Every finding on record at The Springs of Waldron

Based on observation, interview, and record review, the facility failed to ensure foods stored in the dry storage areas, refrigerator, and freezer were covered and sealed, expired food items were promptly removed, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On [DATE] at 11:13 AM, the following observations were made in the kitchen areas: a. An opened box of baking soda was in the cabinet above the food preparation counter. The box had an expiration date of [DATE]. The Dietary Manager (DM) was interviewed and was asked what she use baking soda for. The DM stated the staff used it when a recipe calls for it, but they had not used it to bake anything in a long time. b. Five (5) boxes of baking soda were in a cabinet above the food preparation counter. The boxes had an expiration date of [DATE]. c. An opened box of brown sugar was on a shelf above the food preparation counter. The bag was not sealed. d. An opened bag of grits was on the shelf above the food preparation counter. The bag was not sealed. e. An opened box of plain salt was on shelf above the food preparation counter. The box of salt was not covered. f. An opened gallon of soy sauce was on shelf below the food preparation counter. the manufacturer's instructions on the gallon indicated, Refrigerate after opening. 2. On [DATE] at 11:38 AM, the following observations were made in the storage room: a. An opened 50-pound (lb.) bag of white cake mix. The bag was not sealed. b. An opened 25 lb. bag of fortified milk. The bag was not sealed. c. An opened 25lb. bag of brown sugar. The bag was not sealed. d. An opened 50 lb. bag of cornmeal. The bag was not sealed. 3. On [DATE] at 11:42 AM, the following observations were made on a shelf in the walk-in refrigerator: a. An opened box of doughnuts. The box was not covered. b. An opened clear bag of coconut. The bag was not sealed. c. An opened clear bag of bag of yogurt. The bag was not sealed. d. An opened bag of shredded carrots. The bag was not sealed. e. Two (2) opened boxes of baking soda. The opened boxes had expiration dates of [DATE]. 4. On [DATE] AM at 11:44 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened bag of vegetables blend. The bag was not sealed. b. An opened box of biscuits. The box was not covered or sealed. c. An opened box of chicken nuggets. The bag was not sealed. d. An opened box of peas and carrots. The box was not covered or sealed. e. An opened bag of onion rings. The bag was not sealed. f. An opened bag of fries. The bag was not sealed. g. An opened box of corn on the cob. The box was not covered or sealed. 5. On [DATE] at 12:14 PM, Dietary [NAME] (DC) #1 wore gloves when opening an alcohol packet, contaminating the gloves in the process. DC #1 then used the contaminated gloves to remove an alcohol pad. Without changing gloves or washing her hands, DC #1 touched bread sticks in a pan on the stove with the contaminated gloves. DC #1 wiped the stem of the temperature gauge with an alcohol pad and checked the temperature of the meatballs. DC #1 then used the contaminated glove to push the meatball stuck on the temperature gauge tip into a pan. DC #1 was interviewed immediately and was asked what she should have done after touching dirty objects and before handling food items. DC #1 stated she should have removed gloves and washed her hands. 6. On [DATE] at 12:32 PM, Dietary [NAME] (DC) #1 wore gloves on her hands while serving the lunch meal. DC #1 picked up tray cards, contaminating the gloves. Without changing gloves and washing her hands, DC #1 picked up plates, placed them on the plates inside the trays with her fingers, touching the inside of the plates to be used in portioning food items to be served to the residents. DC #1picked up bread sticks and placed them on the plates to be served to the residents. 7. On [DATE] at 1:03 PM, Dietary [NAME] (DC) #4 opened the refrigerator door, took out a jelly, and placed it on the counter. DC #4 did not wash her hands. She placed gloves on her hands and contaminated the gloves. DC #4 untied the bread bag, removed slices of bread from the bag, placed them on the plate, and spread peanut butter and jelly on the slices of bread to be served to the residents who requested it. 8. On [DATE] at 7:19 AM, DC #1 had gloves on her hands when she was on the tray line serving the breakfast meal. She picked up tray cards and placed them on the trays, contaminating the gloves. Without changing gloves and washing her hands, DC #1picked up plates and bowls, touching the inside of the plates and bowls with her contaminated gloved fingers, and placed them on the steam table shelf for portioning food items to be served to the residents for breakfast meal. DC #1was interviewed and was asked what she should have done after touching and before handling food items. DC #1stated she should have washed her hands. 9. On [DATE] at 7:53 AM, DC #1 tucked her gloved hands below her chest, touched her blouse, and contaminated the gloves. DC #1 then picked up a tray card and held it in her contaminated gloved hand. Without changing gloves and washing her hands, DC #1 picked up a plate with the contaminated gloved fingers inside the plate. Then she picked slices of toast up and placed on a plate to be served to the residents for the breakfast meal. DC #1 was interviewed and was asked what she should have done after touching dirty objects and before handling food items. DC #1 stated she should have removed gloves and washed her hands. 10. A review of facility policy titled, Manual: Food and Nutrition Services-Quick Resources tool: Hand washing not dated and provided by the Dietary Manager indicated hands should be washed as often as possible, before starting to work with food, utensils or equipment and as needed during food preparation and when changing tasks.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff used proper hand hygiene when providing care for 2 (Residents #5, #6) of 3 (Residents #4, #5, #6) sampled residents. The finding include: 1. A review of the significant change Minimum Data Set (MDS), with the Assessment Reference Date of 9/15/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate impaired cognition. Resident #5 was frequently incontinent of bowel and bladder. a. A plan of care for Resident #5, revision date 8/15/2023, revealed Resident #5 had an Activities of Daily Living (ADL) self-care deficit related to impaired mobility, weakness, and fluctuation in mental status. b. On 12/10/2024 at 1:45 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 did not use proper hand hygiene while providing care to Resident #5. This surveyor observed CNA #2 apply a clean brief and place a pillow under the resident's knees with dirty gloves. c. On 12/10/2024 at 2:00PM, CNA #3 stated hand hygiene should be used between glove changes and confirmed that hand hygiene was not done between glove changes. d. CNA #2 stated that she should have applied clean gloves prior to placing a clean brief on resident #5, and she potentially spread germs by handling the resident's pillow with dirty gloves. 2. A review of the quarterly Minimum Data Set (MDS), with the Assessment Reference Date of 10/29/2024, revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Resident #6 had an unhealed stage II pressure ulcer. a. A plan of care for Resident #5, revision date 12/06/2024, revealed Resident #6 was at risk for impaired skin integrity related to impaired mobility and declining health. b. On 12/11/2024 at 7:47 AM, this surveyor observed the Infection Control/Wound Care Nurse provide wound care to Resident #6. The Infection Control/Wound Care Nurse did not don the proper Personal Protective Equipment (PPE) prior to providing care or use proper hand hygiene during care. c. On 12/11/2024 at 7:47 AM, while providing care to Resident #6, the Infection Control/Wound Care Nurse stated after removing gloves I usually use hand sanitizer at this time but did not. 3. On 12/11/2024 at 8:08 AM, the Director of Nursing (DON) stated staff should wash or sanitize hands between glove changes. The DON stated staff should not apply a clean brief with dirty gloves, because you are dirtying your clean. 4. A policy titled Handwashing/Hand Hygiene noted this facility considers hand hygiene the primary means to prevent the spread of infection.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are: 1. On 12/09/2024, the menu for the noon meal documented residents on pureed regular diets and on mechanical soft diets were to receive 4 ounces (oz) of meat balls in sauce. 2. On 12/9/24 at 12:11 PM, Dietary [NAME] (DC) #1 placed 16 meatballs into a blender and ground. DC #1 poured the ground meatballs into a pan and placed it on the steam table to be served to 17 residents who required mechanical soft diets. 3. On 12/9/24 at 12:30 PM, during the noon meal service, DC #1 used a 2-ounce spoon to serve a single portion of ground meatballs to eight (8) residents on mechanical soft diets instead of 4 ounces. At 12:51 PM, the 16 meatballs prepared to be served to 17 residents ran out after serving 8 residents 2 ounces instead of 4 ounces. 