Every finding on record at Tri Cities Rehabilitation and Healthcare Center

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plan for 1 of 5 sampled residents (Resident (R)1). The facility admitted R1 on [DATE], with a diagnosis of diabetes mellitus, with orders obtained for blood glucose monitoring (BGM) and insulin. The facility documented administration of R1's insulin; however, there was no documented evidence of the BGM for the dates of 07/02-04/2026. Per the facility's documentation, R1 was sent to the hospital on [DATE] for hyperglycemia. Review of the hospital documentation revealed R1 presented with a blood sugar reading of 672 with moderate ketones (moderate to large amounts of ketones could lead to a life-threatening condition called ketoacidosis). The findings include: Review of the facility's policy titled, Blood Glucose Monitoring, undated, revealed it was the policy of the facility to perform blood glucose monitoring to diabetic residents as per the Physician's orders. Continued review of the facility policy revealed facility staff were to report critical test results to the Physician timely and document the procedure. Review of the facility's admission Record for R1 revealed the facility admitted the resident on [DATE], with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, unspecified dementia, unspecified depression, unspecified chronic kidney disease, and anorexia. Review of the facility's Physician Orders, dated [DATE], for R1 revealed orders for the resident to have accu checks (fingerstick blood glucose monitoring) before meals (AC) and at bedtime (HS) for diabetes mellitus. Continued review revealed orders for R1 to have Tresiba (insulin) flex touch subcutaneous (SQ) solution per pen injection 100 units (u)/milliliter (ml). Per review of the Tresiba insulin order, R1 was to receive 20 u SQ daily for the diabetes mellitus diagnosis. Additionally, review of the orders revealed an order for a one time dose of Humulin R (regular insulin) 20 units SQ, which was documented as given on [DATE] at 10:30 AM. Review of the facility's Medication Administration Record (MAR), dated [DATE], for R1 revealed no area to document R1's blood sugar results, and therefore, there was no documented evidence of blood sugar results for the resident. Continued review of the MAR revealed documentation noting R1 received the ordered Tresiba 20 u daily on [DATE], [DATE], and on [DATE]. Further MAR review revealed a one time order for R1 to receive Humulin R on [DATE], which was noted as administered. Review of the MAR further revealed however, there was still no documented evidence of blood sugar readings for R1. Review of the facility's Baseline Care Plan, dated [DATE], revealed a check mark noted by diabetes and finger sticks for R1. Further record review revealed however, no documented evidence of blood sugar monitoring for R1 as per Physician's order, except a progress note on [DATE] which noted high. Review of the facility's Discharge Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. Continued review of the Discharge MDS revealed the facility assessed R1 as having an active diagnosis of diabetes mellitus. Review of the facility's Hospital Transfer Form, dated [DATE], revealed R1 was being transferred to the hospital for hyperglycemia (high blood sugar). Further review of the Form revealed however, no documented evidence of any blood sugars noted on it. Review of the hospital's, History and Physical document, dated [DATE], revealed R1 presented to the emergency room (ER) via Emergency Medical Services (EMS) with a report of hyperglycemia. Continued review of the document revealed R1 had an initial blood sugar of 672, per the laboratory (lab) work performed in the ER, with moderate ketones (moderate to large amounts could lead to a life-threatening condition called ketoacidosis). Per review of the ER documentation, the ER Physician spoke with the family about placing R1 on a ventilator; however, as R1 had put a DNR order in place and did not want aggressive life saving techniques, the family refused the ventilator. Continued review of the ER documentation revealed The ER doctor recommended placing R1 in hospice care and the resident was admitted to hospice services on [DATE] and died in hospice care. During an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 2:06 PM, she stated she had cared for R1 one day while the resident was at the facility, and knew the resident was an insulin dependent diabetic. She said she had given R1 the Tresiba insulin, but there had been no blood to be obtained for the resident noted on the MAR. LPN 1 verbally explained how to document residents' blood sugar checks on the MAR. She said the process for blood glucose monitoring was to follow the Physician's orders and looking at the orders for R1 the resident should have had blood sugars obtained as ordered by the doctor. LPN 1 said however, she could not find any documented blood sugars for R1. During an interview with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) on [DATE] at 2:08 PM, the DON stated she had been on vacation when R1 was admitted and had not seen the resident. The DON stated R1's blood sugar had been stable; however, she admitted no blood sugars had been obtained for R1. The DON said R1 had shown no signs of hypo/hyperglycemia, which she knew after talking to the staff who had cared for R1 and told her the resident had been stable. The RNC reported, changes were starting today, which included educating nursing staff on transcribing blood sugar orders correctly so the orders transferred over to the MAR for documentation of the blood sugars. Both the DON and RNC stated the facility was auditing blood sugar checks on other residents to make sure they were being documented correctly. The DON explained R1's admission orders had been checked by the admission nurse, then double checked by another nurse, and were then checked the following morning by the Assistant Director of Nursing (ADON), who signed off on the resident's admission orders. The DON further stated she expected her staff to discuss, either in the next morning meeting or stand down meeting held the same day, any reason why residents had been sent to the hospital. The DON stated that process had been done for the incident, however, there had been no investigation as they basically just discussed R1 having been sent out for hyperglycemia. During interview with Registered Nurse (RN) 1 on [DATE] at 2:15 PM, she stated she had performed R1's admission documentation and assessment. When the State Survey Agency (SSA) Surveyor asked her how the facility had monitored R1's blood sugar, RN 1 would not respond with an answer, and only said, I don't know how to pull up old charts. She reported the facility's process was to follow the Physician's orders for obtaining blood sugars and those blood sugars were to be documented on the resident's MAR. During an interview with the ADON on [DATE] at 2:19 PM, she stated R1 had orders for blood sugar monitoring for AC and HS. She said however, when she signed off on the MAR, she just went in and noted off (whether) the medications matched the Physician orders. The ADON reported she had not looked at the accu checks to ensure the order had been put in correctly, so it transferred over to R1's MAR. She stated she was not aware R1 had not received any accu checks after admission. She explained the accu checks order had not been put in (the facility's computerized system) correctly. The ADON said she had been aware the order for R1's accu checks had not been put in correctly until the DON told her while the SSA Surveyors were there. She reported the facility's process for ensuring new orders were transcribed correctly was looking over all the new orders in clinical meeting. The ADON stated when all the new orders were reviewed in the clinical meeting, all administrative nurses could look at the orders from top to bottom to make sure the orders were put in the computer to automatically transfer to the MAR. She explained however, for R1's orders she just went in and noted the orders off and did not follow the facility's process of having others in the meeting look at the order. The ADON stated she did not look at the orders for R1 from top to bottom to make sure the orders had been placed in correctly, to automatically go onto the MAR. She further stated all blood sugar orders were put in correctly to go to the MAR for documentation. In interview with Family Member (FM) 1 on [DATE] at 4:15 PM, he stated R1's blood sugar had been regulated prior to admission to the facility. He stated R1's blood sugar had stayed normally in the low to middle 200's. FM 1 said R1 was a brittle diabetic and he had made that clear to the facility during the admission process. He reported he received a phone call on [DATE] from a nurse at the facility, who reported R1's blood sugar was reading high and was asking him about the resident's code status, which was do not resuscitate (DNR). FM 1 explained the nurse told him the Physician had ordered a one time dose of Regular insulin and she had given that 10 units of insulin, but the meter was still reading high. He reported when he got to the ER, R1 was near death and was moved quickly to the hospital's intensive care unit (ICU). The FM said the ER doctor wanted to intubate R1; however, she (R1) had made it clear she did not want aggressive life saving treatments and had put her DNR order in place 10 years prior. He stated R1 was having agonal breathing (gasping respirations from not getting enough oxygen) at that point. FM 1 stated R1 was pretty much unresponsive and not alert anymore. In addition, he said the facility could never give him an answer on how her (R1's) blood sugars were running while she had been a resident in the facility. FM 1 stated later I found out they hadn't done any blood sugars on her until she was symptomatic and at that point it was too late, as R1 expired on hospice services in the hospice unit at the hospital. He reported he had told them during the admission process that R1 was a brittle diabetic and had a history of ketoacidosis three times in the last 10 years and had needed hospitalization. The FM stated he was very upset about learning the facility had not done blood sugar checks for R1, and felt like if they had done the checks like the Physician had ordered, she would still be alive. He further stated R1 had been admitted to the hospital on [DATE], and was transferred to the hospice unit on [DATE] and later died on [DATE], while under hospice care. During an interview with the Staff Development Nurse (SDN) on [DATE] at 4:45 PM, she stated she had been working the floor on [DATE] when R1 was sent to the hospital. The SDN said R1 had been fine that morning and was awake and alert. She reported R1 had an order for Tresiba 20 units SQ and she checked R1's blood sugar that morning and it read over 200. The SDN admitted however, she had not documented the reading she obtained of R1's blood sugar in the resident's chart and had just written it on her scrap paper which she had thrown away. The SDN explained, later on I realized there was no place to document the blood sugar; however, had not done anything about that as R1 had been sent to the hospital. She further stated the facility's process was to check the Physician's orders for blood sugar checks, and follow those orders. The SDN additionally said after obtaining the residents' blood sugars, they were to be documented on the MAR. In continued interview with the SDN on [DATE] at 4:45 PM, she stated after breakfast (on [DATE]), she was notified R1 looked bad and she went to assess the resident, who had Kussmaul breathing (fast, deep and labored breathing most often a sign of diabetes-related ketoacidosis, a life-threatening condition). The SDN said she did another blood glucose check on R1 and the meter just read high. She stated she gave R1 the scheduled Tresiba and notified the Physician who ordered an additional one time dose of Humulin R 20 units, which she also gave. The SDN reported she rechecked R1's blood sugar about 10 minutes later and the meter still read high, so she called the Physician who ordered the resident be sent to the local hospital. She said she called EMS and the family and went back to stay with the resident until EMS arrived. The SDC stated when EMS arrived she was told R1 appeared to be in a diabetic ketoacidosis (DKA) state, and the local hospital did not have any intensive care unit (ICU) beds available, so EMS would transport the resident to the next county's hospital. She further stated a blood glucose meter only read up to 500, and any reading higher than 500 would just read high. During an additional interview with the DON on [DATE] at 6:14 PM, she stated it was her expectation for her nurses to follow the residents' Physician's orders. (The SSA Surveyors requested any auditing information the facility might have for auditing to ensure Physician's order; however, the facility could not provide that information to the SSA Surveyors.) She said if staff received an order for accu checks for residents, she expected them to put those orders in the computer and make sure they were correctly put in so the order would be transferred to the MAR for correct documentation to occur. The DON reported the facility's process involved bringing all new orders to the clinical meeting and all the administrative nurses looked at the order(s) from top to bottom to ensure the order(s) flagged to be documented on the MAR. The DON further stated she expected nurses to check both the order type and supplemental documentation so the order was entered correctly (into the facility's computerized medical record system). During an interview with the Administrator on [DATE] at 6:28 PM, he stated he was a part of the facility's Interdisciplinary Team (IDT) Meeting each morning. The Administrator stated he could not remember what was discussed regarding R1 in the IDT Meeting; however, he was sure the SDN had discussed the resident's issue. He reported the incident was not reported to him until the following Monday morning, which would have been [DATE] (two days later), as R1's transfer had been reported to the on call nurse. He said he was not made aware of why R1 had been admitted to the hospital. The Administrator explained he would not be notified of any resident transfers to the hospital unless there was a concern about the reasoning behind the transfer. He said there had been no concerns ,as he was not aware blood sugar checks were not being done for R1 until the SSA Surveyors entered the building. The Administrator stated it was his expectation for all Physician's orders to be put in the computer correctly and the facility was doing education now over correct transcription of Physician's orders which would cover all the nursing staff. He said the nurse managers reviewed all new orders for residents in the daily clinical meeting to make sure orders were put in the computer correctly. The Administrator reported there had been no investigation as he had not been aware of no blood sugars being done for R1 until the SSA Surveyors came to investigate. He further stated nobody in administration had been aware of the no blood sugars being done for R1 until the SSA Surveyors entered the building. In addition, the Administrator said nobody looked at the Physician's orders to make sure staff were following them as ordered.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 22 sampled residents.The findings include: Review of the facility policy titled, Infection Prevention and Control Program revised 04/28/2025, revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Continued review revealed environmental cleaning and disinfection shall be performed according to facility policy. Further review revealed all staff had responsibilities related to the cleanliness of the facility and were to report problems outside of their scope to the appropriate department. Observation on 02/09/2026 at 2:45 PM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed no bag was in the trash can. Continued review revealed a bed pan and graduate were located on the floor of the bathroom. Further observation revealed an opened pack of wipes located on a geri-chair. Observation on 02/09/2026 at 3:00 PM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed an unbagged urinal located between the wall and handrail next to the toilet. Further observation revealed a bedside commode located in the bathroom unbagged with an opened brief lying on top of the bedside commode. Observation on 02/09/2026 at 3:05 PM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed two opened packages of briefs lying on the bathroom floor. Observation on 2/09/2026 at 3:10 PM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed a package of opened briefs lying on the floor. Further observation revealed an opened unpackaged brief located between the wall and handrail behind the toilet. In interview on 02/09/2026 at 3:20 PM, Certified Nursing Aide (CNA) 1 stated personal items such as briefs and wipes were to be kept in the resident's closet. CNA 1 further stated any items located in the bathroom were to be placed in a bag for sanitary reasons as that could be an issue with infection control. CNA1 stated that they were responsible for caring for the residents that utilize the bathrooms in question but could not give an answer as to why the items were left in the bathroom floor. CNA1 stated, I don't know why they are in the bathroom, they're usually kept in the resident closets. Observation on 02/11/2026 at 11:30 AM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed oxygen tubing hanging on the handle of the toilet. Continued observation revealed a bed pan and graduate located on the floor of the bathroom. Further observation revealed an opened pack of wipes located on a geri-chair that was stored in the restroom. Observation on 02/11/2026 at 11:35 AM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed an unbagged urinal between the wall and handrail next to the toilet. Further observation revealed the bedside commode remained stored in the bathroom unbagged with an opened brief located on top of it. Observation on 02/11/2026 at 11:40 AM, of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER], revealed the two opened packages of briefs remained lying on the bathroom floor. On 02/11/2026 at 11:45 AM, observation of the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER] revealed an opened package of briefs lying on the floor. Further observation revealed an opened unpackaged brief remained located between the wall and handrail behind the toilet. In interview on 02/11/2026 at 12:00 PM, the Director of Nursing (DON) after observing the bathrooms, stated it was unacceptable for that to be occurring. The DON said her staff knew better, as they were educated monthly on infection control. She reported the importance of sanitizing and bagging items was to lower the risk of spreading illnesses from resident to resident. The DON further stated she would not be satisfied with the infection control observation issues if it was her mother or father living in the facility. In interview on 02/11/2026 at 2:00 PM, with the Infection Preventionist (IP), she stated her expectations for staff was for them to follow what they had been taught monthly pertaining to infection control. The IP stated that she usually conducts drop ins on the floor to observe CNAs and nurses to ensure that infection control was being followed such as handwashing, gowning up, bagging items not being used and that she has never found an issue on the floors with infection control practices. In interview on 02/11/2026 at 2:20 PM, the Administrator stated his expectation for infection control and storage was for staff to put dirty items in the dirty storage until cleaned and put back into service on the floor.

