)'s wander guard was functioning?" The DON stated, "Sadly, no it wasn't. ...We interviewed staff members that were here. I asked the staff if they heard an alarm and I didn't have anyone tell me they heard an alarm. We did an in-service with all staff on residents with Dementia. I did an in-service with the nurses on weekends and weekdays. I will complete the in-services by the end of the week. The DON and ADON (Assistant Director of Nursing) will visually watch three times a day that the system is being done." o. On [DATE] at 3:55 p.m., the DON presented a Strategic Action Plan dated [DATE] which documented, "...Problem: Elopement... Date: [DATE]. Action / Intervention: All residents with Code Alert bracelets were checked to (ensure) bracelets working properly. Person Responsible: DON. Target Date: [DATE]. Date: [DATE]. Action / Intervention: All staff to be inserviced regarding procedures for Dementia patients who wander. Person Responsible: Admin (Administrator) / DON. Target Date: [DATE]. Date: [DATE]. Action / Intervention: Nurses re-educated to facility procedure of checking placement of code alert bracelet each shift and walking resident to front door each day to be sure system is working properly. Person Responsible: DON. Target Date: (Blank). Date: [DATE]. Action / Intervention: DON/ADON to monitor system check by nurses 3 (times) (per) week to (ensure) system is working; being followed by staff. Person Responsible: DON/ADON. Target Date: (Blank). Date: [DATE]. Action / Intervention: Code alert wand (transmitter tester) ordered to check transmitters to prevent having to take residents to front door. Also extra transmitter ordered. Person Responsible: Medical Records. Target Date: (Blank). The Strategic Action Plan documented no action plan for staff education regarding testing of transmitters using the transmitter tester once it was delivered to the facility. 4. On [DATE] at 5:50 p.m., the DON was asked, "How long have you been the Director of Nurses?" The DON stated, "I started the last week of November in 2010 - 9 months." The DON was asked, "Was there any reason you had not reviewed the wander guard system directions prior to [DATE]?" The DON stated, "No, it was in place and I just continued what was in place. I didn't know we were to check functioning of bracelets until (Resident #5) eloped and I read the directions."