4. On 12/9/24 at 12:53 PM, DC #1 placed 21 meat balls into a pan and handed it to the Dietitian. The Dietitian poured the meatballs into a blender, ground, and poured the ground meat content into a pan and placed it on the steam table to be served to the remaining nine (9) residents who received mechanical soft diets. At 12:58 PM, DC #1 used a 2-ounce spoon to serve a single portion of ground meat balls to residents on mechanical soft diets, instead of 4 ounces. 5. On 12/09/24 at 1:50 PM, the Assistant Dietary Manager (ADM) was asked if she could weigh the meatballs starting from one (1) meatball. She did so and stated one (1) meatball weighed 1 ounce, two (2) meatballs weighed 2 ounces, and three (3) meatballs weighed 3 ounces. 6. On 12/10/24 at 11:38 AM, DC #1 was interviewed and asked if there was any reason she should not serve the proper number of meatballs, and if she checked the menu or recipe to determine how many meatballs to cook for the number of residents who received meal trays from the kitchen. DC #1 stated she didn't think she did enough. She gave three (3) meatballs each to about 15 residents and gave two (2) meatballs to the rest of the residents. DC #1 stated she would have run out of meatballs if she had given three (3) meatballs to each resident. DC #1 confirmed that she did not prepare enough. She would have needed to use at least three (3) or four (4) bags of meatballs, but there were only two (2) bags available in the freezer and that's what she used.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the physician's order for wound care was followed correctly for 1 (Resident #6) of 3 (Residents #4, #5, #6) sampled residents. The finding include: A review of the quarterly Minimum Data Set (MDS), with the Assessment Reference Date of 10/29/2024, revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. Resident #6 had an unhealed stage II pressure ulcer. The plan of care for Resident #6, revision date 12/06/2024, revealed Resident #6 was at risk for impaired skin integrity related to impaired mobility and declining health. A review of the Treatment Administration Record (TAR) revealed that Resident #6 had a physician's order for treatment to right side of the sacrum to cleanse with normal saline (NS), pat dry, apply Leptospermum (Manuka) honey (a medication used to treat wounds and burns), and cover with duoderm (a hydrocolloid, moisture-retentive wound dressing used for partial and full-thickness wounds with exudate). On 12/11/2024 at 7:47 AM, this surveyor observed the Infection Control/Wound Care Nurse provide wound care to Resident #6. This surveyor observed the Infection Control/Wound Care Nurse clean the wound with dermal wound cleanser, apply Leptospermum (Manuka) honey (a medication used to treat wounds and burns), and a hydrocolloid dressing. On 12/11/2024 at 8:50 AM, the Infection Control/Wound Care Nurse stated, I messed up. I misread the order and used wound cleanser rather than normal saline. On 12/11/2024 at 9:20 AM, the Director of Nursing (DON) stated that wound cleanser and normal saline are not the same. Therefore, the physician's order was not followed. The DON stated not following the physician's order could harm the resident and affect the healing of the wound. A review of the facility policy titled Wound Care noted the purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure incontinence care was provided to 1 (Resident #5) of 3 (Residents #4, #5, #6) sampled residents in a manner to promote cleanliness and/or prevent skin breakdown. The findings include: A review of the significant change Minimum Data Set (MDS), with the Assessment Reference Date of 9/15/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate impaired cognition. Resident #5 was frequently incontinent of bowel and bladder. A plan of care for Resident #5, revision date 8/15/2023, revealed Resident #5 had an Activities of Daily Living (ADL) self-care deficit related to impaired mobility, weakness, and fluctuation in mental status. On 12/10/2024 at 1:45 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 provide incontinence care to Resident #5, who had been incontinent of bladder. CNA #2 and CNA #3 did not clean all areas of the perineal and buttock areas that had been exposed to urine. On 12/10/2024 at 2:00 PM, CNA #2 and CNA #3 both confirmed all areas exposed to urine were not cleaned. CNA #2 stated not cleaning all areas exposed to urine could potentially cause urine to remain on the resident and/or cause skin breakdown. On 12/11/2024 at 8:08 AM, the Director of Nursing (DON) stated when staff provide incontinent care to the resident all areas exposed to urine should be cleaned to get germs, urine, and/or stool off the resident's body and prevent skin breakdown. A review of facility policy titled Perineal Care noted the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne diseases in building water system. The facility failed to have staff use appropriate Personal Protective Equipment (PPE) when providing care to a resident on droplet precautions for 1 (Resident # 2) sampled resident. The findings include: 1. A review of a facility policy titled, Water Management Program dated 02/12/2024, indicated the following: a. The control measures, locations, and frequency-controlled measures shall be implemented at the location of risk areas on a weekly basis by the maintenance director or designee. Common control measures include but are not limited to the following: i. Visual inspection ii. Disinfection levels iii. Temperature checks. b. Monitor and respond- when it is determined that the control limits are not usually met, the maintenance director shall report to the water management team and corrective actions shall occur. Control measures and limits include: i. Total dissolved solids (TDS) PPM acceptable range 0-399 ii. pH acceptable range 6.5-8.5 iii. Hot water temperature acceptable range >108 and < state established anti scold limit. Cold water temp acceptable range <77. 2. On 07/30/2024 at 1:20 PM, the Surveyor interviewed the Maintenance Director about Legionella. The Maintenance Director denied knowing anything about it. Stated they had heard of it but is not sure what it was. 3. On 07/30/2024 at 1:24 PM, the Surveyor asked the Administrator about their process for Legionella. The Administrator stated maintenance takes care of it. When told maintenance didn't know anything about it, the Administrator called corporate maintenance who provided a copy of their policy and procedure that stated the team shall include but not be limited to the Administrator, Director of Nursing, Infection Prevention and Maintenance Director. The Infection Prevention Nurse was unavailable at the time. 4. On 07/30/2024 at 2:15 PM, the Surveyor interviewed the Director of Nursing (DON) about being on the water management team. The Director of Nursing stated they didn't know anything about it, they just started about two months ago. The DON stated understanding of what it is but had not been monitoring it here. 5. Resident #2's care plan with a revision date of 07/29/2024 indicated, .Resident #2 had a diagnosis of COVID 19 .Resident is on droplet precautions due to testing positive for COVID-19 on 7/22/2024 Resident will not be socially isolated through plan of tx (treatment) this qtr (quarter) .Disinfect all equipment used before it leaves the room . Droplet isolation: Gown, gloves, and mask to be worn at all times while providing care/in room .Educate resident/family/staff regarding preventive measures to contain the infection . a. A review of physician's orders dated 7/22/24 indicated, .droplet precautions until 08/02/2024 related to positive COVID on 7/22/24 . b. On 07/30/2024 at 2:29 PM, the Surveyor observed the Droplet Precaution sign on the door that showed pictures with instructions of proper usage of Personal Protective Equipment (PPE) and stated Droplet Precaution Stop: Everyone must wear mask; Doctors and staff Must: Wear eye protection, gown and gloves with specific directions for the order it must be done. Wash hands or use hand sanitizer, gown, mask, eye cover and gloves. c. On 07/30/2024 at 1:30 PM, the surveyor observed Certified Nursing Assistant (CNA) #1 enter Resident # 2's room and bring out a lunch tray with only a surgical mask on. CNA #1 was asked what the signs were on the door as they stopped and read them and stated it was precaution in case they spit or sneezed on you, they only wear a surgical mask when entering the room to pick up tray but if she needs to turn, reposition or clean her they fully dress out. The surveyor noticed on the door were face shields, gloves and gown on the hanger for PPE. d. On 07/30/2024 at 2:20 PM, CNA #1 brought N95 mask and placed them in the PPE hanger. CNA #1 and CNA #2 were going in the room together. Prior to entry the surveyor asked why the signs were up, what did the Resident have? CNA #1 & CNA #2 were unable to answer. When asked what the need is for using the correct PPE, they said to protect themselves from getting sick then after a few moments they said to prevent other residents from getting ill as well. e. On 07/30/2024 PM at 3:00 PM, the Surveyor asked the DON what the protocol for proper PPE for Resident #2. The DON pointed at the sign on the door and stated gown, mask, eye cover and gloves; to discard gloves, eye cover, gown and mask. When asked what the importance was of using proper PPE, the DON stated to prevent the spread of illness to other residents.