Based on observation, interview, record review, and facility policy review, the facility failed to serve meals in accordance with the established menu and required portion sizes, which had the potential to affect all residents consuming their meals from the facility's kitchen. The findings include: Review of the facility policy titled, Dietary Supervision, undated, revealed the Dietary Manager was responsible for the overall dietary program and was accountable for ensuring acceptable standards of food preparation and service. Per review of the policy, the Dietary Manager, was responsible for serving of all diets, maintenance of food service standards, and the training and supervision of dietary staff to ensure compliance with established dietary practices and procedures. Review of the facility policy titled, Menus and Adequate Nutrition, date reviewed/revised 09/01/2024, revealed the facility was responsible for ensuring menus were developed, prepared, followed, and approved in accordance with established national nutritional guidelines and resident needs. Continued review the policy required dietary services (staff) to ensure menu substitutions provided had comparable nutritional value. Review of the facility policy titled, Standardized Menus, reviewed/revised 09/01/2024, revealed the facility was required to follow menus as planned, approved and signed by a Registered Dietitian (RD). Per review, the facility was also to ensure the menus were implemented by dietary services staff using standardized portions identified in ounces and/or measurements. Continued review revealed the policy required dietary management oversight to ensure menus were being followed as planned, revised as necessary based on resident needs and preferences, and maintained on file. Further review revealed dietary services leadership was responsible to ensure menu accuracy, portion consistency, and ongoing review for nutritional adequacy to support residents' nutritional needs. Observation, on 02/09/2026 at 11:45 AM, during the lunch meal service, revealed dietary staff utilized a scoop identified as a 4-ounce (oz) serving to portion beef noodle casserole for residents. Review of the posted menu and/or serving guide revealed the planned serving size for the beef noodle casserole was to have been 6 oz. of casserole. Further observation revealed no additional scoops or portions were observed being added by dietary staff to the residents' plates during the meal service. Observation, on 02/09/2026 at approximately 12:15 PM, during lunch meal preparation, revealed a Dietary Aide (DA) portioned chicken salad onto bread to prepare sandwiches using a scoop identified as a 1 7/8-oz serving. Further observation revealed staff did not add extra portions of the chicken salad during sandwich preparation. During interview with R35, on 02/09/2026 at 2:31 PM, he stated there had been time the meals he was served was not enough to make him feel full, and he would still be hungry. He reported he told nursing staff about that, and sometimes they would bring him a sandwich. R35 further stated other times none of the nursing staff would come back with anything, and he would have to eat a snack he personally had bought. During interview with [NAME] 1 on 02/09/2026 at 12:15 PM, she stated when preparing alternative meals, such as sandwiches, the menu was not referenced to determine the planned portion sizes for the sandwiches. [NAME] 1 stated, I figure you don't want a big scoop of chicken salad and said she always utilized a scoop identified as a 1 7/8-ounce serving when portioning chicken salad. Per interview, [NAME] 1 said she did not enjoy a sandwich with a lot of chicken salad because that would be messy and no one like a messy sandwich. [NAME] 1 further stated it was important to serve the correct amount of food, so residents did not go hungry or experience weight loss. During interview with [NAME] 2 on 02/09/2026 at 12:22 PM, he stated the facility did not have serving scoops available for portion sizes of 1 1/3 ounces, 1 5/8 ounces, and 6 ounces. [NAME] 2 reported approximately two years ago someone from their corporate offices came into the kitchen and told dietary staff they did not use those size scoops enough to keep them and threw the scoops in the garbage. He continued to state when the menu required a scoop size not available at the facility, the closest smaller scoop was used. [NAME] 2 stated when the menu required a scoop size not available at the facility, the closest smaller scoop was used instead of a larger scoop to prevent serving more food than was planned. He further stated however, by using smaller scoop sizes, residents were not receiving the portion sizes indicated on the menu. During interview with the Director of Nursing (DON) on 02/11/2026 at 10:18 AM, she stated it was important for residents to receive meal portions that matched what was indicated on the menu. She said it was important to do that to ensure meals were provided as planned. She stated nursing staff documented residents' meal intakes, and depended on the dietary staff to follow the menus and serve the correct portion sizes. She reported she was aware the Administrator had performed observations of the kitchen recently. The DON said providing meals as planned supported accurate assessment of residents' intake, and assisted in monitoring residents' nutritional status. The DON further stated however, residents' meal intakes could not accurately be recorded if dietary staff were not serving the correct portion sizes as indicated on the menu. During interview with the Administrator, on 09/11/2026 at 10:39 AM, he stated the facility employed a Registered Dietitian (RD). The Administrator said the RD's responsibilities included reviewing residents' medical records, assessing nutritional needs, and reviewing their documented food and fluid intake. He reported the RD's responsibilities also included: monitoring residents' weight changes; and reviewing and approving menus to ensure nutritional adequacy and appropriate portion sizes. The Administrator stated it was his expectation for dietary staff to follow all facility policies and procedures, including following posted menus and serving correct portion sizes as indicated. He further stated he had performed audits on the dietary staff, and had not noted any concerns. The Administrator further stated he had not provided any suggestions to the dietary team on things they could do for improvements. During interview with the RD, on 02/11/2026 at 12:09 PM, she stated inaccurate portioning by dietary staff interfered with her ability to effectively perform her job responsibilities. She said she reviewed residents' charts and their documented food consumption to assess their nutritional status. The RD stated she had instructed the DM to in-service dietary staff after performing a tray line observation where portion sizes were not being followed. She said however, the DM had not communicated with her that the requested in-services were performed. The RD reported when dietary staff did not follow posted menus and served incorrect portion sizes, residents' intake could not be accurately documented. She explained that prevented her from accurately determining what residents were actually consuming. The RD said not being able to accurately determine residents' intake limited her ability to appropriately assess and address their nutritional needs. She stated she had advised the DM to provide in-services to dietary staff regarding the importance of following menus and using correct portion sizes. The RD further stated failure to provide correct portion sizes could result in negative outcomes for residents such as, weight loss, decreased energy, increased risk of falls, and skin breakdown. During interview with the DM, on 02/11/2026 at 3:19 PM, she stated it was important for dietary staff to follow the posted menus and serve the correct portion sizes to meet each resident's nutritional needs. The DM said doing that supported residents' energy levels and their overall health. The DM stated it was her expectation for dietary staff to follow all facility policies and procedures, including serving the correct portion sizes as indicated. The DM reported however, she had not been performing tray audits and had not been actively monitoring dietary staff as they were serving food on the tray line. She reported she discussed scoop sizes with staff upon hire, but didn't really talk about it after that. The DM said she should start talking about using the correct scoops to her staff so they would understand the importance of serving residents the correct portion sizes. The DM stated the correct portion size for chicken salad was 3 ounces and she was aware of which staff member had prepared the sandwiches. The DM further stated the dietary staff member did not always follow the correct portion sizes. She additionally stated she did not have any staff on any performance reviews for not following the correct portion sizes.

Based on observation, interview, and review of facility policy, the facility failed to ensure beverages were served in a palatable manner, to include temperature and taste for 6 out of 22 sampled residents (Resident (R)27, R33, R23, R35, R51, and R40), and had the potential to affect all residents consuming hot beverages from the facility's kitchen. The findings include: Review of the facility policy titled, Standardized Menus, undated, revealed the facility was responsible for providing nourishing and palatable meals to residents in accordance with established nutritional standards. Per review of the policy, it was the responsibility of dietary services staff and (their) oversight personnel to consistently implement menus in a manner that supported meal acceptability and palatability for residents. Observation on 02/10/2026 at approximately 7:40 AM, of the breakfast tray line, revealed dietary staff had prepped coffee and placed it in mugs with plastic lids, on an open metal cart behind the tray line, where it remained prior to being served during breakfast meal service. Review of the facility's posted mealtimes revealed its North Hall was scheduled to be served at 7:50 AM; the South Hall at 8:00 AM; the Restorative Dining Room at 8:00 AM; and the Railroad Dining Room at 8:15 AM. Continued observation, on 02/10/2026 at 8:08 AM, revealed the test tray left the kitchen on the meal cart. Per observation, the test tray was observed in the cart in the Railroad dining area, at 8:09 AM, waiting for nursing staff to deliver trays to the residents. Observation at 8:17 AM, revealed two nursing staff members arrived and began distributing the meal trays to residents. Further observation at 8:21 AM, revealed the last resident tray was delivered, and temperatures were obtained of the food on the test tray, by [NAME] 3 and verified by the Dietary Manager (DM). Additionally, observation and interview, at the time of the temperature checks, revealed the thermometer read 98.6, as reported by [NAME] 3, and confirmed by the DM. During interview with R35, on 02/09/2026 2:31 PM, he stated when he drank the coffee, brought to him by nursing staff, it was cold and bitter. He said he had told staff something needed to be done about the temperature of the coffee. R35 reported he was unsure when he first told nursing staff about the cold coffee; however, said it had been an issue for awhile. During a Resident Council meeting on 02/09/2026 at 3:00 PM, all Resident Council members (R27, R33, R23, and R51) stated hot food and beverages, particularly the drinks, were frequently served cold during meal service. The Resident Council members said they previously reported their concerns, regarding hot beverages being served cold, to facility staff and, at times, they were provided with a replacement hot beverage. Per interview, the Resident Council Members stated however, they were unaware of any actions having been taken by the facility to address the issue of ensuring hot beverages were consistently served at an acceptable temperature. During interview with R40, on 02/09/2026 at 3:25 PM, he stated his coffee was always served ice cold when it arrived in his room during meal service. R40 said he was aware he could obtain hot coffee if he walked to the kitchen himself to get it. The resident further stated however, he should not have to do that because his coffee should be hot and palatable when staff brought it to him. During interview with Dietary Aide 2, on 02/10/2026 at 8:06 AM, he stated dietary staff prepared the coffee and placed it in a non-insulated cart that was used to transport meals to residents. Dietary Aide 2 stated if the coffee remained on the cart for an extended period of time, the temperature would likely decrease affecting the taste. He reported he was not aware of any guidance provided for staff related to temperature monitoring of beverages once they were placed on the meal cart. Dietary Aide 2 further stated, nor had he had been instructed to remove the coffee from the cart and replace it if meal service was delayed. Observation on 02/10/2026 at 8:22 AM, during the test tray observation, the DM and two State Survey Agency (SSA) Surveyors, sampled the coffee. In interview, at the time of observation, the DM stated the coffee was just slightly above room temperature and bitter to the taste. Both SSA Surveyors also sampled the coffee and confirmed the coffee was not being served at an acceptable temperature and agreed it had an acidic and bitter taste. She reported the coffee was not palatable, and residents should always have coffee served at an acceptable temperature and taste. The DM explained she had not been performing tray audits and had not been actively monitoring dietary staff on the tray line or checking temperatures of the food items being served. She stated it was her expectation for her dietary staff to follow all the facility's policies and procedures, including serving food and drink that was palatable to residents. The DM further stated she assumed her dietary staff were following those policies; however, she had not been monitoring them to ensure they were doing so. She additionally reported she could not recall the last time she had conducted a tray line audit. During interview with the Administrator, on 02/11/2026 at 10:39 AM, he stated he had recently performed observations in the kitchen area and had not identified any concerns. He reported however, he had not performed any temperature checks on trays being served to the residents. The Administrator said it was his expectation for dietary staff to follow all policies and procedures including serving food and drinks that were palatable to residents. He stated he had performed audits on the dietary staff and had not noted any concerns. The Administrator further stated, during his audits, he had not provided any suggestions to the dietary staff on things they could do to improve their process.

Based on observation and interviews, the facility failed to ensure staff donned (put on) personal protective equipment (PPE) prior to cleaning the outside of two facility dumpsters. This had the potential for staff, who lacked proper PPE, to carry bacteria into the facility and possibly contaminate areas in which residents live for 69 census residents. Findings include: During an observation on 10/07/24 at 11:30 AM, a tour was conducted of the two outside dumpsters. The two dumpsters were fenced in and on the inside and outside perimeter of the fence contained a large amount of trash. The Maintenance Director (MD) stated bears came into the fenced area and either climbed out of the area with facility trash bags or tossed the trash bags over the fence. The MD stated he had to spend approximately three hours each day cleaning up the debris caused by the bears. The MD stated he did not wear any sort of PPE when cleaning up the trash thrown out by the bears. The MD stated the items that were typically in the trash were used adult incontinence briefs along with food waste from the kitchen. The MD stated he used latex gloves, with no protective boots or gowns. The MD stated he was well aware of the potential bacteria that could be carried back to the facility such as salmonella and e-coli. During an interview on 10/07/24 at 11:40 AM, Dietary Aide (DA) 1 and DA2 were sitting on the outside of the building and faced the dumpsters and confirmed the MD did not don PPE when he cleaned up the trash caused by the bears. During an interview on 10/07/24 at 1:30 PM, the Infection Preventionist (IP) stated she was aware that bears would rummage through the facility's garbage and that staff were cleaning up the trash that the bears had caused. The IP stated she was unaware that staff did not don PPE prior to cleaning up the debris and this was a potential infection control issue. The IP stated staff could potentially be dragging in unwanted bacteria into the facility. The IP stated that staff might need rubber gloves and boots since those items could be washed off. During an interview on 10/07/24 at 1:50 PM, the Director of Housekeeping stated her staff would take out trash to the dumpsters. The Director of Housekeeping stated that she was aware maintenance would clean the area where the bears had dumped and gone through all the bagged trash and there were times the housekeeping staff would complain to her about walking through the trash on the ground and were at times assisting with the cleaning. The Director of Housekeeping stated that the housekeeping staff did not don rubber boots, and this was a potential infection control issue if the staff came back into the facility. During an interview on 10/07/24 at 2:07 PM, the Administrator and the Director of Nursing (DON) both stated they were unaware that staff were cleaning up the debris left by the bears.

Based on observation, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food substitutions, ensuring recipes were followed, and proper scoop sizes were utilized for 67 out of 69 residents residing in the facility. This failure had the potential for residents to lose weight. Findings include: Review of the facility's undated policy titled, Menu Changes, indicated .Changes may be made to the existing menu by the Dietary Manager or Kitchen Supervisor for the following reasons .Product as ordered for meal was out of stock .Menu items which are substituted are noted by the Food Service Manager or Kitchen Supervisor . 1. A review of a document provided by the facility titled, Menu, dated the week of 09/09/24, indicated Monday's lunch meal included country fried steak, gravy, sour cream mash potatoes, and lima beans. During an initial tour of the kitchen conducted on 10/07/24 at 9:55 AM, Cook1 stated he had to replace lima beans with pinto beans since he could not locate the lima beans in the kitchen. Cook1 confirmed there was no evidence on the menu that a substitution had been approved. During an observation conducted on 10/07/24 at 11:46 AM, Cook1 began to serve the lunch meal. The pinto beans were observed served to the residents during this observation. During an interview on 10/09/24 at 12:53 AM, the Dietary Manager (DM) stated the menu for 09/09/24 was not the correct menu for the week. The DM stated she was the staff member to ensure the menus were the correct ones for the associated week. The DM stated the only directions that she and her staff followed were when they had to make powdered mashed potatoes, other than that she and the kitchen staff did not have menus to follow. The DM stated there was beef bouillon stocked and was not sure why Cook1 could not locate. The DM stated water was not to be used to create the pureed beef dish. DM stated the beef bouillon would provide a better taste for the pureed meat dishes. DM stated it was her expectation for the cook staff to use bouillon for the pureed meat dishes and not water. The DM stated there was no reason for the staff to use pinto beans instead of lima beans which were identified on the menu for the residents. During an interview on 10/09/24 at 1:59 PM, the Registered Dietitian (RD) stated that the DM had not been asking for enrichment menus, such as the recipe for pureed meats. The DM stated if water was added instead of beef bouillon, this would have the potential to be nutritionally inadequate. The DM stated there was a process for substitutions of menu items which included the substitution log, and she would then sign off on the substitution log. The DM stated the residents were then to be notified of the substitution. A request was made for a copy of the recipe for pureed meat, but it was not provided before the end of the survey. 2. Review of a document provided by the facility titled, Principle LTC Spring Summer 2024 referred to as menu extension indicated the following: -Pureed fried steak required the use of a number eight scoop or gray handled scoop which served four ounces of pureed meat. -A regular menu item for beans was to be served with a gray handle which served four ounces of beans. -Ground fried steak required the use of a number eight scoop or a gray handled scoop which served four ounces of beef. -Mashed potatoes were to be served one half of a cup or the use of a gray handled scoop which held four ounces. An observation was conducted on 10/07/24 at 11:46 AM, and the following food items were observed prior to being served: pureed fried steak, pinto beans, mashed potatoes, and ground fried steak. Cook1 used a blue handle scoop to serve pureed beef, which indicated two ounces of food; Cook1 used a blue handle scoop to serve pinto beans which indicated two ounces of food; Cook1 used a green handle scoop to serve ground fried steak, which indicated two and two thirds' ounces of food; Cook1 used a green handle scoop to serve mashed potatoes, which indicated two and two thirds of food. During an interview on 10/09/24 at 1:59 PM, when the DM was asked about the scoop size for the observation and stated she did not have the scoop sizes memorized and then went into the kitchen. The DM and the RD were present in the kitchen and a standardized scoop size poster was posted. During an interview on 10/09/24 at 2:40 PM, the RD and the DM entered the kitchen and walked to the posted scoop size and verified each serving and scoop size that was observed during the tray line. The RD stated [NAME] 1 should have used the associated scoop size per direction from the extended menu and this was a standard of practice and had no facility policy. During an interview on 10/10/24 at 12:30 PM, the Administrator and the Director of Nursing (DON) were present. The Administrator stated the residents would prefer to have pinto beans at any time of the week and was not aware of the differences in serving size observed during the tray line and stated he would be providing the DM with more support from the corporate office. The Administrator stated he was aware of the water used instead of bouillon and stated this potentially could affect the palatability of the food being served and potentially less calories.

Based on observation and interview, the facility failed to ensure garbage was properly disposed of and contained; with the potential to affect 69 census residents and staff in the facility. This failure had the potential to attract pests. Findings include: During an initial tour of the kitchen on 10/07/24 at 11:30 AM, there were two outside dumpsters inside a fenced area. The lids to the dumpsters were off the hinges and exposed the partial contents of the inside of each dumpster. On the outside of the fenced area, there was debris which included old food, soup containers, disposable cups, and used adult briefs. A strong odor omitted from the trash. There was also debris which surrounded the trash bins on the inside of the fenced area. Dietary Aide (DA) 1 was present during this observation and stated that bears would climb over the fence and either pull the bags from the dumpster to the outside of the fenced area or would toss the trash bags over the fenced area and then tear the bags apart. At 11:33 AM, the Maintenance Director (MD) came out and stated he cleaned this area on a daily basis and said animal control did not work with the facility to help manage the bears. The DM stated the lids to the dumpsters were not broken but could be popped into place. The MD stated there was an area on top of the fencing which used to be an electric area, but the bears were not bothered by the electric shock. (Cross Reference F880) During an interview with the Administrator and Director of Nursing (DON) on 10/10/24 at 12:30 PM, the Administrator stated his expectation was for the area around the dumpster to be cleaned and confirmed the facility had no formal policy on this issue.

Based on observation, document review, interview, and policy review the facility failed to ensure food items in the kitchen and storage areas were dated and labeled, food temperature logs were completed on a consistent manner, and utensils were not stored in ready to eat food for 67 out of 69 residents. This failure had the potential to lead to food-borne illnesses and cross contamination. Findings include: Review of the facility's policy titled, Food Temperature, dated 02/09/16, indicated .Temperature checklists and thermometers will be available in the kitchen. The Food Service Manager and/or Cooks are responsible for taking food temperatures prior to service of all foods prepared and record on the Steam Table Food Temperature form . Review of the facility's policy titled, Food Storage, dated 08/13, indicated .All incoming foods will have a delivery date and/or open date or used by date . Review of the 2022 Food Code US (United States) FDA (Food and Drug Administration), dated 01/18/23, located at https://www.fda.gov/media/164194/download?attachment, indicated .Chapter 3-13: During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored .In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon .Chapter 3-28: refrigerated, ready-to eat, time/temperature control for food safety food is prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 [degrees] C [Celsius] (41 F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . 1. Review of a document provided by the facility titled Steam Table Food Temperatures revealed: -Breakfast dated 09/02/24 to 09/08/24 indicated there were no temperatures recorded on 09/07/24 and on 09/08/24. -Lunch dated 09/02/24 to 09/08/24 indicated there were no temperatures recorded on 09/07/24 and on 09/08/24. -Dinner 09/02/24 to 09/08/24 indicated there were no temperatures recorded on 09/03/24 through 09/08/24. Review of a document provided by the facility titled Steam Table Food Temperatures revealed: -Breakfast 09/16/24 to 09/29/24 indicated there were no temperatures recorded on 09/20/24 through 09/22/24. -Lunch 09/16/24 to 09/29/24 indicated there were no temperatures recorded on 09/20/24 through 09/22/24. -Dinner 09/16/24 to 09/29/24 failed to record temperatures from 09/16/24 through 09/29/24. During an initial tour of the kitchen on 10/07/24 at 9:38 AM, Cook1 verified that the kitchen staff were not provided with the October temperature log to document the temperatures for the food items to be served. Cook1 also verified the logs for the steam table were also incomplete. During an interview on 10/09/24 at 1:59 PM, the Registered Dietitian (RD) stated she went over the importance of completing temperature logs with the Dietary Manager (DM) in 08/24 to ensure food items were at the proper temperature to ensure food items did not enter into an unsafe temperature zone prior to serving the residents. 2. During an initial tour of the kitchen conducted on 10/07/24 at 9:38 AM, Cook1 and Dietary Aide (DA) 3 opened the reach in refrigerator and the following items were identified: Two large clear containers of cooked cabbage with no date and no label; Mandarin oranges with no date and no label in a large clean plastic container; Cooked beans dated 09/30/24; Fresh tomatoes in a metal container and diced with no label and date; Two large bags of chopped wilted lettuce and one small bag of liquified lettuce with no date and label; Fruit cocktail in a clear plastic container with no date and label; and a bag of log of bologna and sliced with no date and label. DA3 confirmed the items were not labeled or dated. DA3 stated the liquified lettuce should not be in the refrigerator. During an interview on 10/09/24 at 12:53 PM, the DM stated the reach-in refrigerator was to be cleaned each Friday and that the staff member was to verify that food was labeled and dated. During an interview on 10/09/24 at 1:59 PM, the RD stated she began coming to the facility in 08/24 and stated the facility needed to date and label food when it was opened and the date the food was to be used by. The RD stated this was critical to label the date opened and use-by-date since there was potential for residents with a compromised immune system and could cause a food borne illness if the staff did not have this information available. 3. During an initial tour of the kitchen conducted on 10/07/24 at 9:38 AM, Cook1 verified that a scoop was left in a transparent plastic container, which contained multiple colored cereal, a scoop was left in a transparent plastic container which contained cereal flakes, and a scoop was left in a transparent plastic container which contained Cheerios. Cook1 stated by leaving the scoops in and on top of the dried cereal there was potential for cross-contamination. During an interview on 10/09/24 12:53 PM, the DM confirmed by leaving the scoops in the cereal containers there was potential for cross-contamination of the food item. During an interview on 10/09/24 1:59 PM, the RD stated scoops were not to be left in the bin due to the potential for cross-contamination of food. During an interview on 10/10/24 at 12:30 PM, the Administrator and Director of Nursing (DON) were alerted to the three concerns identified in the kitchen. The Administrator stated his expectation was for the kitchen to be maintained and sanitized.

Based on document review, interview, and policy review, the facility failed to ensure the dietary department was managed by a qualified director of food and nutrition services with the potential to affect 67 of 69 residents living at the facility. Findings include: Review of the 2022 Food Code US (United States) FDA (Food and Drug Administration), dated 01/18/23, Chapter 2-3 and located at https://www.fda.gov/media/164194/download?attachment, indicated Certified Food Protection Manager .The person in charge shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program . Review of a document provided by the facility titled, Food Service Manager, dated 07/01/16, indicated .The primary purpose of your job is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current applicable federal, state, and local standards, guidelines, and regulation .Be a certified food protection manager . Review of the Dietary Manager's (DM) employee file revealed she was hired on 10/03/23 as a cook for the facility. Included in the DM's employee file was a handwritten note, dated 05/16/24, that the DM would continue to work as a weekend manager, then transition to the full-time manager and begin testing for her dietary credentials as a Certified Dietary Manager (CDM). During an interview on 10/09/24 at 12:53 AM, DM confirmed she had no prior management experience in a nursing facility prior to 05/16/24. The DM stated she was not far along in her studies to prepare for the CDM exam. During an interview on 10/09/24 at 1:59 PM, the Registered Dietitian (RD) confirmed the DM was not a CDM and had encouraged her to complete the courses. The RD stated she did not supervise the current DM. During an interview on 10/10/24 at 12:30 PM, the Administrator and the Director of Nursing (DON) stated the RD would be coming in more frequently to provide additional training to the DM and the expectation was for the DM to complete her training to become a CDM.

Based on record review and interview, the facility failed to ensure six of six residents (Resident (R) 3, R19, R46, R56, R1, and R8) reviewed for care conferences out of a sample of 23 residents contained evidence the resident and/or her representative participated in the development or revision of their care plans. This failure would affect all residents and/or representatives who were scheduled for quarterly care plan meetings. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 08/19, indicated .Documentation of the invitation [to the resident's care conference] with follow-up is made in the progress notes. If the resident representative chooses not to participate, this is noted in the progress notes. Residents who are able to participate in planning their care and treatment are involved in the care planning process as well .The invitation and the resident's participation, or lack there-of, is documented in the progress notes, to include the offering of an individual review .reviews the care plan after (at a minimum) each admission, quarterly, annual, or significant change assessment . 1. Review of R3's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R3's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which revealed the resident was moderately cognitively impaired. Review of R3's EMR titled care plan Progress Notes located under the Prog (Progress) Note tab failed to contain evidence the resident and/or his representative were invited and then potentially participate in the resident's quarterly care conferences prior to 09/10/24. There was no evidence in R3's EMR that the interdisciplinary team (IDT) held quarterly care conferences to review and revise the resident's care plan after each annual and quarterly assessment. During an interview on 10/07/24 at 2:38 PM, R3 stated he was not sure if he was invited to his quarterly care plan meetings. 2. Review of R19's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R19's EMR titled quarterly MDS with an ARD of 09/12/24 indicated the resident had a BIMS score of 12 out of 15 which revealed the resident was moderately cognitively impaired. Review of R19's EMR titled care plan Progress Notes located under the Prog Note tab failed to contain evidence that the resident and/or his representative were invited and then potentially participate in the resident's quarterly care conferences. There was no evidence in R19's EMR that the IDT held quarterly care conferences to review and revise the resident's care plan after each quarterly assessment. During an interview on 10/07/24 12:28 PM R19 stated she was not sure if she got invited to her quarterly care plan meetings. During an interview on 10/08/24 at 1:16 PM, the Social Services Director (SSD) stated she alerted residents' representatives with an invitation card. SS stated the mailing of the invitation card was done annually and if there was a significant change in the status of the resident. SS stated she was unaware that residents and/or their representatives were to be invited to care conferences on a quarterly basis. SS stated the facility did not hold quarterly care conferences nor did they document in the residents' clinical records that a care conference was held. 3. Review of R46's undated Admission Record located in the EMR under the Profile tab, revealed R46 was admitted to the facility 08/12/22 with diagnoses including chronic obstructive pulmonary disease, chronic congestive heart failure, chronic kidney disease, schizophrenia, and anxiety disorder. Review of R46's quarterly MDS with an ARD of 05/22/24, revealed the resident had a BIMS score of 15 out of 15, which indicated R46 was cognitively intact. During an interview on 10/07/24 at 3:42 PM, R46 stated that he was not invited to care plan meetings. During an interview on 10/09/24 at 2:07 PM, the DON stated that there has not been a care plan meeting because R46 refused to attend. The DON was asked if there had been an interdisciplinary team care plan meeting, and she stated she would find out. Further interview with the DON on 10/10/24 at 1:26 PM revealed that there had been no care plan meetings for R46. 4. Review of R56's undated Admission Record located in the EMR under the Profile tab, revealed R56 was admitted to the facility 12/15/22 with diagnoses including right side hemiplegia following cerebral infarction, type two diabetes mellitus with diabetic chronic kidney disease and neuropathy, schizoaffective disorder, bipolar disorder, depression, anxiety, and chronic post-traumatic stress disorder. Review of R56's quarterly MDS with an ARD of 05/03/24, revealed the resident had a BIMS score of 99, which indicated facility staff were unable to complete the interview. Further review revealed the resident had short-term and long-term memory problems and cognitive skills for daily decision making was moderately impaired - decisions poor, cues/supervision required. During an interview with the DON on 10/09/24 at 1:52 PM it was determined that the last care plan meeting for R56 was in January 2023. The DON further stated that an invitation to a care plan meeting was mailed to the resident's representative on 08/02/24, and the facility has not heard back. Further interview revealed the DON was not aware that quarterly care plan meetings were not being scheduled. 5. Review of R1's Admission Record, dated 10/09/24 and located in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated diagnoses which included anoxic brain damage and functional quadriplegia. The record revealed the resident's medical decision-maker was her father, Family Member (FM) 1. Review of R1's quarterly MDS with an Assessment Reference Date (ARD) of 09/11/24 and located in the EMR under the MDS tab, revealed a BIMS assessment was not able to be completed due to the resident's poor cognition and inability to communicate. Review of a R1's Progress Note, dated 09/11/24 and located in the EMR under the Notes tab, revealed, Completed resident's quarterly MDS interview. Resident alert, mostly non verbal. Resident with dx (diagnoses) including Anoxic brain damage, mood affective disorder, anxiety, depression, chronic bronchitis, convulsions, hypokalemia, contractures, functional quadriplegia. Resident requires total care per staff. Receives gtube feeding as ordered, resident is NPO [nothing by mouth]. Incont [incontinent] of bowel and bladder with attends [adult brief] in use. Contractures noted. Dad visits daily. Hearing adequate. No speech, mumbles sounds at times. Vision is highly impaired. Resident is unable to answer when attempting pain interview. Interviewed staff on all shifts that provide care to resident. Staff reports no s/s [signs/symptoms] or indicators of pain noted in last 5 days. No SOB [shortness of breath] noted at this time. Will continue to observe and proceed with current POC [Plan of Care]. Review of R1's comprehensive record revealed nothing to indicate an interdisciplinary team care planning meeting had been held for R1 since 03/17/24 (almost seven months prior to survey) or that FM1 had been invited to a care planning meeting since that date. Review of R1's care planning invitation card, dated 03/17/24 and provided directly to the survey team, revealed FM1 was most recently invited to a care planning meeting on that date. During an interview on 10/08/24 at 11:51 AM, FM1 stated he visited his daughter in the facility daily and stated he did not recall ever receiving an invitation to a care planning meeting for R1. He stated if he was invited to a care planning meeting he would attend and stated he actually had a few questions he would like addressed by the facility. 6. Review of R8's Admission Record, dated 10/09/24 and located in the EMR under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included epilepsy and schizoaffective disorder. The record revealed the resident was his own medical decision-maker. Review of R8's quarterly MDS with an ARD of 07/05/24 and located in the EMR under the MDS tab, revealed a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Review of a R8's Progress Note, dated 10/07/24 and located in the EMR under the Notes tab, revealed, Resident is own RP [representative]. Care plan card [an invitation to the resident's care planning meeting] delivered to resident in his room. Denies need for care plan meeting at this time. Review of R8's comprehensive record revealed nothing to indicate an interdisciplinary team care planning meeting had been held for R8 related to the 10/07/24 meeting invitation or any time since 03/02/22 (almost two and 1/2 years prior to survey). During an interview on 10/08/24 at 1:24 PM, the SSD confirmed she was responsible for scheduling care planning meetings for residents and ensured an invitation to the meeting was provided to the resident and/or their responsible party. She confirmed that recent IDT care plan meetings had not been held for R1 or R8 and stated she was not aware an IDT care plan meeting needed to be held for each resident quarterly unless the resident or the RP requested a meeting. She stated a care planning meeting had not been held for R8 because he said he didn't need one and confirmed FM1 had not been invited to a care planning meeting, nor had an IDT care plan meeting been held for R1 since March of 2024. She stated, We just don't have a care plan meeting if they (residents) don't want one. No IDT meeting at all. During an interview on 10/10/24 at 12:35 PM, the Administrator and Director of Nursing (DON) confirmed the facility should be conducting care plan meetings for each resident at least quarterly and with any significant change of condition, confirmed their expectation was an IDT care plan meeting be held with all pertinent departments in attendance for each meeting, and confirmed they expected an invitation be provided to each resident and/or representative prior to each meeting. The DON confirmed care plan meetings had not recently been held for any residents who stated they did not want a meeting held according to the report she received from the SSD. The Administrator and DON both stated future care plan meetings, and invitations to these meetings were expected to be clearly documented in each resident's record. 15189 18947