Based on record review and interview, the facility failed to ensure the Medical Director fulfilled his/her responsibility for the implementation of resident care policies and/or the coordination of medical care in the facility. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time of death needed to be called. c. During an interview on [DATE] at 04:05 PM, the Funeral Home Owner/Deputy Coroner confirmed that he/she was called by the nursing home on his/her funeral home answering service line for a body pick up for the funeral home and that the coroner's office did not dispatch him/her to call time of death. d. During an interview on [DATE] at 09:39 AM, LPN #01 stated he/she called the Administrator and the Medical Director to report the resident had expired but had not contacted the coroner's office directly. e. During an interview on [DATE] at 09:22 AM, the Administrator confirmed he/she was to be notified of a resident expiring in the facility but was not notified Resident #04 had expired until [DATE], and that the County Coroner had not been notified by the facility or the Medical Director. f. During an interview on [DATE] at 09:27 AM, the Medical Director confirmed he/she received a text message on [DATE] at 02:53 PM that Resident #04 had expired. The Surveyor asked, What is the procedure when you are notified a resident has expired? The Medical Director stated, Umm, usually they will just contact me if a resident passed. The Surveyor asked, Did you come into the facility and attend the death of the resident? The Medical Director stated, As far as I know we've never come in to pronounce patients. The Surveyor asked, Did you contact the County Coroner's office to notify them that [Resident #04] had expired in the facility? The Medical Director stated, No, usually the facility will do that without having to be told.

Based on interview and record review, the facility failed to ensure the Administrator was responsible for the overall operation of the facility. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress Note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time of death needed to be called. c. During an interview on [DATE] at 04:05 PM, the Funeral Home Owner/Deputy Coroner confirmed that he/she was called by the nursing home on his/her funeral home answering service line for a body pick up for the funeral home and that the coroner's office did not dispatch him/her to call time of death. d. During an interview on [DATE] at 09:39 AM, LPN #01 stated he/she called the Administrator and the Medical Director to report the resident had expired but had not contacted the coroner's office directly. e. During an interview on [DATE] at 09:22 AM, the Administrator confirmed he/she was to be notified of a resident expiring in the facility but was not notified Resident #04 had expired until [DATE], and that the County Coroner had not been notified by the facility or the Medical Director.

Based on interview and record review, the facility failed to ensure compliance with all applicable Federal, State, and local laws, regulations, and codes by failing to ensure a death was reported to the Coroner's office. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress Note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time of death needed to be called. c. During an interview on [DATE] at 04:05 PM, the Funeral Home Owner/Deputy Coroner confirmed that he/she was called by the nursing home on his/her funeral home answering service line for a body pick up for the funeral home and that the coroner's office did not dispatch him/her to call time of death. d. During an interview on [DATE] at 09:39 AM, LPN #01 stated he/she called the Administrator and the Medical Director to report the resident had expired but had not contacted the coroner's office directly. e. During an interview on [DATE] at 09:22 AM, the Administrator confirmed he/she was to be notified of a resident expiring in the facility but was not notified Resident #04 had expired until [DATE], and that the County Coroner had not been notified by the facility or the Medical Director. f. During an interview on [DATE] at 09:27 AM, the Medical Director confirmed he/she received a text message on [DATE] at 02:53 PM that Resident #04 had expired. The Surveyor asked, What is the procedure when you are notified a resident has expired? The Medical Director stated, Umm, usually they will just contact me if a resident passed. The Surveyor asked, Did you come into the facility and attend the death of the resident? The Medical Director stated, As far as I know we've never come in to pronounce patients. The Surveyor asked, Did you contact the County Coroner's office to notify them that [Resident #04] had expired in the facility? The Medical Director stated, No, usually the facility will do that without having to be told. g. A facility In-Service titled, Death in Facility, provided by the Administrator on [DATE] at 09:56 AM documented, .1. Order obtained to release body to funeral home (our Doctor) .3. MD/NP [Medical Director/Nurse Practioner] notification documented .5. Coroner notified documented (Make contact, have to talk to them!!!) . h. Facility policy titled, Post-Mortem Care Policy and Procedure provided by the Administrator on [DATE] at 10:07 AM documented, .Procedure: 1. Follow regulations for reporting deaths to the coroner's office. Licensed nurse will obtain an order from the physician or physician designee releasing the body to the mortuary before beginning post-mortem care . i. The 2010 Arkansas Code Title 20 - Public Health And Welfare Subtitle 2 - Health And Safety Chapter 18 - Vital Statistics Act Subchapter 6 - Deaths S [DATE] - Registration generally documented: .(c) (1) (A)The medical certification shall be completed, signed, and returned to the funeral director within two (2) business days after receipt of the death certificate by the physician in charge of the patient's care for the illness or condition that resulted in death . (2) The Arkansas State Medical Board shall enforce by rule subdivision (c)(1) of this section concerning the time period in which the medical certification shall be executed . (3) A registered nurse employed by the attending hospice may complete and sign the medical certification of death and pronounce death for a patient who is terminally ill, whose death is anticipated, who is receiving services from a hospice program certified under [DATE], and who dies in a hospice inpatient program or as a hospice patient in a nursing home. (4) If the hospice patient dies in the home, the registered nurse may make pronouncement of death. However, the coroner and the chief law enforcement official of the county or municipality where death occurred shall be immediately notified in accordance with [DATE]. (5) The Department of Health shall provide hospitals, nursing homes, and hospices with the appropriate death certificate forms, which will be made available to the certifier of death. When death occurs outside these health facilities, the funeral home shall provide the death certificate to the certifier of death. (d) If the cause of death appears to be other than the illness or condition for which the deceased was being treated or if inquiry is required by either of the laws referred to in subsection (c) of this section, the case shall be referred to the office of the State Medical Examiner or coroner in the jurisdiction where the death occurred or the body was found for investigation to determine and certify the cause of death. If the State Medical Examiner or county coroner determines that the case does not fall within his or her jurisdiction, he or she shall within twenty-four (24) hours refer the case back to the physician for completion of the medical certification. (e) When inquiry is required by either of the laws referred to in subsection (c) of this section, the State Medical Examiner or coroner in the jurisdiction where the death occurred or the body was found shall determine the cause of death and shall complete and sign the medical certification within forty-eight (48) hours after taking charge of the case. (f) If the cause of death cannot be determined within forty-eight (48) hours after death, the medical certification shall be completed as provided by regulation. The attending physician or State Medical Examiner or county coroner shall give the funeral director or person acting as the funeral director notice of the reason for the delay, and final disposition of the body shall not be made until authorized by the attending physician or State Medical Examiner or county coroner .

Based on observation, record review and interview, the facility failed to ensure opened packages of food were sealed and dated in the dry storage room to maintain food freshness and prevent the potential for infestation, and the facility failed to ensure the ice machine was clean to prevent the potential for foodborne illness. The failed practices had the potential to affect 50 residents who received a meal tray from the kitchen, as documented on a list provided by the Business Office Manager on 8/22/23 at 12:43 PM. The findings included: On 08/21/2023 with Dietary Employee #1, the following was observed: a. At 9:56 AM, there was one bag of cookie wafers unsealed and undated. b. Dietary Employee #1 at 10:07 AM, wiped the area of the ice machine where the ice is dispensed with a white napkin. Observation of the white napkin after Dietary Employee #1 completed wiping the ice machine showed dark brownish black particles on the napkin. The Surveyor asked Dietary Employee #1 to describe what is on the napkin? Dietary Employee #1 stated, I would say it's mold. During interview on 08/23/2023 at 03:15 PM the Dietary Manager (DM) confirmed the dark brownish black particles on the cloth that wiped the ice machine. Review of the facility ' s policy titled, Sanitation of Dining and Food Service Areas, provided by the Assistant Director of Nursing on 8/22/2023 at 9:59 AM showed, dining services staff will uphold sanitation of the dining areas according to a written schedule. Review of facility's policy tittled Dry Storage Areas, provided by Nurse Consultant #2 on 08/22/2023 at 12:00 PM showed, dry storage areas will be maintained in a condition which protects stored foods from infestation. Review of the facility ' s policy titled Cleaning Instructions Ice Machine and Equipment Policy and Procedure, provided by the Nurse Consultant on 8/22/2023 at 12:00 PM showed, the ice machine and equipment will be cleaned on a regular basis to maintain a clean and sanitary condition.

Based on observation, interview, and record review, the facility failed to serve residents in a manner that promoted dignity for 3 (Residents #2, #22, #26) of 9 (Residents #2, #22, #25, #26, #29, #31, #36, #42, #43 ) sampled residents that eat their meals in the dining room. The findings included: On 08/21/2023 at 12:06 PM the Surveyor observed Resident #2 seated at a table in the dining room with another resident. The second resident received a lunch tray at 12:08 PM, while Resident #2 did not receive a lunch tray until 12:17 PM. The second resident had completed eating their lunch before Resident #2's tray arrived. On 08/21/2023 at 12:08 PM the Surveyor observed Resident #22 seated at a table in the dining room with another resident. A lunch tray was delivered to each resident at 12:08 PM, but Resident #22 did not receive assistance with eating until 12:16 PM. On 08/21/2023 at 12:10 PM the Surveyor observed Resident #26 seated at a table in the dining room with two other residents. A lunch tray was delivered to the other two residents at 12:14 PM. Resident #26 did not receive a tray until 12:29 PM, and the other residents seated at the table had completed their meals and left the dining hall. Kitchen staff began clearing the dirty dishes from the table while Resident #26 was still eating. Review of Resident #26's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/29/2023 showed Resident #26 required assistance with setup for eating. Review of Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/23/2023 showed, required limited assistance from one person for eating. On 08/23/2023 at 3:25 PM, the Surveyor asked the Dietary Manager if he was aware residents seated together were being served at different times. The Dietary Manager said he was not aware of residents seated together being served meal trays at different times, and he was not aware of a policy concerning serving meals. During interview on 08/23/2023 at 3:29 PM, the Assistant Director of Nursing (ADON) confirmed residents seated at the table should all be served and eating at the same time. The ADON stated This has been an ongoing issue we've been trying to address. Review on 08/23/2023 at 9:18 AM of facility's policy titled Dining and Meal Service Policy and Procedure undated showed meals will be served to all individuals at the table at the same time and assisted with eating at the same time.