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than 5% with two errors, involving two of five residents (Residents (R) 46 and R73), conducted out of a total of 28 opportunities for error, resulting in a 7.14% error rate out of 23 sample residents. R46 was not prompted to rinse his mouth after the administration of an inhaled steroid medication and the insulin pen was not left inserted in R73's subcutaneous (fatty) tissue for the required amount of time to ensure full absorption of the insulin. These failures created the potential for residents to experience negative physical impact related to the administration of their medications. Findings include: Review of the facility's policy titled, Administration of Kwikpen Insulin Pen Policy/ Procedure, dated 09/20, read, in pertinent part, Procedure: Dose Selection and Injection: 3. Inject the dose by inserting the needle into the skin in the back of the upper arm, abdomen or thigh. Press the injection button in all the way. Hold the button in that position for approximately 5 seconds then withdraw the needle. 1. Review of R46's Admission Record, dated 10/09/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The record indicated the resident's diagnoses included chronic obstructive pulmonary disease (COPD). Review of R46's Order Summary Report, dated 10/09/24 and located in the EMR under the Orders tab, indicated orders for the resident to receive Tiotropium Bromide Monohydrate (Spiriva-an inhaled steroid medication) 18 MCG (micrograms) per inhalation one time daily to treat his COPD. The original order date for the medication was 10/02/24. During an observation on 10/09/24 at 9:29 AM, the Certified Nursing Assistant/Kentucky Medication Assistant (CNA/KMA) 3 was administering R46's medications. The resident's Spiriva was observed to be administered but the resident was not prompted to rinse his mouth after the administration of the medication. R46 did not rinse his mouth prior to CNA/KMA3's exit from his room. During an interview on 10/09/24 at 9:42 AM, CNA/KMA3 stated she was not aware the resident's mouth needed to be rinsed after the administration of his steroid inhaler. 2. Review of R73's Admission Record, dated 10/09/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The record indicated the resident's diagnoses included type two diabetes. Review of R73's Order Summary Report, dated 10/09/24 and located in the EMR under the Orders tab, indicated orders for the resident to receive Humulin R Injection Solution 100 UNIT/ML (units per milliliter) (insulin) per sliding scale four times daily related to her diagnosis of type two diabetes. The original order date for the insulin was 09/16/24. During an observation on 10/08/24 at 11:14 AM, Registered Nurse (RN) 2 was observed administering R73's insulin. The resident received two units of sliding scale insulin per insulin pen related to her blood sugar reading of 236. The insulin pen needle was inserted into the resident's skin and the insulin was injected. After injection of the insulin, the needle was removed immediately (not left inserted for the expected amount of time to ensure full absorption of the medication). During an interview on 10/08/24 at 11:32 AM, with RN2 stated she thought the needle should have been left inserted in R73's skin for 10 seconds after administration of the insulin. She confirmed she had not done this. During an interview on 10/09/24 at 3:58 PM, the Director of Nursing (DON) stated her expectation was the resident's mouth to be rinsed after the administration of an inhaled steroid medication and the insulin pen needle was to be left inserted in a resident's skin for 10 seconds after the administration of insulin. During an interview on 10/10/24 at 12:43 PM, the Administrator confirmed his expectation was medications were to be administered according to established guidelines/policies/procedures and per the direction of the DON.

Based on observation, record review, and interviews, the facility failed to ensure one of four residents (Resident (R) 36) reviewed for accidents was assessed for her use of side rails, had a care plan in place for use of the rails, and had an informed consent for the use of side rails out of 23 sample residents. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed. Findings include: Review of R36's Admission Record, dated 10/09/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated diagnoses which included hemiplegia and hemiparesis following a stroke. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/24 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was completely dependent upon staff to move about in her bed and to transfer in and out of her bed. The assessment did not indicate side rails were in use for R36. Review of R36's Order Summary Report, dated 10/09/24 and located in the EMR under the Orders tab, indicated no orders for the resident's use of side rails on her bed. Review of R36's comprehensive care plan, most recently dated 08/06/24 and located in the EMR under the Care Plan tab, indicated nothing to reflect the resident's use of side rails. The care plan indicated the resident was completely dependent upon staff to move in her bed and transfer in and out of her bed. Review of R36's record revealed nothing to show the resident had been recently assessed for use of bed rails or that informed consent had been provided for the use of rails. During observations on 10/07/24 at 11:36 AM, 11:56 AM and 1:44 PM, on 10/09/24 at 9:46 AM, 11:56 AM, and 12:04 PM, R36 was observed lying in her bed with a wing-tip mattress and bilateral 1/3 side rails in the raised position at the head of her bed. The resident's bed was in a low position and fall mats were placed on both sides of her bed during each of the observations. During an observation and interview alongside Certified Nursing Assistants (CNA) 2 and CNA5 on 10/09/24 at 11:56 AM, they both confirmed the resident's side rails were raised at the top of her bed and stated they didn't think residents should have raised bed rails when a wing tipped mattress was on their bed unless a resident was able to use the rails somehow. Both staff members confirmed R36 was not able to use bed rails to move within her bed or to transfer in and out of her bed. During an observation and interview alongside Registered Nurse (RN) 1, R36 was in bed with her bilateral side rails in the raised position at the top of her bed on 10/09/24 at 12:04 PM. RN1 indicated she was in charge of ensuring bedrails were necessary for all residents using rails in the facility and stated any resident using rails should have an assessment, care plan, and documentation of informed consent for use of the rails. During an interview with the Administrator and Director of Nursing (DON) on 10/10/24 at 12:39 PM, the DON stated any resident using side rails on their bed was expected to have informed consent as well as a care plan and assessment for use of side rails. She stated she thought R36's use of side rails had fallen through the cracks. The Administrator agreed with the DON's statements.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a trauma survivor received trauma-informed, culturally competent care accounting for resident's experiences and preferences to avoid triggers (psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) leading to potential re-traumatization for one of three residents (Resident (R) 56) reviewed for mood/behavior of 23 sample residents. The failure had the potential to affect residents with a diagnosis of post-traumatic stress disorder which could interfere with residents' quality of life. Findings include: Review of the facility's policy titled, Trauma and Post Traumatic Stress Disorder (PTSD) Informed Care, dated 08/19, revealed .The intent of this section is to ensure that a resident who upon admission, was assessed and displayed or was diagnosed with a mental or psychosocial adjustment difficulty or a history of trauma and/or PTSD receives the appropriate treatment and services to correct the initial assessed problem or to attain the highest practicable mental and psychosocial well-being. Residents who were admitted to the nursing home with a mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD, will receive appropriate person-centered and individualized treatment and services to meet their assessed needs .The Social Worker will: Ensure that the IDT, which includes the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered. This is done through an assessment of the resident's expressions or indications of distress to determine if services are needed . During an observation and interview on 10/07/24 at 10:25 AM the resident utilized a wheelchair and was able to self-propel. The resident was observed with right side paralysis. The resident was able to answer yes or no questions but was aphasic. The resident nodded her head affirming that she had a diagnosis of PTSD. When asked if she had nightmares related to PTSD, the resident was unable to answer yes or no. Review of R56's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R46 was admitted to the facility 12/15/22 with diagnoses including right side hemiplegia following cerebral infarction, schizoaffective disorder, bipolar disorder, depression, anxiety, and chronic post-traumatic stress disorder (PTSD). Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated facility staff were unable to complete the assessment. Further review revealed the resident had short-term and long-term memory problems, cognitive skills for daily decision making and had moderately impaired decisions, poor, cues/supervision required. Review of R56's attending physician's progress note, dated 03/05/23, located under the Misc tab of the EMR, revealed that the resident has a history of a stroke and automobile accident with multiple injuries. Review of R56's Trauma Informed Assessment, dated 12/16/22, located under the Assessments tab of the electronic medical record revealed that under the Life Events Checklist .3. Any transportation accident (car, boat, train, plane accidents) .12. Any life-threatening illness or injury .17. Any other very stressful event or experiences .'Doesn't apply' was checked. Review of R56's admission Social History, dated 12/16/22 and located under the Assessments tab of the EMR, revealed .7. History of Mental Health Problems was left blank. Review of the quarterly Social Services - V 2 assessment, dated 08/01/24 and located under the Assessments tab of the EMR revealed .7. History of Mental Health Problems was left blank. Further review of R56's medical record revealed a care plan for PTSD had not been developed. The care plan failed to identify specific traumatic events. There was not a trauma-informed care approach (delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma) to providing care to R56. During an interview on 10/09/24 at 9:54 AM, the Certified Nursing Assistant (CNA) 4 stated that she was not aware of any psychiatric diagnoses for R56. During an interview on 10/09/24 at 9:56 AM, it was revealed that the Registered Nurse (RN) 3 was not aware of R56's diagnosis of PTSD and she proceeded to log onto the computer to look at the resident's diagnoses. During an interview on 10/09/24 at 11:21 AM, the Social Services Director (SSD) revealed that when the social service assessments were completed, she does not usually plug anything in on the section for history of mental health problems. SSD stated that she was aware of the resident's diagnosis of PTSD but did not recall what the resident's representative told her related to the resident's diagnosis of PTSD. During an interview on 10/10/24 at 1:20 PM, the Director of Nursing (DON) determined that her expectation was that staff needed to assess a resident with a diagnosis of PTSD for the cause, triggers, and what hurt or helped the resident.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 38) reviewed for weight/nutrition was provided with recommended and physician prescribed interventions to prevent weight loss of 23 sample residents. This failure created the potential for R38 to experience further weight loss. Findings include: Review of the facility's policy titled, Weight Policy, dated 08/13, read, in pertinent part, It is the policy of the facility to weigh residents on admission and on a monthly basis thereafter. If a resident either gains or loses 5% in 30 days or 10% in 180 days, the following steps will be completed: 1) The resident will be re-weighed 2) Dietary Manager will be notified if he/she determines weight variance is significant 3) Physician and responsible party will be notified 4) Continuing weight loss or gain of 5% monthly, 10% in 180 days, or a total gradual weight loss or significant gain will be brought before the weight management team to determine if a significant change has occurred 5) Weight committee/Care Plan Team will review and take appropriate measures to resolve weight loss or gain 6) The dietician will review residents with significant weight loss. Review of R38's Admission Record, dated 10/09/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated diagnoses which included heart disease, chronic kidney disease, and acute respiratory failure. Review of R38's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/24 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated the resident had no known significant weight loss prior to admission and indicated the resident was not on a prescribed weight loss regimen. Review of R38's Order Summary Report, dated 10/09/24 and located in the EMR under the Orders tab, indicated an order dated 09/06/24 for the resident to receive a regular diet with regular texture and add a Mighty Shake (a nutritional supplement) with each meal. Review of R38's Medication Administration Record (MAR), Treatment Administration Record (TAR), and Certified Nursing Assistant (CNA) daily documentation, all dated 09/04/24/through 10/09/24, revealed nothing to show R38 had been receiving the ordered Mighty Shakes with meals. Nothing was recorded in the record to indicate R38 had been refusing the supplements. Review of R38's Nutrition/State of Nourishment Care Plan, dated 09/01/24 and located in the EMR under the Care Plan tab indicated the resident's state of nourishment was less than body requirement characterized by weight loss, inadequate intake. Goals included Will not experience significant weight loss through next review. Interventions included diet as ordered, offer substitutions for uneaten meals, weigh per facility protocol, and refer to dietitian for evaluation/recommendations. Review of R38's weight records indicated the following weights, which indicated a significant loss of 12.69% weight loss in one month prior to 10/03/24. The record also indicated R38 was not re-weighed, per facility policy, after she lost seven pounds between 09/19/24 and 10/03/24 (a loss of 5.65% in two weeks): -08/29/24: 134.0 pounds -09/05/24: 133.0 pounds -09/09/24: 134.0 pounds -09/12/24: 127.0 pounds -09/19/24: 124.0 pounds -10/03/24: 117.0 pounds Review of R38's Registered Dietician Recommendations, dated 09/04/24 and provided directly to the survey team, indicated a recommendation to update R38's likes/dislikes and liberalize her diet related to her poor oral intake. The document included a recommendation for R38 to receive Mighty Shakes with her meals. Review of R38's undated Meal Card, provided directly to the survey team, revealed the resident was to receive Mighty Shakes three times daily with meals. During observation on 10/08/24 at 12:26 PM and again on 10/09/24 at 12:15 PM revealed R38 was being served and consuming her lunchtime meals. The resident was observed to be served a regular diet and received assistance to set up her meal prior to consumption. The resident did not receive her ordered Mighty Shake with either of the meals observed. During an interview on 10/09/24 at 12:15 PM, Certified Nursing Assistant (CNA) 4 indicated she was very familiar with R38 and stated the resident did not receive a Mighty Shake with her meals. She stated residents who received a supplement with their meals were populated on a list on the CNA tablet. CNA4 showed the surveyor the list of residents who received supplements and R38 was not on the list. During an interview on 10/09/24 at 12:28 PM, CNA6 indicated she was very familiar with R38 and stated the resident was supposed to receive a Mighty Shake with each meal, however if the resident received a Mighty Shake with breakfast, she did not receive one with lunch because if the resident was served too many supplements, she would not eat her real food. During an interview on 10/09/24 at 1:37 PM, the Dietary Manager (DM) stated she was not familiar with R38 since she did not interact with her very much. She stated she received a weekly email from the Registered Dietitian (RD) with recommendations for residents who were losing weight, but that she did not do anything to follow-up with the recommendations until she received an order from the nursing staff related to the recommendations. She stated she was not aware of R38's weight loss. During an interview on 10/09/24 at 2:00 PM, the RD confirmed she was familiar with R38 and stated she was aware of her recent weight loss. The RD stated her most recent recommended intervention for the resident's weight loss was to add Mighty Shakes with each of her meals. She confirmed her recommendations were emailed, weekly, to the Director of Nursing (DON) and the DM. The RD stated the facility's process was to document the administration of the Mighty Shakes in the CNA documentation. The RD stated her expectation was facility staff would obtain a re-weight if a resident experienced a weight loss of more than 5% between weights and her recommendations should be followed related to nutritional interventions to prevent weight loss. During a follow-up interview with the RD on 10/09/24 at 3:05 PM, she stated she had just spoken with nursing staff regarding R38's weight loss and the lack of documentation of administration of the recommended and ordered Mighty Shakes and staff reported to her they were not providing the resident with the shakes with each meal because the shakes filled the resident up and then she would not eat her meal. The RD stated the information had not been previously communicated to her by nursing staff and that her expectation was facility staff would communicate any deviation in the recommended plan of care immediately so that she was able to address any concern related to the resident's diet. The RD confirmed she was not able to locate any documentation to show R38 had been receiving the Mighty Shakes in the resident's record. During an interview on 10/10/24 at 12:30 PM, the DON and the Administrator stated their expectation was residents would be re-weighed with any significant weight loss of more than 5% and RD recommendations were expected to be followed.

18947 Based on record review, interviews, and review of facility policy, the facility failed to ensure two out of three residents (Resident (R) 15 and R48) reviewed for abuse/neglect were free from physical abuse of 23 sample residents. R15 and R48 got into a physical altercation in the facility's smoking area and both residents were injured related to the altercation. The facility's failure to ensure measures were in place to prevent the incident of resident-to-resident abuse between R15 and R48 created the potential for both residents to continue to be abused leading to potential physical and/or psychosocial harm to the residents. Findings include: Review of the facility's policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, dated 05/01/13, revealed, in pertinent part, The facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, and abuse of our residents or misappropriation of their property. 1. Review of R48's Admission Record, dated 10/09/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated diagnoses which included type two diabetes, restlessness and agitation, and cognitive communication deficit. Review of R48's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/24 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was severely cognitively impaired. Review of R48's Progress Note, dated 06/11/24 and located in the EMR under the Notes tab, revealed, Allegation of resident to resident altercation. Residents separated. Resident assessed for injuries with small scratch noted to upper lip and skin tear to the right lower arm. Resident denied pain and showed no s/s of pain upon assessment. MD [Medical Doctor] and RP [Resident Representative] notified. Review of the facility's Incident and Accident Logs, dated 01/01/24 through 10/08/24 and provided directly to the survey team, revealed an incident of resident-to-resident abuse between R15 and R48, entered on 06/11/24. Review of a document provided by the facility titled Initial Report, dated 06/11/24, indicated the resident-to-resident, which involved R15 and R48, happened on this same date. The report indicated the residents' representatives and physician were notified of the incident. According to the report, R15 was out in the back waiting for a smoke break, when R48 wheeled up next to her. The report indicated R15 directed R48 to move to a certain spot and the two residents began to slap each other. Both residents were immediately separated. Interviews were gathered from R15 and R48 and witness statements. There have been no further incidents of resident-to-resident with R15 and R48. Review of the facility's final investigation summary, dated 06/17/24 and provided directly to the survey team, related to the incident of resident-to-resident abuse between R15 and R48 on 06/11/24 was reviewed and revealed, At approximately 12:30 pm on 6-11-24, resident [R15] was in the back courtyard waiting on smoke break when resident [R48] wheeled up next to her. After that [R15] apparently tried to direct [R48] to sit in a certain spot pointing with her hand. At approximately 12:35 p.m., the two residents began to slap and hit each other until two staff members arrived in the area and separated the two. The facility is monitoring the residents for further behaviors; and Each (resident) suffered scratches requiring minor first aide. 2. Review of R15's EMR titled Admission Record indicated the resident was admitted to the facility in 09/28/10 with a diagnosis of schizophrenia. Review of R15's EMR quarterly MDS with an ARD of 04/26/24 indicated the resident had a BIMS score of eight out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated that the resident had no behaviors directed to others. The assessment revealed the resident used a wheelchair for mobility and had an impairment on one side of her upper extremity. Review of R15's EMR titled Incident Report located under the Prog (Progress) Note, dated 06/11/24, indicated R15 was involved in a resident-to-resident with R48 and R11 and sustained three small scratches to her left upper/inner arm. The scratches had scant blood and some bruising. The resident denied any pain. R15's representative and physician were notified of the incident. During an interview on 10/09/24 at 12:44 PM, R15 stated she remembered the resident-to-resident altercation with R48, and she was currently not afraid of R48. During an interview on 10/10/24 at 10:11 AM, Certified Nursing Assistant (CNA) 1 stated R15 could become agitated if things did not go her way. CNA1 stated the resident-to-resident incident between R15 and R48 was the first time this happened, and he stated he witnessed the two of them begin to argue and then went after each other. CNA1 stated he went and separated the two residents and reported the incident. CNA1 stated he considered the resident-to-resident abuse since both residents sustained scratches. During an interview with the Administrator and Director of Nursing (DON) on 10/10/24 at 12:44 PM, both indicated their expectation was residents should not be subjected to any type of abuse. The DON stated, It is our job to protect them (residents).

Based on observation, interview, record review, and a review of the facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received respiratory care and services in accordance with professional standards of practice. Interviews with the Administrator and Director of Nursing (DON) revealed only licensed nursing staff (Registered Nurses (RNs) and Licensed Practical Nurses (LPNs)) should administer/monitor resident oxygen therapy. However, interviews with staff revealed on 08/29/19, at approximately 8:00 PM, State Registered Nurse Aide (SRNA) #1 replaced Resident #1's empty oxygen tank and initiated liquid oxygen therapy via a new tank for the resident. The findings include: Review of the facility's Respiratory Care Services Agreement, dated 12/01/10, revealed the facility assumed the responsibility for services rendered to residents in the facility. Review of the facility policy titled Oxygen Therapy, dated (MONTH) 2013, revealed staff were to administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. The policy also stated facility residents that received oxygen should be kept as comfortable as possible. The policy did not address who should administer oxygen and/or monitor oxygen therapy. However, interview with the DON on 09/10/19 at 2:15 PM revealed only licensed nursing staff should administer/monitor oxygen for residents. Review of Resident #1's medical record revealed the facility admitted the resident on 12/21/18 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required oxygen therapy and was interviewable with a Brief Interview for Mental Status (BIMS) score of twelve (12). The MDS also indicated the resident required extensive assistance of two (2) staff members for bed mobility and transfers. Review of Resident #1's physician orders dated (MONTH) 2019 revealed the resident had an order for [REDACTED]. Interview with SRNA #1 on 09/10/19 at 1:20 PM revealed LPN #1 had directed him to exchange Resident #1's liquid oxygen tank, with a new tank, at approximately 8:00 PM on 08/29/19. SRNA #1 stated LPN #1 frequently directed him to exchange residents' oxygen tanks. The SRNA also stated he was not aware it was not standard practice for SRNAs to administer oxygen to facility residents. Interview with LPN #1 on 09/10/19 at 1:25 PM revealed she was assigned to care for Resident #1 during the 7:00 PM to 7:00 AM shift on 08/29-30/19. She stated Resident #1's oxygen tank was almost empty and needed replacing early in her shift (unable to recall exact time). LPN #1 stated she retrieved a new oxygen tank from the facility storage area, and checked the tank to ensure it functioned properly. The LPN stated she delegated the exchange of Resident #1's oxygen tank to SRNA #1. LPN #1 stated she was not aware that it was not standard practice for her to delegate oxygen administration to SRNAs in the facility. However, continued interview with LPN #1 and review of Resident #1's nurse's notes dated 08/30/19 at 3:52 AM (approximately 8 hours after the resident's oxygen tank was exchanged) revealed she was called to the resident's room and observed the resident's oxygen tank making noise and leaking white dry ice on the outside of the tank. LPN #1's documentation also stated the resident's nasal cannula broke and red marks were observed to the resident's left upper arm and his/her forearm. Resident #1 informed the LPN that the tank had leaked and burned his/her arm. Interview with the DON on 09/10/19 at 2:15 PM revealed it was not standard practice for SRNAs to administer oxygen to residents in the facility. She also stated LPN #1 should have exchanged Resident #1's oxygen tank on 08/29/19. Interview with the Administrator on 09/10/19 at 2:30 PM revealed SRNAs had not been trained, nor was it standard practice in the facility for unlicensed staff to administer oxygen to facility residents. He also stated the nurse should have exchanged Resident #1's oxygen tank as required on 08/29/19.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the accuracy of the resident's medical record for one (1) of nineteen (19) sampled residents (Resident #3). Resident #3 had a physician's orders [REDACTED]. However, the physician monthly order sheets for (MONTH) 2019 through (MONTH) 2019 revealed the orders stated the resident was to be a Full Code. The findings include: Review of the facility's policy, Receipt of physician's orders [REDACTED]. Review of Resident #3's medical record revealed the facility admitted the resident on 03/28/19, with [DIAGNOSES REDACTED]. Review of Resident #3's Advance Directive/Advance Care Planning Summary, dated 03/27/19, revealed the resident's responsible party had elected for the resident to have a Do Not Resuscitate (DNR) order. Review of a signed physician's orders [REDACTED]. Review of the comprehensive care plan for Resident #3 revealed an intervention dated 03/28/19, for the resident to have a code status of DNR. However, review of Resident #3's computer-generated monthly physician's orders [REDACTED]. Interview conducted with Registered Nurse (RN) #3 on 07/11/19 at 3:36 PM, revealed she assisted with checking computer-generated monthly orders for accuracy. RN #3 stated she reviewed the previous month's physician's orders [REDACTED]. [REDACTED].#3 stated RN #2 also checked the orders to ensure accuracy of the orders. RN #3 stated Resident #3's code status should have been changed to DNR beginning with the (MONTH) 2019 orders, but stated it must have been missed. Interview with RN #2 on 07/11/19 at 4:52 PM, revealed she and RN #3 were responsible for checking the computer-generated physician's orders [REDACTED]. RN #2 stated Resident #3's code status should have been changed beginning with the (MONTH) 2019 orders, to accurately reflect the resident's DNR status, but had been missed. Interview conducted with the Director of Nursing (DON) on 07/11/19 at 4:54 PM, revealed RN #2 and RN #3 were responsible for checking the monthly physician's orders [REDACTED]. The DON stated Resident #3's monthly physician's orders [REDACTED].