Surveyor: [NAME], [NAME] Based on observation, record review, and interview, the facility failed to ensure residents received an enhanced diet to meet the nutritional needs for 3 (Resident #12, #25, and #26,) of 12 (Resident #6, #44, #16, #17, #29, #21, #26, #25, #12, #27, #22 and # 47) sampled residents who had a physician's order for an enhanced diet. This failed practice had the potential to affect 19 residents who had a physician's order for an enhanced diet as documented on a list provided by Nurse Consultant #1 on 08/24/2023 at 01:01PM. The findings included: During observation of Resident #26 ' s meal tray card on 08/21/2023 at 12:47 PM showed an enhanced diet, and mashed potatoes was the enhanced food item Resident #26 received fried fish, pinto beans, buttered noodles, and cantaloupe on her tray. During the noon meal service on 08/23/2023 at 12:18 PM the following was observed: a. Resident #12 ' s tray was sitting at the dietary window ready to be served with enhanced diet written on the tray card. The Surveyor asked Dietary Employee #2 what is the enhanced food item? Dietary Employee #2 stated, mashed potatoes. There were no mashed potatoes on the tray. The Surveyor asked why are residents not receiving their enhanced foods? Dietary Employee #2 stated, I didn't pay attention. I was in a hurry. b. Resident # 25 did not receive an enhanced diet and had enhanced diet on the tray card. Resident #25 did not have an enhanced food item on the tray. c. Resident #26 ' s tray card read enhanced. Resident #26 did not have an enhanced food item on the tray. The Surveyor asked CNA #2 which food item is enhanced? CNA #2 stated, I honestly don't know. Review of physician ' s Order Summary Report showed the following: a. Resident #12 ' s order dated 04/14/2023: regular -enhanced foods, regular texture, consistency, and add fortified foods for all meals. b. Resident #25 ' s order dated 10/28/2022: regular enhanced diet, mechanical texture, and regular consistency. c. Resident #26 ' s order dated 06/27/2023: regular enhanced foods diet, regular texture and consistency. Review of Resident ' s Care Plans showed the following: a. Resident #12's Care Plan with an initiated date of 03/28/2023 and a revision date of 07/17/2023: regular enhanced diet with regular texture and consistency and receives house supplement as ordered. b. Resident #25 ' s Care Plan with an initiated date of 07/17/2023: regular-enhanced diet with mechanical soft texture and regular consistency. c. Resident #26's Care Plan with an initiated date of 12/26/2022 and a revision date or 07/17/2023: regular-enhanced diet with regular texture and consistency. During interview on 08/24/2023 at 10:15AM Licensed Practical Nurse (LPN) # 3 confirmed Resident #6 was on an enhanced diet due to weight loss. During interview on 08/24/2023 at 10:20 AM, the DON confirmed Resident #6 was on an enhanced diet due to weight loss in June. During interview on 08/24/2023 at 10:45AM, the Surveyor asked the Dietary Manager (DM) are you aware the kitchen is not sending out enhanced diets? The DM stated I do now. My staff told me yesterday. Review of facility ' s policy titled Diet Orders Policy and Procedure provided by Nurse Consultant #1 on 08/24/2023 at 12:37 PM showed, the facility will provide a therapeutic diet that is individualized to meet the nutritional and clinical needs of the resident. Diets will be offered as ordered by the physician.

Surveyor: [NAME], [NAME] Based on observation, record review and interview, the facility failed to ensure adequate supervision for 2 of 2 Residents (Resident #6 and #39) sampled residents who desired to smoke. The findings are: During interview on 08/21/2023 at 10:23 AM, Resident #6 stated, The staff went through my stuff without permission. They took my cigarettes and lighter. I went out with a friend to smoke. Review of Resident #6's Care Plan with an initiation date of 06/09/2023 showed, Resident goes off facility property with family to smoke, and will not suffer injury from unsafe smoking/electronic smoking device practices. Resident and family educated on safe smoking. Review of Resident #6's Nursing -Tobacco/e-cigarette Assessment and Care Plan-V1 dated 08/22/2023 showed, Resident #6 smokes with supervision, requires a smoking apron, and needs facility to store smoking material. During interview on 08/22/2023 at 08:50 AM, LPN #2 stated, There is no smoking policy, administration is working on it. The residents check themselves out and go to the end of the road to smoke. No one from the facility goes with them. During interview on 08/22/23 at 12:35 PM, the Social Services Director (SSD) said there is no smoking policy. The residents sign themselves out and go across the parking lot to the trees and must have family or friends with them. The residents keep their smoking materials in their rooms. The SSD confirmed Resident #6 and Resident #39 got the code to the door and went out to smoke. During interview on 08/22/2023 at 12:50 PM, The Director of Nursing (DON) said there is no smoking policy. The residents sign themselves out to go off the grounds with family or friends to smoke. The Surveyor asked the DON what if family or friends are not available to take a resident to smoke how does the facility navigate the resident ' s rights? The DON stated, There's nothing I can do. I don't have the smoking paraphernalia for them to safely smoke. The residents keep their own smoking paraphernalia in their room in a lock box. Resident #6 knows the code. She didn't sign out or tell anyone. She asked another resident to go with her. During a telephone interview on 08/22/23 at 5:30 PM LPN #5 said Residents #6 and #39 went over to the smoking area all weekend. During interview on 08/23/2023 at 12:25 PM, the Surveyor asked the Activity Director to explain the time and location Resident #6 and Resident #39 went outside of the building to smoke on the night of 08/16/2023. The Activity Director stated, They were at the edge of the parking lot that is connected to the walking trail, and it was 10:21 PM. During interview on 08/23/2023 at 12:00 PM, Resident #34 stated, I smoke in the courtyard a couple of times in the afternoons. Staff goes with me. I keep my cigarettes and lighter with me all the time. Review of the facility ' s policy titled Smoking/Tobacco/Electronic Smoking Device Policy and Procedure with an updated date of 04/27/2023 provided by Nurse Consultant #1 on 08/22/2023 at 1:30 PM, showed, the purpose is to provide a safe environment for those residents who choose to smoke. The facility will identify smoking areas for residents to utilize for smoking.

Based on observation, interview, and record review, the facility failed to revise Care Plans to reflect the current needs of 2 (Residents #10 and #43) of 29 (Residents #2, #4, #6, #10, #16, #17, #18, #21, #22, #25, #26, #27, #29, #30, #31, #32, #34, #39, #41, #42, #43, #44, #47, #50, #52, #53, #154, #204 and #205) sampled residents. The findings included: The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/2023 for Resident #10 showed Resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) an assessment of care needed as, extensive assistance with one-person physical assist. Review of Resident #10's Care Plan initiated on 10/30/2021 showed Resident required set-up/supervision by 1 staff with personal hygiene, nail care, and oral care. Review of the MDS with an ARD of 07/28/2023 for Resident #10 showed Resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes with extensive assistance, two+ person physical assist. Review of Resident #10's Care Plan initiated on 10/30/2021 showed Resident requires set-up/supervision by 1 staff for toileting. Review of the MDS with an ARD as of 05/18/2023 for Resident #43 showed Resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture with one-person physical assist. Review of Resident #43's Care Plan initiated 11/17/2021 showed Resident can move and reposition herself in bed. During interview on 08/23/2023 at 3:58 PM the MDS Coordinator confirmed the discrepancy between Resident #43's most recent MDS assessment and the Care Plan. Review of facility's policy on 08/24/2023 at 9:18 AM titled, Care Plan Policy and Procedure provided by Nurse Consultant #1 showed each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches.

Based on interview and record review, the facility failed to ensure a resident with a Mental Disorder was referred for a Level II PASARR (Preadmission Screening and Resident Review) evaluation for 1 (Resident #43) out of 2 (Resident #10 and #43) sample mix. The findings included: Review of Resident #43's Care Plan showed a diagnosis of bipolar disorder, and antipsychotic medications r/t bipolar disorder with an initiated date of 11/27/2021 and revised on 07/11/2023. During interview on 08/22/2023 at 3:40 PM, the BOM confirmed Resident #43 does not have a State Designated Professional Associates letter for Level II PASARR. During an interview on 08/23/2023 at 08:29 AM 08:29 AM, with a State Designated Professional Associate regarding a PASSAR Level II for Resident # 43 who stated the resident was not being tracked. During interview on 08/23/2023 at 3:40 PM, the Director of Nursing (DON), said, we try to get the preadmission screening completed before they come in. The DON confirmed there was not a PASARR Level II for Resident #43 and confirmed a resident with a diagnosis of bipolar should have a Level II. During interview on 08/23/2023 at 04:01 PM, the DON stated, I found out some additional information on Resident # 43. In 2021 the resident came from Texas and the PASARR was probably just overlooked. Review of facility's policy titled Pre-Admission Screening and Resident Review [PASRR] Policy and Procedure provided by Consultant #1 on 08/24/2023 09:18 AM, showed, PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing home for long term care. The facility is to review resident diagnosis and medications upon admission and throughout the resident stay to determine if a level two request for resident review is to be completed and incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report in the resident's assessment, care planning, and transitions of care. A resident review for level II evaluation should be considered for the following residents with Tier one diagnosis such as Bi-Polar.

Based on record review and interview, the facility failed to ensure the state inspection results are available to residents without having to ask. This failed practice had the potential to affect all 52 residents in the facility. The findings included: During interview on 08/22/2023 at 9:30 AM, the Administrator confirmed there were three Presidents of the Resident Council Resident #7, #38, and #43. On 08/22/23 at 1:10 PM, the Surveyors met with the Resident Council with Resident #5, #42, #31, #37, and #40 in attendance. The three Presidents were not in attendance. The Resident Council was asked, do you know where the results of the state inspection are posted, and can you read them without having to ask for them? The Resident Council stated collectively they did not know. During interview on 08/22/2023 at 2:00 PM, the Surveyor asked the Activity Director why did the presidents not attend the Resident Council meeting? The Activity Director said one Resident was in the shower, one Resident was getting a haircut, and one Resident said he had been interviewed by the state. During interview on 08/23/23 at 03:30 PM, the Activity Director confirmed residents should have access to the state inspection results without asking for them. Review of the facility ' s policy titled, Resident Rights and Quality of Life Policy and Procedure provided by Nurse Consultant #1 on 08/24/2023 at 9:18 AM showed all residents have the right to examine facility survey results.

Based on record review and interview, the facility failed to ensure the residents know where the Ombudsman contact information is posted, and the facility failed to ensure the residents have been informed of their rights and given information of how to file a formal complaint with the State Agency. The failed practice had the potential to affect all 52 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Administrator on 08/21/2023 at 1:00 PM. The findings included: During interview on 08/22/2023 at 9:30 AM, the Administrator confirmed there were three Presidents of the Resident Council Resident #7, #38, and #43. On 08/22/2023 at 1:10 PM, the Surveyors met with the Resident Council with Resident #5, #42, #31, #37, and #40 in attendance. The three Presidents were not in attendance. The Surveyor asked the Resident Council members, do you know where the Ombudsman poster with contact information is posted? The Resident Council members collectively said they did not know. The Surveyor asked the Resident Council members, have you been informed of your rights and given instructions on how to formally file a complaint with the State? The Resident Council members stated collectively they did not know. During interview on 08/22/2023 at 2:00 PM, the Surveyor asked the Activity Director why did the Presidents not attend the Resident Council meeting? The Activity Director said one Resident was in the shower, one Resident was getting a haircut, and one Resident said he had been interviewed by the State. During interview on 08/23/2023 at 3:30 PM, the Activity Director, confirmed residents should know where the Ombudsman poster is located and have the right to be informed of how to contact the Office of Long-Term Care (OLTC) if they have complaints. Review of the facility ' s policy titled, Resident Rights and Quality of Life Policy and Procedure provided by Nurse Consultant #1 on 08/24/2023 at 9:18 AM showed residents have the right to communicate with people, and to services inside and outside of the facility, and have immediate access to any representative of the State and the State's Long Term Care Ombudsman.

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more activities of daily living (ADL) for 1 (Resident #26) of 10 (Resident# 6, #18, #21, #26, #34, #39, #44, #47, #204 and #205) residents whose MDS were reviewed. The findings included: Review of Resident #26 ' s Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 03/29/2023 showed Resident required limited assistance with 1-person physical assist with bed mobility and limited assistance with 1- person physical assist. Review of the Minimum Data Set a Quarterly Assessment with an Assessment Reference Date of 06/29/2023 showed the resident required extensive assistance with 2-person physical assist with bed mobility and extensive assistance with 1- person physical assist. During interview on 08/24/2023 at 3:08 PM, the MDS Coordinator (MDSC) confirmed a decline in 2 or more areas between the last 2 MDSs of Resident #26. During interview on 08/24/2023 at 3:20 PM, the Director of Nurses (DON) confirmed the MDSC should accurately code the MDSs. Review of a form titled Assessment Management Requirements and Tips for Annual Assessments dated October 2019 provided by the DON showed, significant change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention, and a significant change is appropriate if there are either two or more areas of improvement or decline.

Based on observation, interview, and record review, the facility failed to provide repositioning assistance for 1 (Resident #43) of 5 (Resident #10, #21, #27, #43 and #44) sampled residents that required the assistance of one or more staff members for bed repositioning per a list provided by Nurse Consultant #2 on 08/24/2023 at 8:56 AM. The findings included: On 08/21/2023 at 10:21 AM, the Surveyor observed Resident #43 lying in bed. The bed was inclined, and Resident #43 was slouched down in bed at an angle, with her head and feet extending from either side of the bed. The Surveyor asked Resident #43, are you comfortable? Resident #43 stated, No my neck and back are hurting. The Surveyor asked are you able to reposition yourself without assistance? Resident #43 stated, No please I need help. On 08/22/2023 at 7:19 AM the Surveyor observed, with LPN #1, Resident #43 lying slouched down in bed with her feet and lower legs hanging off the right side of the bed and her head hanging off the left side. The Surveyor asked Resident #43 do you need help? Resident #43 stated, Yes I'm not comfortable, I need help moving. During interview on 08/22/2023 at 1:51 PM Certified Nursing Assistant (CNA) #5 confirmed responsibility for the care of Resident #42. The Surveyor asked CNA #5 if Resident #43 required assistance to reposition in bed. CNA #5 stated, Yes, I have to pull her up. Review of Resident #43's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/2023 showed, Resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture requiring one-person physical assist. Review of facility's policy titled Positioning the Resident Policy and Procedure provided by Nurse Consultant #1 on 08/24/2023 at 9:18 AM showed, the purpose is to change the resident ' s position with good body alignment.