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two (2) of twenty-three (23) sampled residents (Resident #58 and Resident #78). Resident #58 utilized a gastrostomy tube (feeding tube) for medication administration and fluid intake; however, the facility failed to document on the resident's MDS that the resident utilized a feeding tube. In addition, the facility documented that Resident #78 was discharged to the hospital; however, the resident was discharged home. The findings include: Interview with the Administrator on 04/26/18 at 11:50 AM, revealed the facility did not have a policy related to accuracy of Minimum Data Set (MDS) assessments, but utilized the current Resident Assessment Instrument (RAI) Manual. 1. Review of the RAI 3.0 User's Manual revealed staff should code 01 for question A2100, if a resident was discharged to the community (private home/apartment, board/care, assisted living, or group home). Review of the medical record for Resident #78 revealed the facility admitted the resident on 02/09/18, with [DIAGNOSES REDACTED]. Review of the discharge MDS for Resident #78 completed by the facility on 02/09/18 revealed staff documented that the resident was discharged to the hospital; however, a review of Resident #78's discharge summary dated 02/09/18 revealed the resident left against medical advice and was discharged home on[DATE]. Interview with the MDS Coordinator on 4/26/18 at 2:45 PM, revealed she completed the discharge MDS assessment for Resident #78. She stated she made a mistake on the MDS and should have coded that the resident was discharged home. 2. Review of the RAI 3.0 User's Manual revealed the presence of any type of tube that could deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system, which included but was not limited to nasogastric tubes, gastrostomy tubes, jejunostomy tubes, or percutaneous endoscopic gastrostomy (PEG) tubes, should be coded on the MDS in Section K. Further review of the User's Manual revealed staff should also code the amount of nutrition/hydration the resident received from the tube. Review of Resident #58's medical record revealed the facility admitted the resident on 12/11/14, with [DIAGNOSES REDACTED]. Review of Resident #58's physician orders [REDACTED]. Further review revealed the resident also had an order that the resident's feeding tube could be used for delivery of medication. However, a review of Resident #58's Quarterly MDS assessment dated [DATE] revealed staff documented that the resident did not have a feeding tube and documented that no calories or fluids were provided via the resident's feeding tube. Interview on 04/26/18 at 2:34 PM with the nurse who completed Resident #58's MDS revealed she did not document that the resident had a feeding tube because the resident did not receive any nutrition via the tube. After reviewing the definition of a feeding tube for MDS purposes, the nurse stated she should have documented that the resident had a feeding tube because the resident received water and medication through the tube. Interview with the Director of Nursing (DON) on 04/26/18 at 3:07 PM, revealed she randomly reviewed MDS assessments for accuracy and had not identified any concerns with MDS assessments not being coded accurately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program for preventing and controlling infections and/or communicable diseases. Observation revealed staff failed to clean the blood glucose monitoring device prior to placing the device in a storage case. Although staff removed the device for cleansing/disinfection, staff failed to clean/disinfect the storage case and placed the clean device back in the dirty case. The findings include: Review of the facility's policy titled Glucometer-Cleaning & Disinfection, revised on 09/04/14, revealed the glucometer should be cleaned after each use with an Environmental Protection Agency registered germicidal disposable cloth/wipe and allowed to thoroughly air dry before storing the glucometer in a specified storage area. Observation on 04/25/18 at 11:05 AM, revealed Licensed Practical Nurse (LPN) #1 obtained a blood sample from Resident #42 to test the resident's blood glucose level utilizing a blood glucose monitoring device. LPN #1 did not clean/disinfect the blood glucose monitoring device before placing the device in a storage case. The LPN then removed the blood glucose monitoring device and cleaned the device with a Sani Wipe with bleach. However, the LPN did not clean the storage case and placed the blood glucose monitoring device back in the case. Interview with LPN #1 on 04/26/18 at 2:32 PM, revealed she should have cleaned the blood glucose monitoring device before placing the device in the storage case. Interview with the Director of Nursing (DON) on 04/26/18 at 2:45 PM revealed LPN #1 should have cleaned the blood glucose monitoring device before placing it in the storage case. The DON stated she randomly monitored to ensure staff cleaned/disinfected blood glucose monitoring equipment and had not identified any concerns.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of fifteen (15) sampled residents (Resident #10) and one (1) unsampled resident (Resident A) received adequate supervision to prevent accidents/injury during smoking. In addition, the facility failed to provide an environment free from hazards. Observation revealed the facility failed to store cleaning supplies, personal hygiene items, medications, and electrical appliances in accordance with the facility's procedures. The findings include: Review of the facility's Safety Management Plan (use of Tobacco Products/Smoking Materials), revised on 05/25/16, revealed residents are permitted to smoke in accordance with facility policy and the exception granted by the City Smoking Ordinance, and as recognized in the resident's individual plan of care. According to the plan, residents must be supervised when using lit smoking materials. A review of the Smoking Policy (dated January 2009) revealed residents, staff, and visitors would be allowed to smoke only in designated smoking areas and the smoking areas would be posted. The policy noted non-adherence to this policy could be grounds for discharge for the resident. 1. Review of the medical record revealed the facility admitted Resident A on 07/12/13 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the facility assessed Resident A and determined the resident was unable to complete the interview to evaluate his/her mental status, and had short/long-term memory loss with moderately impaired decision-making skills. The facility further assessed the resident to be independent with bed mobility, transfers, ambulation, and locomotion (on and off the unit). Review of the comprehensive care plan revised on 11/01/16 revealed the facility identified that Resident A was a chronic smoker who required supervision. Interventions included to evaluate the resident's ability to smoke safely on a consistent and regular basis, to provide a smoking apron for the resident, to supervise the resident while smoking, and to place smoking materials at the nurses' station for storage. A review of the Smoking Evaluation completed by the facility on 03/22/17 for Resident A revealed the facility staff determined the resident was an unsafe smoker and must be supervised while smoking. Resident A was observed on 03/21/17, at 9:52 AM to be in the facility courtyard unsupervised with two (2) other residents, who were observed to be smoking cigarettes. Review of the smoking list provided by the facility revealed Resident F, Resident G, and Resident H were assessed to be able to smoke independently. A review of the Brief Interview for Mental Status (BIMS) scores revealed Resident F had a score of twelve (12), which indicated the resident had moderately impaired cognition and Residents G and H had a score of fifteen (15), which indicated the residents were alert/oriented. Interviews conducted with Residents F, G, and H on 03/22/17, at 5:20, 5:25 PM, and at 5:50 PM revealed staff did not watch Resident A when he/she was smoking. Resident G stated the staff gave cigarettes to Resident A and he/she (Resident G) or one of the other residents who was allowed to keep their lighters would light cigarettes for Resident A. Residents F, G, and H further stated that Resident A would also get cigarette butts out of the ashtray and smoke them without staff supervision. Interview conducted with SRNA #2 on 03/22/17, at 2:15 PM revealed the facility did not maintain a smoking schedule for the residents and no staff was assigned to take the residents to smoke. The SRNA stated scheduled smoking stopped when the facility changed to smoke-free last year. The SRNA further stated the residents who smoked were permitted to smoke whenever they wanted in the designated smoking area outside in the courtyard. SRNA #2 added that she wasn't sure if smoking aprons were still available for resident use. SRNA #1 also stated in interview on 03/22/17 at 2:20 PM that there were no scheduled smoke breaks for residents since the facility had gone smoke-free. SRNA #1 stated she believed there was only one resident (Resident #13) who required supervision for smoking and either staff or the resident's family took him/her to smoke. Interview with Geriatric Care Attendant (GCA) #1 on 03/22/17, at 2:20 PM, revealed she was aware Resident A required supervision during smoking. However, GCA #1 stated she was not aware the resident was required to utilize a smoking apron until this morning (03/22/17) when the MDS nurse told her. Interview with the Activity Director (AD) on 03/22/17 at 2:25 PM, revealed she assisted staff with smoke breaks at times, but had not been using smoking aprons for residents who had been assessed to require supervised smoking. Interview with SRNA #3 on 03/22/17, at 2:26 PM, revealed he had not seen any staff supervise residents who smoke or seen aprons being used for residents. SRNA #3 further stated he had never been asked to supervise a resident during smoking. Interview with the Director of Nursing (DON) on 03/22/17 at 3:05 PM, revealed the facility implemented a smoke-free policy during the summer of 2016. The DON stated smoking assessments were conducted at least quarterly to evaluate residents who expressed a wish to smoke to determine if the resident required supervision during smoking periods. The DON confirmed the facility currently had ten (10) residents who smoked independently and two (2) who required supervision. The DON also confirmed the facility did not have scheduled smoke breaks and residents were permitted to smoke whenever they wanted in the designated smoking area. In addition, the DON stated a GCA would usually supervise the resident, but if the GCA was not available any staff person should supervise the resident. The DON also stated the video cameras were used to monitor residents in the designated smoking areas. Interview with the facility Administrator on 03/22/17, at 6:40 PM, revealed smoking safety for residents was determined through a nursing assessment for the individual resident. The Administrator stated he was not familiar with the criteria of the assessment. The Administrator stated staff was responsible to take the residents to smoke who had been assessed to need supervision and to use the smoking aprons. The Administrator further stated he had cameras in his office where he was able to monitor the designated smoking area and had not identified any problems. 2. Review of the medical record for Resident #10 revealed the facility readmitted the resident on 05/31/11 with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the facility assessed Resident #10 to have a Brief Interview for Mental Status score of 6, which indicated severe cognitive impairment. However, a review of Resident #10's Smoking Evaluation dated 03/20/17 revealed the facility assessed Resident #10 to be a safe smoker and to be able to smoke independently. Observation on 03/22/17 at 1:34 PM revealed Resident #10 had a cigarette and a cigarette lighter in his/her possession. Interview with Resident #10 on 03/22/17 at 1:34 PM revealed the facility had assessed the resident to be a safe smoker. Resident #10 stated he/she usually smoked alone in the courtyard or outside of the dining room. Observation of Resident #10 on 03/22/17 at 3:42 PM revealed he/she reported being upset. Resident #10 stated, I'm mad because someone came into my room while I was outside smoking and took my jacket. The resident stated he/she asked a nurse about his/her jacket and the nurse stated she called Laundry and they had taken the resident's jacket because State's here and it had burn holes in it, and State would take smoking away if they saw it. Resident #10 confirmed the jacket had burn holes in the sleeve because the resident had lost his/her right arm and used his/her left hand to smoke. Observation on 3/22/17 at 3:09 PM and 4:52 PM revealed Resident #10 sitting alone outside in the courtyard smoking. Interview with SRNA #2 on 03/22/17 at 2:15 PM and SRNA #1 on 03/22/17 at 2:20 PM revealed staff was not required to go outside with residents to smoke. However, SRNA #2 stated only certain residents could go out to smoke on their own. Interview with SRNA #3 on 03/22/17 at 2:26 PM revealed there were no scheduled smoking breaks for residents and he had never been asked to take a resident out to smoke. Interview with Licensed Practical Nurse (LPN) #2 on 03/22/17 at 7:41 PM revealed she assessed Resident #10 to be a safe smoker. LPN #2 stated she had watched the resident smoke and the resident demonstrated no unsafe behaviors with smoking. The LPN stated the resident lights the cigarette, ashes it, and extinguishes it without any problems. LPN #2 further stated Resident #10 was assessed monthly for safe smoking and she had not identified any problems with him/her smoking. Further interview with LPN #2 revealed she did not know why Resident #10 had a BIMS of six (6) because the resident's cognition was good and the resident's BIMS should be higher. LPN #2 stated maybe the resident just didn't want to answer the questions that day. 3. Review of facility's policy titled General Safety Rules, revised December 1998, revealed chemicals were required to be kept in a locked compartment of the housekeeping cart. Interview with the facility Nurse Consultant on 03/22/17 at 3:39 PM revealed the facility did not have a policy specific to accidents and hazards for residents. However, interview with the facility DON on 03/22/17 at 6:58 PM revealed hair dryers and clippers should not be stored near water. Continued interview with the DON revealed shampoo, body wash, and shaving cream should be put up if not being used. The DON further stated that eye drops and cleaning supplies should not be stored in resident rooms and should be stored under lock. Review of the Safety Data Sheet (SDS) for antiseptic mouth rinse under Section 2, Hazards Identification for Industrial Setting: Emergency Overview, revealed the product may be harmful if swallowed. Continued review of SDS under Section 4, First Aid Measures, revealed if the product was ingested, medical attention should be sought immediately. Review of the SDS for aerosol disinfectant, sanitizer, and deodorizer spray under Section 11, Toxicological Information, revealed if the product was inhaled it may cause irritation of the respiratory tract, headaches, dizziness, nausea, vomiting, and malaise. Continued review of the SDS sheet revealed if the product was ingested it may cause central nervous system depression, gastrointestinal irritation, nausea, vomiting, and diarrhea. Review of the SDS for no-rinse perineal cleanser under Section 4, First Aid Measures, revealed that if the product was ingested a physician or Poison Control Center should be called immediately. Continued review of the SDS under Section 11, Toxicological Information, revealed the product was not intended for ingestion. Review of the Drug Facts label for tetrahydrozoline zinc sulfate (over the counter eye drops) revealed keep out of reach of children. Continued review of the product label revealed If swallowed, get medical help or contact a Poison Control Center right away. Observation on 03/20/17 at 2:13 PM during the initial tour revealed the showroom door in the Rail Road area was propped open by a chair. Continued observation revealed a hair dryer and hair clippers were plugged into an electrical outlet with no staff present in the shower room. Further observation of the shower room revealed one (1) bottle of pyrithione zinc (dandruff shampoo), one (1) can of shaving cream, and two (2) bottles of body wash were on a handrail in a shower stall with the shower curtain open and accessible to residents. In addition, one (1) bottle of shampoo and body wash was observed on the sink in the shower room. Observation of resident room 204 on 03/22/17 at 10:27 AM revealed a can of aerosol disinfectant, sanitizer, and deodorizer spray on the floor to the right side of Resident B's bed. Continued observation revealed a bottle of tetrahydrozoline zinc sulfate on a three (3) drawer table to the right side of Resident B's bed. Further observation of resident room 204 revealed two (2) bottles of antiseptic mouth rinse, one (1) bottle of instant hand sanitizer (alcohol based), one (1) bottle of body spray, three (3) bottles of shampoo, two (2) bottles of body wash, and one (1) bottle of no-rinse perineal wash on Resident C's bedside table and all were accessible. Review of Resident B's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident B to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated Resident B was moderately impaired cognitively. Interview with Resident B on 03/22/17 at 10:27 AM revealed he/she had been using the aerosol disinfectant, sanitizer, and deodorizer to clean his/her bathroom. Continued interview with Resident B revealed a resident who was confused wandered into his/her room regularly. Interview with Licensed Practical Nurse (LPN) #4 on 03/22/17 at 2:57 PM revealed the facility had four (4) or five (5) wandering residents. Continued interview with LPN #4 revealed shower room doors were required to be closed and hair dryers and clippers were supposed to be locked in a cabinet if staff was not present in the shower room. Further interview with LPN #4 revealed body wash, shampoo, and shaving cream should be put up when not in use in the shower room. LPN #4 also reported residents were not supposed to have aerosol cleaning spray or eye drops in their rooms. Interview with State Registered Nurse Aide (SRNA) #6 on 03/22/17 at 3:35 PM revealed shower room doors should not be propped open and hair dryers and clippers should be locked up if unattended. Continued interview with SRNA #6 revealed shampoo, body wash, and shaving cream were to be put up if not being used. SRNA #6 reported residents should not have hand sanitizer, mouthwash, eye drops, or cleaning spray in their rooms. Interview with Registered Nurse (RN) #2 on 03/22/17 at 4:02 PM revealed the facility had five (5) or six (6) wandering residents. Continued interview with RN #2 revealed hair dryers and clippers were to be locked up if left unattended. RN #2 reported shampoo, body wash, and shaving cream was to be locked up if not being used. Further interview with RN #2 revealed she did not see any problem with residents having hand sanitizer in their rooms as long as the resident knew not to drink it. Interview with the facility DON on 03/22/17 at 6:58 PM revealed she made daily rounds to monitor for accident hazards and had not identified any concerns.

Based on observation, interview, record review, and review of the facility's comprehensive care plan policy and facility investigation it was determined the facility failed to have an effective system to ensure services were provided by qualified persons in accordance with each resident's plan of care for one of five sampled residents (Resident #1). Resident #1 was assessed by the facility to be at risk for wandering and elopement. The resident's plan of care directed facility staff to know the resident's location in the facility and complete/document 15-minute checks of the resident's location. On 07/30/12, Resident #1 left the facility grounds without the staff's knowledge and was discovered at approximately 4:20 PM, about one-fourth mile from the facility walking beside a busy highway. A review of the "Every 15 Minute Checks" monitoring tool revealed the facility had last documented a check of Resident #1's location at 3:00 PM on 07/30/12. Immediate Jeopardy was determined to exist on 07/30/12. An acceptable Allegation of Compliance was received on 08/06/12, which alleged removal of Immediate Jeopardy on 08/05/12. The State Agency determined the Immediate Jeopardy was removed on 08/05/12, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled "Resident Care Plan," with a revision date of 09/19/11, revealed it was the policy of the facility to provide an interdisciplinary written care plan based on the physician's orders [REDACTED]. According to the policy, the resident care plan would be an ongoing process and would include current problems and/or needs identified from a complete assessment including the Minimum Data Set (MDS) assessment and Care Areas Assessment (CAA) relevant to the resident's response to aging, illness, and his/her general health status. The policy stated the care plan may consist of but is not limited to a permanent problem list, nursing summary, resident care guide, and physician's orders [REDACTED]. A review of the facility's investigation dated 08/03/12, revealed on 07/30/12, at approximately 4:20 PM, the Administrator received an outside call from a dispatcher at the Police Department. The police dispatcher stated they had received a report of a person wearing burgundy pants and a plaid shirt walking away from the facility which the caller suspected could be one of the facility residents. It was noted the Administrator had remembered Resident #1 wearing burgundy pants and a plaid shirt earlier in the day. The Administrator immediately notified the Director of Nursing (DON) and they went out the front of the building. The Administrator observed a person walking down the road and this person was identified in the investigation as Resident #1. The investigation stated it took approximately 10 minutes to get the resident back into the facility. The facility moved the resident to room [ROOM NUMBER]-A and placed the resident on 1:1 observation. A review of the medical record for Resident #1 revealed the resident was admitted by the facility on 05/20/10, with [DIAGNOSES REDACTED]. A review of the most recent MDS assessment dated [DATE], revealed Resident #1 was assessed by the facility to have moderately impaired cognition and to be independent with ambulation. The medical record for Resident #1 also revealed a wandering assessment completed for Resident #1 by the facility, dated 06/21/12, which indicated a score of 9 for the resident. According to the wandering assessment, any score greater than 5 meant the resident was at risk for wandering and elopement. A review of the Comprehensive Care Plan for Resident #1, revised on 06/28/12, revealed Resident #1 was assessed by the facility to be at risk for wandering and also at risk for unsupervised exits from the facility. The interventions on the Care Plan for Resident #1 were for the resident to be in the At Risk Wandering Ways Program, in which staff was expected to check daily to ensure the resident had an alarm bracelet on, and to ensure the alarm bracelet had been functioning properly. According to the care plan, staff was to ensure the resident's picture was on the wandering resident board. A review of the Resident Care Guide for Resident #1, which was undated, revealed the resident was at risk for wandering, was to have an alarm bracelet, and staff was to monitor the resident's location in the facility. A review of the monitoring tool which was used by the nurses to document the location checks of residents who were at risk for wandering titled "Every 15 Minute Checks," revealed the staff had completed the 15-minute checks for Resident #1 on 07/30/12, through 3:00 PM. However, there were no documented 15-minute checks of Resident #1 after 3:00 PM. An interview conducted with State Registered Nursing Assistant (SRNA) #3 on 08/02/12, at 2:05 PM, revealed the SRNA was responsible for the care of Resident #1 on 07/30/12. The SRNA revealed she was required to check the care guide for each resident she was assigned at the beginning of every shift to ensure she was aware of the individual resident care she was responsible to provide. The SRNA stated Resident #1 wandered throughout the facility and was required to wear a Wanderguard alarm bracelet. The SRNA stated she was required to check the location of the resident every 15 minutes. The SRNA stated the last time she saw the resident prior to his/her eloping from the facility was at approximately 3:00 PM at the South Unit nurses' station. An interview conducted with Licensed Practical Nurse (LPN) #4 on 08/02/12, at 2:45 PM, revealed the LPN was responsible for administering the medications for Resident #1 on 07/30/12. The LPN stated she had completed and documented the 15-minute checks on Resident #1 on 07/30/12, until 3:00 PM. After 3:00 PM, the LPN stated the Charge Nurse (CN) was responsible for both the checks and the documentation. The LPN stated all nursing staff was required to check the resident care guide at the beginning of every shift to obtain the information regarding the care needs of a resident. An interview conducted with LPN #1 on 08/02/12, at 2:55 PM, revealed she was the Charge Nurse for the South Unit on 07/30/12, and was responsible for ensuring the 15-minute checks were completed on Resident #1. The LPN stated she was in the DON's office when the Administrator notified them of a possible missing resident. The LPN stated the last time she had observed Resident #1 on 07/30/12, prior to the elopement, was at 3:45 PM, when the resident was in the smoking room. The LPN stated she had forgotten to complete the 15-minute checks after 3:45 PM, and had forgotten to complete the documentation of the 3:00 PM to 3:45 PM "Every 15 Minute Checks." The LPN stated all nursing staff was required to check the care guide at the beginning of every shift to obtain the information regarding the care needs of a resident. The LPN said Resident #1's care guide included an intervention to monitor the resident's whereabouts. According to the LPN, Resident #1 required every 15 minute checks because he/she was assessed to be at risk for wandering. The LPN stated she just forgot to document the resident's location. An interview conducted with the DON on 08/06/12, at 3:50 PM, revealed the resident care guides included resident care information and staff was required to check the care guides at the beginning of every shift. The DON stated it was the CN's responsibility to ensure the resident care guides/plan of care was implemented which included the 15-minute checks and documentation on Resident #1's location. The DON stated she made rounds frequently throughout the day to ensure residents were being provided the care they require. The DON stated she conducted random spot checks for documentation. However, she had not identified any problems related to location checks not being completed for wandering residents. --A review of the Allegation of Compliance revealed the following: On 07/30/12, once Resident #1 had returned back to the facility, a complete head to toe assessment was conducted by the Charge Nurse and the resident was found to be uninjured. On 07/30/12, an investigation was initiated by the Administrator and the DON regarding the elopement of Resident #1. The investigation was completed on 08/03/12. On 07/30/12, Resident #1 was fitted with a new Wanderguard alarm bracelet, and then moved to a new resident room in the inner hallway. On 07/31/12 and 08/01/12, the MDS Nurses reassessed all residents in the facility for wandering, implemented alarms as indicated, added every 15 minute checks if indicated, and updated care plans as directed by the wandering assessments. Beginning on 08/03/12, nursing staff was in-serviced by the Administrator, DON, and Staff Facilitator (SF) on ensuring resident care plans and care guides were followed and communication was made to the Administrative Team immediately if any resident exhibited any changes in behavior, wandering, going to the exit doors, trying to exit the facility, or making statements that they were going to leave the facility. The in-service also included that nurses were required to ensure checks and documentation were completed for all residents who required every 15 minute checks. On 08/04/12, nursing staff was in-serviced on the facility's "Wandering Risk Potential Protocol," by the Administrator, DON, and SF. Staff was educated regarding what steps to take to implement a plan for resident safety. On 08/04/12, "wandering boards" showing pictures of residents assessed by the facility to be at risk for wandering and elopement, were reviewed and updated as needed by the MDS Nurses. An updated list of wandering residents was posted at each nursing station. On 08/04/12, all residents' charts were reviewed by the MDS nurses and the DON for the past six months. The review ensured all behaviors were identified, and any attempts or verbalization of wanting to leave the facility or increased agitation were addressed. The review included reviewing resident progress notes, wandering risk assessments, care plans, and care guides. A weekly audit tool will be utilized by the Quality Assurance (QA) Nurse to ensure all residents who have been identified by the facility to be at risk for wandering have care plan interventions in place to plan for the resident's safety and well-being in the facility and to prevent an unsupervised exit. The results of the audit will be reviewed weekly in the Quality Assurance meeting. On 08/05/12, a new audit tool was instituted which will be completed by the DON, ADON, QA Nurse, MDS Nurses, SF, Treatment Nurses, and the Social Worker (SW). The audits will be completed Monday through Friday and will include a review of the residents' progress notes, and will ensure all 15-minute checks and alarm bracelet check sheets are filled out completely. The audit will also include updating the residents' care plans and care guides as needed. Information documented on Saturday and Sunday will be audited on Monday. The results of the audit will be reviewed weekly in the Quality Assurance meeting. --The surveyor validated the corrective actions taken by the facility as follows: A review of the progress notes for Resident #1 revealed on 07/30/12, at 6:31 PM, LPN #1 documented she completed a head to assessment of Resident #1 and no injuries were identified. An interview conducted with LPN #1 on 08/06/12, at 10:20 AM, revealed she completed the head to toe assessment on Resident #1 after the resident had eloped on 07/30/12. The LPN revealed she assessed the resident to have no injuries. A review of the facility's investigation regarding the elopement of Resident #1 on 07/30/12, completed by the Administrator and the DON, revealed it was completed on 08/03/12. A review of the audit tool to monitor the Wanderguard alarm bracelets revealed Resident #1's Wanderguard bracelet was changed to a new bracelet on 07/30/12. The documentation revealed the bracelet was now located on the resident's left lower extremity with an expiration date of June 2015. Observation of Resident #1 on 08/07/12, at 9:30 AM, revealed the resident was wearing a Wanderguard alarm bracelet on his/her left lower extremity with an expiration date of June 2015. A review of nurse's notes for Resident #1 dated 07/30/12, revealed the resident was moved from resident room [ROOM NUMBER], which was near an exit door, to resident room [ROOM NUMBER]-A in the Railroad Crossing Unit which located the resident's room away from any outside doors. Observation of Resident #1 on 08/07/12, at 9:30 AM, revealed the resident was residing in resident room [ROOM NUMBER]-A and LPN #6 was observed providing 1:1 observation at the time. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, and on 08/06/12, at 4:50 PM, with SRNA #8 revealed Resident #1 was currently being provided with 1:1 supervision, which meant a staff member had to be within eyesight of the resident at all times. A review of a wandering assessment for Resident #1 revealed it was completed on 07/30/12, after the resident had left the facility unnoticed and unsupervised. A review of wandering assessments completed for all residents in the facility revealed the residents were assessed for wandering behaviors. The assessments were completed on 07/31/12 and 08/01/12. Two residents (unsampled Residents G and H) triggered as an elopement risk and were placed on the Wandering Ways program, and their care plans were updated, pictures were added to the wander boards, names were added to the wander lists at each nursing station, and an alarm bracelet was placed on Resident H. Resident G refused to wear the alarm bracelet and the resident was placed on every 15 minute checks due to the refusal. A review of Resident G's and Resident H's care plans revealed the care plans were updated with interventions to prevent elopement. An interview conducted with the MDS Coordinator on 08/07/12, at 10:55 AM, revealed she had assisted in assessing all the residents in the facility on 07/31/12 and 08/01/12, for wandering behaviors. The MDS Coordinator stated residents' care plans were also updated and interventions were instituted for residents related to wandering, if needed. A review of the in-service rosters revealed on 08/03/12, the Administrator, DON, and SF initiated an in-service for all facility nursing staff regarding resident care plans and care guides being followed, and communication regarding resident behaviors, wandering, going to doors, trying to get out, or statements that they are going to leave being made to the administrative team immediately and verbally. The in-service also included completing documentation, including visualization of the resident, 15-minute checks, and immediately notifying the on-call nurse, Administrator, and/or the DON if any of the above behaviors occurred. The education will be ongoing until all facility nursing staff has attended and will be in-serviced by their next scheduled shift. A review of in-service rosters revealed on 08/04/12, an in-service was initiated by the Administrator, DON, and SF related to staff being required to follow the wandering risk protocol immediately with any resident that experiences increased agitation, or a change in the resident's condition that may warrant an elopement potential. The in-service reviewed the guidelines contained in the protocol, implementing a plan, what to do if a resident refuses to wear an alarm such as adding every 15 minute checks, what to do when assessing for wandering, what to do if the staff feels a door is not working properly, and the importance of not giving out the door codes. The in-service will be ongoing until all staff has attended. All staff is required to receive the in-service prior to their next scheduled shift. The in-service will be provided to all newly hired employees. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, and on 08/06/12, at 4:50 PM, with SRNA #8 revealed the staff attended in-services regarding the door alarms, not to give codes to anyone, what to do with a wandering resident, and reporting immediately to the Charge Nurse and to the Administrator. The staff revealed they were required to stay by any door they felt wasn't working properly, until Maintenance arrived to correct the problem. The staff revealed wander boards were available in each charting room, by the time clock, and in the QA office. The staff also revealed they were required to check the resident care guides at the beginning of their shifts. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, on 08/06/12, at 4:50 PM, with SRNA #8, on 08/07/12, at 10:30 AM, with LPN #6, and on 08/06/12, at 10:20 AM, with LPN #1 revealed staff was required to check the resident care guides at the beginning of every shift, and administrative staff was to be notified of any change in behaviors. Staff further stated all 15-minute check observations were required to be completed and documented. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, on 08/06/12, at 4:50 PM, with SRNA #8, on 08/07/12, at 10:05 AM, on 08/06/12, at 10:05 AM, with LPN #6, and on 08/06/12, at 10:20 AM, with LPN #1 revealed staff was to notify administrative staff if a resident exhibits any change in behaviors. The staff revealed they also discussed the wandering risk protocol at the in-service. An observation on 08/07/12, at 8:05 AM, revealed on 08/04/12, wander boards located in the North and South charting rooms, by the time clock, and in the Quality Assurance office had been updated by the MDS staff. The boards were reviewed which revealed two new resident pictures had been placed on the boards. A review of the list for wandering residents revealed an updated list had been placed at both nursing stations. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, and on 08/06/12, at 4:50 PM, with SRNA #8 revealed the staff was able to verify where wandering boards were posted. The staff stated they were located in each charting room, by the time clock, and in the QA office. The staff members were also able to identify where the wandering lists were located at the nurses' stations. A review of the audit sheets completed by the DON and MDS Nurses on 08/04/12, revealed a six-month chart review was completed on all residents for any behaviors that had not previously been identified for attempts/verbalizing wanting to leave the facility, and increased agitation. An interview conducted with the DON on 08/07/12, at 11:30 AM, revealed she assisted with the audit of resident charts with a six-month look-back period. The DON stated they had audited progress notes, care plans, care guides, and wandering assessments for any behaviors that could lead to wandering or elopement, with the care plans and care guides being updated if needed. A review of the daily audit tool which was completed by the DON, Assistant Director of Nursing (ADON), Quality Assurance (QA) nurse, MDS Nurse, SF, Treatment Nurse, and Social Worker (SW) revealed all resident medical records were audited daily by reviewing the resident progress notes to identify any residents who have begun exhibiting increased wandering behaviors for whom additional interventions may be necessary. The audit also included reviewing all 15-minute check sheets, testing of resident alarm bracelets, and updating the care plans as needed. The audits listed any corrective actions needed. The audits will be continued by the facility on an ongoing basis. An interview conducted with the DON on 08/07/12, at 11:30 AM, revealed she assisted with audits of the residents' medical records daily to ensure any resident who began exhibiting behaviors that could lead to wandering or elopement had interventions in place to prevent them from leaving the facility unsupervised. The DON stated they also checked the 15-minute check sheets, as well as the testing of the alarm bracelet sheets. The DON stated she made rounds throughout the day at different times and observed to ensure the care was being provided as required by the residents. Review of the auditing tool, which will be completed weekly by the Quality Assurance (QA) Nurse, revealed the tool included an audit of resident chart reviews to ensure all residents who have been identified as being at risk for wandering have interventions on the care plan in place to address the wandering and to prevent the unsupervised exit of a resident. The QA Nurse would immediately report any potential concerns to the Administrator and the DON. The results of the audits will be reviewed by the Administrator and the DON at the weekly QA Committee meeting that is composed of the Administrator, DON, ADON, SF, MDS Nurse, SW, and Treatment Nurse. An interview conducted with the QA Nurse on 08/07/12, at 11:40 AM, revealed the QA Nurse would report any potential concerns she identified during the audits to the DON or the Administrator. The QA Nurse stated she was required to report her findings at the weekly QA meeting.