Based on observation, interview, and record review, the facility failed to ensure fingernails were kept trimmed for 1 (Resident #10) of 29 (Residents #2, #4, #6, #10, #16, #17, #18, #21, #22, #25, #26, #27, #29, #30, #31, #32, #34, #39, #41, #42, #43, #44, #47, #50, #52, #53, #154, #204, #205) sampled residents who relied on the facility for nail care per a list provided by Nurse Consultant #2 on 08/24/2023 at 08:56 AM. The findings included: On 08/21/2023 at 10:38 AM the Surveyor observed Resident #10 fingernails with jagged edges extending 1/2 past the tips of the fingers. During interview on 08/21/2023 at 10:38 AM, the Surveyor asked Resident #10 do you like your nails that length? Resident #10 stated No, I wish they would cut them. Resident #10 said the facility staff cuts her nails and the staff is aware of the nails needing cut. On 08/23/2023 at 1:10 PM the Surveyor observed Resident #10 ' s fingernails with jagged edges extending 1/2 past the tips of the fingers. During interview on 08/23/2023 at 1:22 PM the Surveyor asked LPN #1 who was responsible for cutting the nails for residents. LPN #1 said the aides cut the residents nails unless the resident is a diabetic. The Treatment Nurse cuts the nails of the diabetic residents. LPN #1 confirmed Resident #10 ' s fingernails needed to be cut. During interview on 08/23/2023 at 1:36 PM, the Assistant Director of Nursing (ADON) confirmed Resident #10's nails needed to be cut. Reveiw of facility's policy titled Nail Care Policy and Procedure. on 08/24/2023 at 9:18 AM provided by Nurse Consultant #1 showed all residents will have nails cleaned and trimmed once weekly or as needed per resident request.

Complaint # was substantiated with these findings. Based on observation, record review and interview, the facility failed to ensure supervision was provided to prevent accidents for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents who were at risk for elopement. The facility failed to reassess Resident #1, who exhibited signs of wanting to leave the facility prior to eloping on 5/17/11. The facility failed to utilize the alarm system for the exit doors (4 of the 9 were used by both visitors and employees entering and exiting the building) or to ensure the exit doors were monitored by another means. The failed facility practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #1 who left the facility unnoticed by staff and walked approximately 0.6 miles on a highway. The Administrator was informed of the Immediate Jeopardy on 5/24/11 at 11:00 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 4/26/11 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status and was independently ambulatory. a. The Wander Data Collection Tool dated 4/19/11 (date of admission) documented, "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? No... Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes... Is the resident a new admission or re-admission (within the past 30 days) and not accepting the new situation? No... Does the resident verbally express the desire to go home or packed belongings to leave? No. (Wants to visit her brother for a little while)... Summary of Findings: (Blank). Based off of Summary of Findings, resident is (blank)." b. A Nurse's Note dated 4/22/11 at 1:00 p.m. documented, "At end of 200 hall trying to open doors. Reoriented and (friend) called to come see her. 1:30 p.m. - Stated to this nurse that she is locked up like a dog and just wants to go see brother. (Physician) faxed about behavior." c. The resident's Plan of Care dated 5/2/11 did not document that Resident #1 was at risk for elopement. d. A Nurse's Note dated 5/17/11 at 3:40 p.m. documented, "This nurse approached by (friend). (Friend) stated resident was not in room. Staff searched facility room by room. DON (Director of Nursing) notified. Viewed on camera, resident wandered out of facility at 3:30 p.m. as visitors were entering the facility. Police notified. 4:15 p.m. - resident returned to facility accompanied by family friend who stated she had made it to the (public building) when he was called to come get her. No injuries noted upon arrival... Signs posted on all doors in facility reminding visitors to watch for residents when entering or exiting building." 1) A DMS-7734 dated 5/17/11 documented, "On 5/17/11 at approximately 3:45 p.m., (Resident #1) was reported not to be in her room. This was reported by the people that came to visit resident ... The DON was notified by (Licensed Practical Nurse (LPN) #1). At 4:00 p.m., the DON immediately checked the security camera and noted that at 3:31 p.m., (Resident #1) exited out of the 200 hall door as a family member was entering... (Resident #1) had walked to the (public building) and asked to use a phone to call a friend... (Friend) was called and he picked (Resident #1) up and brought her back to the facility at 4:15 p.m." 2) On 5/23/11 at 4:06 p.m., LPN #1, the nurse who was on duty at the time Resident #1 eloped, was asked during a telephone interview what happened the evening of 5/17/11. She stated, "I had started my med (medication) pass. Most of the residents at that time are in the dayroom. (The resident ' s Friend) told me she wasn't in her room. We searched room to room and then the DON looked on the camera and saw her leave like at 3:30 p.m. out the 200 hall door while I was in the day room passing pills." LPN #1 was asked if she had ever observed the resident attempt to leave the building. She stated, "I have not seen her try to get out or heard her say she didn't want to be here." LPN #1 was asked if she was aware that Resident #1 attempted to leave the building on 4/22/11. She stated, "Now that you mention it, I had an incident of her refusing her meds one day and she was wondering where her brother was, but no one has reported to me that she had tried to get out." 3) On 5/23/11 at 5:13 p.m., CNA #3, who was on duty when Resident #1 left the faciity on [DATE], was asked if Resident #1 was at risk for elopement prior to her leaving the facility on 5/17/11. She stated, "I was surprised she left, but I knew she could be one that would because when she first got here, she dressed herself, put her purse on her shoulder and said she was going to get a milkshake." The CNA was asked if she reported this to the nurse on duty. She stated, "She told the nurse herself she wanted to leave." CNA #3 was asked where she was when the resident exited the building. She stated, "I was in another resident's room helping them and a family member." e. On 5/23/11 at 4:28 p.m., Nursing Assistant (NA) #1 was asked about Resident #1's behaviors. She stated, "The first night she was here, she had an incident where she was a little upset because she was saying her brother needed to take her to a doctor's appointment and it was 9:30 p.m. at night. She was saying she had to get out." f. On 5/23/11 at 4:45 p.m., Certified Nursing Assistant (CNA) #1 was asked if Resident #1 had ever shown signs of wanting to leave the facility. She stated, "I've not seen her trying to exit, but the 2nd day she was here she said she wanted to go home." The CNA was asked how she and other CNAs identified residents who were at risk for elopement prior to Resident #1 leaving the facility on 5/17/11. She stated, "By just watching for residents going to the doors, but now we have the feet stickers on their doors." g. On 5/23/11 at 4:56 p.m., CNA #2 was asked if Resident #1 was at risk for elopement prior to her leaving the facility on 5/17/11. She stated, "I wasn't surprised she left. I knew she could wander and get confused." CNA #2 was asked if she had ever known the resident to attempt to leave the building prior to 5/17/11. She stated, "Yes ma'am. The first day she was here, she got very irate in the evening and she said she had family in the hospital that needed her and that she needed to see them and she was going to call the cops." CNA #2 was asked how she and other CNAs knew who was at risk for elopement prior to Resident #1 leaving on 5/17/11. She stated, "By watching, paying attention. Now we have the feet on their door." h. On 5/23/11 at 5:56 p.m., CNA #4 was asked if Resident #1 was at risk for elopement prior to her leaving the facility on 5/17/11. She stated, "I was surprised that she left, but she's always wanting to go home. You know how new residents are. She didn't think it was right to be here." The CNA was asked how she and other CNAs identified residents who were at risk for elopement prior to Resident #1 leaving on 5/17/11. She stated, "By watching them, but now we have feet on the doors." i. On 5/24/11 at 8:10 a.m., the DON was asked how the facility identified residents who were at risk for elopement prior to Resident #1's elopement on 5/17/11. She stated, "We always do the Wander Data Collection Tool on everybody when they come in." She was asked, even though the form was completed on admission, how the facility made direct care staff aware of who was at risk for elopement. She stated, "By observation. We watch. To my knowledge, during the day when I'm here, she's never attempted that." The DON was informed of the Nurse's Note dated 4/22/11 that documented the resident was attempting to exit the building and the comments the resident made to staff about leaving. She stated, "I've never been told that. To my knowledge she wasn't considered at risk for elopement before she left." She was asked why the Wander Data Collection Tool assessment wasn't updated to document the resident was at risk for elopement after the resident attempted to leave on 4/22/11. She stated, "I'll have to look at that." She was asked what steps the facility had taken to ensure Resident #1 or other residents who were at risk for elopement would not elope again. She stated, "We have the STOP signs on the exit doors, but those have always been there. The cognitively impaired hopefully will see that and stop. The red sign has been on the doors about a year." The DON added, " The aides know when they make rounds, don't skip a room - go and find the resident. Of course we've added the feet sticker to their name tags on the doors to alert staff who is at risk. There will be a statement in our newspaper article tomorrow about visitors making sure residents don't follow them out of the facility." The DON was asked how visitors were supposed to know who all the residents were. She did not respond. The red sign on the doors documented, "Attention: Visitors. It is necessary to use the code to enter and leave the building. If you can't remember the code, please ask a staff member for assistance. Also, to ensure the safety of our residents, please make sure the door is completely shut. If a resident is by the door, please ask for assistance or go to another door. We appreciate your cooperation. " j. On 5/24/11 at 9:30 a.m., CNA #5 was asked if Resident #1 was at risk for elopement. She stated, "I've seen others wander more than her, but I've been told to keep my eye on her." CNA #5 was asked if she had been instructed on how often to visualize the resident to ensure she was still in the building. She stated, "Another CNA told me to check on her like every 20 minutes. I look for her every chance I get." k. On 5/24/11 at 9:45 a.m., CNA #6 was asked if she was shocked that Resident #1 had eloped. She stated, "Well I didn't really think she'd exit, but I've heard her say before that she wanted to go home." The CNA was asked how she knew who was at risk for elopement prior to Resident #1 leaving. She stated, "If residents wander or if they go to the doors." She was asked how she could identify now who was at risk for elopement. She stated, "They put little feet up to identify residents at risk." CNA #6 was asked if she had been instructed on how often to visualize the resident to ensure she was still in the building. She stated, "I try to make sure every little bit to know where these people are." l. On 5/24/11 at 10:35 a.m., all entrance/exit doors in the facility had keypads that required a code to enter or exit. The code was the same for all doors. During the survey, visitors frequently used four of the nine doors. One of the frequently used doors was the door through which Resident #1 exited on 5/17/11. The facility did not use a wanderguard system. m. On 5/24/11 at 10:50 a.m., the Administrator was asked about visitors using so many entrance/exit doors and the possibility of a resident exiting the building unnoticed again. He stated, "I see what you' re saying. The problem is our parking. People park all around the building and it's more convenient to use a door in that area." 2. The facility's policy and procedure titled, "Elopement Prevention" , dated 1/5/11 documented, "Definition: Elopement of residents is defined as leaving a facility by a resident who has an impaired decision making ability to own safety needs and is at risk for injury outside the confines of the facility without the knowledge of staff. The purpose of this policy is to ensure effective systems are in place to provide reasonable caution to prevent elopement... The facility has a responsibility to maintain an environment which will keep its residents safe and protect them from harm. Prior to or at admission, each resident shall be assessed for the potential for elopement. Residents will then be re-assessed quarterly and if they develop wandering behavior at any time after admission." 3. The Immediate Jeopardy was removed and the scope and severity reduced to an "E" on 5/24/11 at 11:15 a.m. when the facility implemented the following plan of removal: a. On 5/24/11 at 11:15 a.m., the full alarm system at the nurse's station was turned on and each door was checked for proper function. This alarm system board lights up and rings when a door in the facility is opened. Staff will check the board upon hearing the alarm sound to determine if a visitor or a resident is entering or exiting the facility. If the Kitchen or Dietary alarm sounds, their staff will be paged overhead to monitor who entered or exited the door. b. On 5/24/11 at 11:20 a.m., new signs for all visitors were posted to enter through the main front lobby entrance only. c. On 5/24/11 at 11:40 a.m., the Charge Nurses on each hall completed a visual check of all residents on their halls to ensure all residents are accounted for. d. On 5/24/11 at 12:10 p.m., (Maintenance) changed codes on all exits except for main front lobby entrance. e. On 5/24/11 at 12:30 p.m., all staff were educated on the new alarm system at the nurse's station and the new codes for the doors. Staff will be allowed to enter and exit any doors in facility, but visitors will only be allowed to enter and exit through the main front lobby entrance. f. On 5/24/11, the Administrator will appoint a person to sit in the front lobby for 24 hours daily until new security system is in place to monitor the lobby area and front doorway to ensure a resident does not attempt to leave facility. At this time of 1:45 p.m., (employee) is monitoring the front doorway/lobby area. g. On 5/24/11, a staff member will monitor daily that the nurse's station security system is functioning properly. The ward clerk will check on the 7-3 (7:00 a.m. - 3:00 p.m.) shift daily, Dietary Team Leader will be responsible to check system for 3-11 (3:00 p.m. - 11:00 p.m.) shift. The Charge Nurse on 11-7 (11:00 p.m. - 7:00 a.m.) shift will be responsible for checking the system. This will be continued until the new elopement safe system is implemented. h. On 5/24/11, the Administrator contacted the company who provides our security system to implement a new security alarm system."