Based on observation, interview, record review, review of the facility investigation, and policy review, it was determined the facility failed to have an effective system to ensure one of five sampled residents (Resident #1) received adequate supervision to prevent accidents. The facility failed to ensure that key codes used to access exit doors were secured and that staff completed location checks per the plan of care for Resident #1. On 07/30/12, Resident #1, who the facility assessed as having Dementia and being a risk for wandering/elopement, left the facility grounds without the staff's knowledge and was discovered at approximately 4:20 p.m., about one-fourth mile from the facility walking beside a busy highway. A review of the "Every 15 Minute Checks" monitoring tool revealed the facility staff had last documented a check of Resident #1's location at 3:00 PM on 07/30/12. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/30/12. An acceptable Allegation of Compliance was received on 08/06/12, which alleged removal of Immediate Jeopardy on 08/05/12. The State Agency determined the Immediate Jeopardy was removed on 08/05/12, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled "Wandering Risk Potential Protocol," with a revision date of 10/19/11, revealed the facility would implement guidelines to identify a resident's risk for inappropriate wandering within or outside of the facility, and to ensure a resident's safety in regards to the identified behavior. The policy stated a "Risk Wandering Assessment" would be completed upon admission, re-entry to the facility, and quarterly. The policy directed if the resident's score on the assessment was greater than 5, then the facility would develop a care plan for the resident's risk for wandering, with interventions to ensure the resident's safety being addressed. The policy also stated that a "wandering board" of identified potential wanderers could be implemented whereby pictures of potential wanderers would be placed and located for staff awareness but not in view of visitors in the facility. A review of the facility's investigation and interview with the Administrator and Director of Nursing (DON) on 08/02/12, at 10:30 AM, revealed on 07/30/12, at approximately 4:20 PM, the Administrator received an outside call from Dispatch at City Hall that they thought one of the facility's residents was walking away from the facility and that the person was wearing burgundy pants and a plaid shirt. The Administrator stated he remembered Resident #1 having on burgundy pants and a plaid shirt earlier in the day. He notified the Director of Nursing (DON) and they went out the front of the building. The Administrator stated he observed a person across the road approximately one-fourth mile from the facility. The DON stated she and Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, and LPN #6 went to the person while the Administrator went back to direct the staff to begin a head count of all residents and to specifically look for Resident #1. The DON stated the person beside the roadway was Resident #1 and he/she was agitated. The DON stated it took approximately 10 minutes to get the resident back into the facility. Further interview with the Administrator on 08/02/12, at 10:30 AM, revealed once the resident was back in the facility staff conducted a head to toe assessment which revealed the resident had not sustained an injury, and both the family and the resident's physician were notified. The Administrator stated he immediately checked if the resident was wearing a Wanderguard bracelet and stated it was on the resident. According to the Administrator, he then checked the alarms on the exit doors and found them to be in working order. Resident #1's Wanderguard bracelet was checked and found to be in working order. The Maintenance Supervisor (MS) was notified by the Administrator to return to the facility and perform a second check on the exit doors. The Administrator revealed after the second check was completed, which showed the doors were working properly, the MS changed the keypad code on all exit doors. The Administrator stated when a resident wearing a Wanderguard bracelet approaches the door, the door will automatically lock; however, when the code is pushed on the keypad, it automatically releases the door lock and the door alarm will not sound. The Administrator stated a new transmitter was placed on Resident #1 as a precautionary measure. The Administrator stated Resident #1's room was located near the exit door. Both the DON and the Administrator revealed they decided to move the resident to the Railroad Crossing Unit which would be farther from the exit door. The facility moved the resident to room 202-A and placed the resident on 1:1 observation. The Administrator stated he asked the resident how he/she had gotten out of the facility and the resident had taken him to the keypad and started punching numbers and stated, "It did not work this time." The Administrator and the DON both stated the door code was only to given to employees and they were unaware of any resident or visitor ever having the door code. The Administrator stated the facility had not routinely changed the door code. However, the MS had changed the code to all the exit doors on 07/30/12, after Resident #1 eloped from the facility. A review of the medical record for Resident #1 revealed the resident was admitted by the facility on 05/20/10, with [DIAGNOSES REDACTED]. A review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and to be independent with ambulation. The medical record also revealed an "At Risk Wandering Assessment," dated 06/21/12, which revealed the resident was assessed to have dementia and moderate cognitive loss, poor decisions, and also required supervision. The facility assessed the resident to have a score of 9. According to the assessment, any resident scoring greater than 5 on the assessment was at risk for wandering. The assessment stated the resident was on the At Risk Wandering Ways Program, with a Wanderguard (alarm bracelet) to be used. A review of the Comprehensive Care Plan for Resident #1 with a revision date of 06/28/12, revealed the resident was assessed to be at risk for wandering and at risk for unsupervised exits from the facility. The interventions listed on the Care Plan were for the resident to be in the At Risk Wandering Ways Program, to check daily to ensure the resident has an alarm bracelet on and that it is functioning properly, and to ensure the resident's picture was on the wandering resident board. A review of the Resident Care Guide for Resident #1, which was undated, revealed the resident was at risk for wandering, was to have an alarm bracelet, and staff was to monitor for the resident's location in the facility. A review of the monitoring tool which was used by the nurses to document the location checks revealed staff had completed the 15-minute checks for Resident #1 on 07/30/12, through 3:00 PM; however, there was no documentation the 15-minute checks were completed after 3:00 PM. An interview conducted with State Registered Nursing Assistant (SRNA) #3 on 08/02/12, at 2:05 PM, revealed SRNA #3 and SRNA #4 were both responsible for the care of Resident #1 on 07/30/12. The SRNA stated she was required to check the care guide for each resident she was assigned to at the beginning of every shift to locate the care needs required for each resident. The SRNA stated Resident #1 wore a Wanderguard alarm bracelet due to wandering behaviors. The SRNA stated staff was required to do every 15 minute checks to ensure the location of the resident. The SRNA stated she did not document the 15-minute checks, the nurse did the documentation. The SRNA stated the last time she saw the resident prior to his/her eloping from the facility was at approximately 3:00 PM, at the South Unit nurses' station. The SRNA stated she observed visitors using the keypad to unlock the door. The SRNA stated she had only known the codes to the doors being changed three to four times in five years. The SRNA stated she could not recall ever being told who could have the code to the exit doors. An interview conducted with SRNA #4 on 08/03/12, at 12:10 PM, revealed both SRNA #3 and SRNA #4 were responsible for providing care for Resident #1 on 07/30/12, at the time the resident eloped from the facility. The SRNA stated Resident #1 was required to have a Wanderguard bracelet and also to have every 15 minute checks which were to be documented by the nurse. The SRNA stated she had not seen the resident for approximately 30 to 40 minutes prior to the nurse informing her a resident had eloped, and staff then began doing a head count of all residents living on the South Unit. The SRNA stated she felt the resident had followed someone out of the facility exit. The SRNA stated if a resident was wearing a Wanderguard bracelet when they approached the door it would lock and would not unlock until the correct code was entered on the keypad. The SRNA stated she had observed visitors using the keypad to unlock the door. The SRNA stated she had never known the codes to the exit doors to be changed until after Resident #1 had gotten out of the facility. The SRNA stated she could not recall ever being told who could have the code to the exit doors. An interview conducted with LPN #4 on 08/02/12, at 2:45 PM, revealed the LPN was responsible for medications for Resident #1 on 07/30/12. The LPN stated she completed and documented the 15-minute checks on Resident #1 on 07/30/12, until 3:00 PM. After 3:00 PM, the LPN said it was the Charge Nurse's responsibility to complete and document the 15-minute checks on Resident #1. The LPN stated only staff was to have door codes and she had never observed visitors using the door codes. An interview conducted with LPN #1 on 08/02/12, at 2:55 PM, revealed she was the Charge Nurse for the South Unit on 07/30/12, and was responsible for ensuring the 15-minute checks were completed on Resident #1. The LPN stated she was in the DON's office when the Administrator notified them of a possible missing resident. The LPN stated Resident #1 was agitated when they got to him/her. The LPN revealed the resident was wearing a Wanderguard bracelet. When the resident was returned to the facility, the LPN completed a head to toe assessment, with no injuries to the resident observed. The LPN stated she asked the resident where he/she was going and the resident answered, "I am going home." The LPN stated the only way the resident could have gotten out the door was to have keyed in the right code on the keypad at the exit door, or followed someone out after they had keyed in the code. The LPN stated the last time she had observed Resident #1 on 07/30/12, prior to the elopement, was at 3:45 PM, when the resident was in the smoking room. The LPN stated had forgotten to complete the 15-minute checks after 3:45 PM, and had forgotten to complete the documentation of the 3:00 PM to 3:45 PM "Every 15 Minute Checks." The LPN stated the care guide was where the information was found regarding the care needs that each resident required, and staff was required to check the care guides for every resident they were assigned at the beginning of every shift. The LPN stated Resident #1 was care planned to require every 15 minute checks due to being assessed as at risk for wandering. The LPN stated only staff was to have door codes and she had never observed a visitor using the door codes. A group interview with five residents, who had been assessed by the facility to be interviewable, on 08/02/12, at 11:10 AM, revealed they had never observed a resident going outside the exit doors except with staff or family. Resident A stated he/she was aware of the previous door code prior to the facility changing the code on 07/30/12. The resident stated he/she had overheard the code from the staff talking. Resident B stated his/her family was aware of the code to the exit doors. The resident stated his/her family did not have to bother the staff when leaving. Resident B stated he/she had also gotten the code from overhearing the staff, and then had given it to family members. An interview conducted with the Maintenance Supervisor (MS) on 08/02/12, at 5:00 PM, revealed he had not routinely changed the door codes. The MS stated that when he changed the door codes on 07/30/12, it was the first time he had changed the codes in the past year. The MS stated when a resident wearing a Wanderguard bracelet approached the door, the door locked and would only open if the code was entered on the keypad. The MS stated the only way Resident #1 could have gotten out of the facility was if he/she had followed someone out the door or if the resident keyed in the code to the door. An interview conducted with the Staff Facilitator (SF) on 08/03/12, at 3:25 PM, revealed she was responsible for conducting staff training in-services and for orientation of all new staff. The SF stated staff was told during initial orientation how to use the door codes and that the codes were not to be given to anyone. The SF stated staff was also told to be discreet when using the code. The SF stated she provided an in-service to staff every other week and she mentioned the door codes and importance of not giving the codes to anyone other than the facility staff. The SF stated Resident #1's picture was on the wander board, which contained the pictures of residents who were assessed by the facility to be wanderers. The SF stated the wander boards were hung by the time clock, in both charting rooms in the nursing stations, and in the Quality Assurance office. The SF stated she instructed all new employees on the residents on the wander board, location of the board, and the importance of all staff monitoring the residents who were placed on the board for possible elopement. --A review of the Allegation of Compliance (AOC) revealed the following: On 07/30/12, once Resident #1 returned back to the facility, a complete head to toe assessment was conducted by the Charge Nurse and the resident was found to be uninjured. On 07/30/12, an investigation was begun on Resident #1 regarding the resident's elopement. The investigation was completed on 08/03/12. On 07/30/12, Resident #1 was fitted with a new Wanderguard alarm bracelet and moved to a new resident room in the inner hallway. On 07/31/12 and 08/01/12, the MDS Nurses reassessed all residents for wandering, implemented alarms, added every 15 minute checks, and updated care plans as indicated by the wandering assessments. Beginning on 08/03/12, staff was in-serviced by the Administrator and the Maintenance Supervisor (MS) on the manual audible alarm use and 15-minute alarm check sheets that were to be completed by the nurse. The in-service included where the alarms were located, how to reset the alarm, and that facility staff must respond immediately if the alarm sounded. Beginning on 08/03/12, nursing staff was in-serviced by the Administrator, DON, and Staff Facilitator (SF) on ensuring resident care plans and care guides were followed. The in-service also directed staff to communicate with the Administrative Team immediately if a resident exhibits a change in behavior, wandering, going to the exit doors, trying to exit the facility, or making statements that they were going to leave the facility. The in-service directed nurses to ensure visual checks and documentation were completed every 15 minutes on all residents whose care plan/guide required the 15-minute checks. On 08/03/12, the Administrator conducted an in-service with all facility staff related to the manual alarms being activated on all exit doors, how to use the alarm, how to turn the alarm on, how to reset the alarm, where the keys are located, and that extra keys would be kept by the MS and the Administrator. The in-service included instruction to nurses, medication aides and SRNAs on documenting that the manual alarms were checked every 15 minutes to ensure they were in the 'on' position. The AOC also revealed during business hours, 8:30 AM-4:30 PM, Monday through Friday, the manual alarm on the front door (main entrance) would be deactivated in lieu of the Admissions Coordinator (AC) being physically present at the door. The secure care alarm on the main entrance would still be activated. On 08/04/12, nursing staff was in-serviced on the facility's "Wandering Risk Potential Protocol" by the Administrator, DON, and SF. Staff was educated regarding what steps to take in order to implement a plan for resident safety. On 08/04/12, education was begun for all facility staff on the steps to take if an exit door was not functioning properly, and the importance of not giving out the door codes. On 08/04/12, wandering boards showing pictures of residents assessed by the facility to be at risk for wandering and elopement were reviewed and updated as needed by the MDS Nurses. An updated list of wandering residents was posted at each nursing station. On 08/04/12, all residents' charts were reviewed by the MDS nurses and the DON for the past six months. The review ensured all behaviors were identified, and any attempts or verbalization of wanting to leave the facility or increased agitation addressed. The review included reviewing resident progress notes, wandering risk assessments, care plans, and care guides. A weekly audit tool was developed by the Quality Assurance (QA) Nurse to ensure all residents identified as at risk for wandering have care plan interventions implemented to ensure the resident's safety and to prevent an unsupervised exit. The results of the audit will be reviewed weekly in the Quality Assurance meeting. On 07/30/12, an audit tool was instituted by the facility to be completed by the Maintenance Supervisor (MS) daily to ensure doors and alarms were functioning properly. Any potential concerns will have immediate corrective action taken by the MS to correct the issue. The problem and the action taken to resolve the issue will be brought to the attention of the Administrator immediately. The results of the audit will be reviewed weekly in the Quality Assurance meeting. On 08/05/12, a new audit tool was instituted which will be completed by the DON, ADON, QA Nurse, MDS Nurses, SF, Treatment Nurses, and the Social Worker (SW). The audits will be completed Monday through Friday and will include a review of the residents' progress notes, and ensure all 15-minute check and alarm bracelet check sheets are filled out completely. The audit will also include updating the residents' care plans and care guides as needed. Information documented on Saturday and Sunday will be audited on Monday. The results of the audit will be reviewed weekly in the Quality Assurance meeting. --The surveyor validated the corrective actions taken by the facility as follows: A review of the progress notes for Resident #1 revealed on 07/30/12, at 6:31 PM, LPN #1 documented she had completed a head to assessment of Resident #1 and no injuries were identified. An interview conducted with LPN #1 on 08/06/12, at 10:20 AM, revealed she had completed the head to toe assessment on Resident #1 after the resident had eloped on 07/30/12. The LPN revealed she had assessed the resident to have no injuries. A review of the facility's investigation regarding the elopement of Resident #1 on 07/30/12, completed by the Administrator and the DON revealed it had been completed on 08/03/12. A review of the audit tool for the secure care doors revealed the reviews had begun on 07/30/12, and were completed by the MS, and were ongoing and also revealed the codes were changed on 07/30/12. The audit sheets revealed the Administrator had tested the doors with alarm bracelets on 07/30/12 and 07/31/12. An invoice was reviewed to replace the secure care door panels, dated 08/03/12. An interview conducted with the Administrator on 08/07/12, at 11:45 AM, revealed the new door panels were an upgrade and the door will automatically lock when a resident gets near the door with a Wanderguard bracelet and will not unlock even if the code was keyed in. A review of the audit tool to monitor the Wanderguard alarm bracelets revealed Resident #1's Wanderguard bracelet was changed to a new bracelet on 07/30/12. The documentation revealed the bracelet was now located on the resident's left lower extremity with an expiration date of June 2015. Observation of Resident #1 on 08/07/12, at 9:30 AM, revealed the resident was wearing a Wanderguard alarm bracelet on his/her left lower extremity with an expiration date of June 2015. A review of nurse's notes for Resident #1 dated 07/30/12, revealed the resident was moved from resident room 122, which had been near an exit door, to resident room 202-A in the Railroad Crossing Unit, which located the resident's room away from any outside doors. Observation of Resident #1 on 08/07/12, at 9:30 AM, revealed the resident was residing in resident room 202-A. LPN #6 was observed providing 1:1 supervision for the resident. A review of a wandering assessment for Resident #1, revealed it was completed on 07/30/12, after the resident left the facility unnoticed and unsupervised. A review of wandering assessments completed for all residents in the facility revealed the residents were assessed for wandering behaviors. The assessments were completed on 07/31/12 and 08/01/12. Two residents (unsampled Residents G and H) triggered as an elopement risk and were placed on the Wandering Ways program, and their care plans were updated, pictures added to the wander boards, names added to the wander lists at each nursing station, and an alarm bracelet was placed on one resident (Resident H); however, the other resident (Resident G) refused to wear the alarm bracelet and every 15 minute checks were added due to the refusal. Resident H was placed on every 15 minute checks because the resident had exhibited wandering behaviors. A review of both Resident G's and Resident H's care plans revealed the care plans were updated with interventions to prevent elopement. An interview conducted with the MDS Coordinator on 08/07/12, at 10:55 AM, revealed she assisted with the At Risk Wandering Assessments of the facility residents on 07/31/12 and 08/01/12. The MDS Coordinator stated residents' care plans were updated if needed and interventions were instituted for residents related to wandering if needed. A review of the in-service rosters revealed on 08/03/12, the Administrator, DON, and SF initiated an in-service for all facility nursing staff which covered the following: staff following and implementing resident care plans and care guides, and communication to the administrative team immediately of resident behaviors and residents wandering, going to doors, trying to get out, or making statements they were going to leave. The in-service also included instructing staff to document 15-minute checks and immediately notify the on-call nurse, Administrator, and/or the DON if any of the above behaviors occur. The education will be ongoing until all facility nursing staff has attended and will be in-serviced by their next scheduled shift. A review of in-service rosters revealed on 08/04/12, an in-service was initiated by the Administrator, DON, and SF regarding staff which directed staff to follow the "Wandering Risk Protocol" immediately for any resident who experienced increased agitation or a change in condition that may warrant an elopement potential. The in-service reviewed the guidelines contained in the protocol, implementing a plan, direction for staff if a resident refuses to wear an alarm such as implementing every 15 minute checks, how to assess for wandering, staff actions if the staff feels a door is not working properly, and the importance of not giving out the door codes. The in-service will be ongoing until all staff has attended. All staff is required to receive the in-service prior to their next scheduled shift. The in-service will be provided to all newly hired employees. A review of the audit sheets revealed manual alarms were checked every 15 minutes to ensure they were in the 'on' position. Observation on 08/06/12 and 08/07/12, revealed the Admissions Coordinator was physically present in the front lobby at the front door to the facility. An interview conducted with the Admissions Coordinator (AC) on 08/06/12, at 4:20 PM, revealed she was responsible for monitoring the main entrance to the facility from 8:30 AM until 4:30 PM. The AC stated she had been trained by the facility to check the wander board for pictures of wandering residents daily. The AC stated she is required to call for assistance if a wandering resident approaches the door. Observation on 08/07/12, at 8:05 AM, revealed on 08/04/12, wander boards located in the North and South charting rooms, by the time clock, and in the Quality Assurance office had been updated by the MDS staff. The boards were reviewed, which revealed two new resident pictures had been placed on the boards. A review of the list for wandering residents revealed an updated list had been placed at both nursing stations. An interview conducted on 08/06/12, at 4:20 PM, with SRNA #6, on 08/06/12, at 4:30 PM, with SRNA #7, on 08/06/12, at 4:45 PM, with SRNA #4, and on 08/06/12, at 4:50 PM, with SRNA #8 revealed the staff was able to verify where in the facility wandering boards were posted (in each charting room, by the time clock, and in the QA office) and were able to relay the location of the "Wandering Lists." The staff revealed they were required to check these every shift as well as the resident care guides. According to the above staff, they had attended in-services regarding the following: the door alarms, instructions on not to give the door codes to anyone, and immediately notifying the charge nurse and Administrator if a resident began exhibiting wandering behaviors. In addition, the staff stated if a door was not functioning properly a staff person was required to stay by the door until Maintenance arrived to correct the problem. A review of the audit sheets completed by the DON and MDS Nurses on 08/04/12, revealed a six-month chart review was completed on all residents for any behaviors that had not previously been identified. These behaviors included attempts to leave the facility or verbalizing wanting to leave the facility and increased agitation. The resident care plans, care guides, progress notes, and wandering risk assessments were also reviewed/audited. An interview with the DON on 08/07/12, at 11:30 AM, confirmed she had assisted with the above audits. A review of the Quality Assurance audit tool completed on the exit doors to ensure the doors were functioning properly was conducted. The audit tool was completed by the Maintenance Supervisor on a daily basis and he was to report any problems to the Administrator. An interview with the Maintenance Supervisor on 08/07/12, at 11:05 AM, confirmed he completed the door audits daily and reported any problems to the Administrator. A review of the daily audit tool used by the facility which was completed by the DON, Assistant Director of Nursing (ADON), Quality Assurance (QA) Nurse, MDS Nurse, SF, Treatment Nurse, and Social Worker (SW) revealed the resident charts are being audited daily. This audit includes a review of the resident progress notes to identify any resident displaying an increase in wandering behaviors for whom additional interventions may be necessary. The audit included reviewing the 15-minute check sheets, testing of resident alarm bracelets, and updating the care plans as needed. The audits also included if any corrective actions were needed. The audit will be continued by the facility ongoing. An interview with the DON on 08/07/12, at 11:30 AM, confirmed she was assisting with the daily chart audits. An interview conducted with the DON on 08/07/12, at 11:30 AM, revealed she was assisting to audit the charts daily to ensure any resident who began exhibiting behaviors that could lead to wandering or elopement had interventions in place to prevent them from leaving the facility unsupervised. The DON stated they also checked the 15-minute check sheets, as well as the testing of the alarm bracelet sheets. The DON stated she makes rounds throughout the day at different times and observes staff to ensure the care is being provided as required by the residents. Review of the auditing tool, which will be completed weekly by the Quality Assurance (QA) Nurse, revealed the tool included an audit of resident chart reviews to ensure all residents who have been identified as being at risk for wandering have interventions on the care plan in place to address the wandering and to prevent the unsupervised exit of a resident. The QA Nurse would immediately report any potential concerns to the Administrator and the DON. The results of the audits will be reviewed by the Administrator and the DON at the weekly QA Committee meeting that is composed of the Administrator, DON, ADON, SF, MDS Nurse, SW, and Treatment Nurse. An interview conducted with the QA Nurse on 08/07/12, at 11:40 AM, revealed the QA Nurse would report any potential concerns she identified during the audits to the DON or the Administrator. The QA Nurse stated she was required to report her findings at the weekly QA meeting.