Every finding on record at Union City Health and Rehabilitation

Based on Centers for Disease Control and Prevention (CDC) guidelines, facility policy review, Glucometer (a device used to check blood sugar levels with the use of a blood sample) User's Guide review, skills check off list review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens for 2 of 2 (Resident #6 and Resident #48) sampled residents reviewed for blood glucose monitoring. Licensed Practical Nurse (LPN) A failed to perform hand hygiene when donning and doffing gloves and failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with current infection control recommendations and facility policy. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility's policy, placed the residents at risk for potential contamination with bloodborne pathogens and had the likelihood to cause serious injury, harm, impairment, and/or death, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately clean and disinfect a multi-use blood glucose meter during medication administration for Resident #6 and #48. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/19/2025 at 3:29 PM, in the Private Dining room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J. The Immediate Jeopardy for F-880 began on 8/19/2025 and continued through 8/20/2025. The Immediate Jeopardy was removed on 8/21/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/20/2025 at 7:18 PM, and was validated onsite by the surveyors on 8/21/2025 through review of in-services, audits, and staff interviews conducted on all shifts. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the CDC Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/2024, revealed .Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions .These recommendations apply in .Long-term care settings .Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place .If healthcare providers use blood glucose testing or insulin administration devices on more than one patient, equipment and supplies may become contaminated. Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus [HBV-a serious liver infection most commonly spread by exposure to infected body fluids], hepatitis C virus [HCV-an infection caused by a virus that attacks the liver and is spread by contact with contaminated blood], HIV [Human Immunodeficiency Virus-an immune system disease that interferes with the body's ability to fight infection and disease], and other infections. Unsafe practices include .Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses .Failing to change gloves and perform hand hygiene between fingerstick procedures . 2. Review of the facility's policy titled, Glucometer, Cleaning, and Decontamination of, dated 1/2025, revealed .It is the policy of this facility to follow recommendations from the CDC or manufacturer's guidelines.Verify glucometer is placed on a barrier prior to laying glucometer on the Medication cart and/or over bed table after each use. Then disinfect after each use the exterior surfaces following the manufacturer's directions or may use a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim, or a dilute bleach solution. Review of the facility's policy titled, Hand Hygiene, dated 1/2025, revealed .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on acceptable standards.Hand hygiene is one of the most effective measures to prevent the spread of infection.All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other. residents.Before and after direct contact with residents, Before preparing or handling medications.After removing gloves. Review of the facility's policy titled, Infection Prevention and Control Program, dated 1/2025, revealed .Decrease the risk of infection to residents.The facility personnel will.provide care in a way that minimizes the spread of infection. 3. Review of the (Named Glucometer) User's Guide dated 2016 (no month), revealed .Cleaning and Disinfecting.Please use a soft cotton to wipe the system.Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients.Used gloves should be removed and hands washed before proceeding to the next patient.Do not use other cleaners or disinfectants. 4. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus and Malignant Neoplasm of Bladder. Review of the Care Plan dated 1/8/2025, revealed, .Has Diabetes Mellitus.Blood Sugar as ordered by doctor.Monitor/document/report to MD [Medical Doctor]. Review of the Physician Order dated 1/14/2025, revealed Humalog Insulin (medication used to treat diabetes) 100 Units/milliliter (ML) subcutaneously (under the skin) inject as per sliding scale before meals and at bedtime: For blood glucose 151-200 administer 3 Units. For blood glucose 201-250 administer 6 units. For blood glucose 251-300 administer 9 Units. For blood glucose 301-350 administer 12 units. For blood glucose 351-400 administer 15 units. For blood glucose less than 60 or greater than 400 notify MD. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9, which indicated Resident #48 had moderate cognitive impairment. Active diagnoses included Type 2 Diabetes Mellitus. Review of the Physician's Order dated 8/18/2025, revealed Lantus (insulin used to treat diabetes) 100 units/ml. Inject 8 units subcutaneously in the morning. Review of the Medication Administration Record (MAR) dated 8/19/2025, revealed Resident #48 received insulin before meals. Documentation on Resident #48's MAR revealed blood glucose levels were checked at 7:30 AM and 11:30 AM on the day of the surveyor's onsite survey. Observation on Hall 100 on 8/19/2025 at 10:56 AM, revealed LPN A removed a glucometer from the medication cart, placed the glucometer on top of the medication cart without cleaning the glucometer or use of a barrier, gathered blood glucose monitoring supplies, donned gloves without performing hand hygiene, and entered Resident #48's room. LPN A placed the glucometer on the Resident's over bed table without a barrier, cleaned Resident #48's left hand first finger with an alcohol pad, obtained a blood specimen, doffed (removed) gloves without performing hand hygiene, picked up the glucometer up with a bare hand, and exited the room. LPN A placed the glucometer on top of the medication cart, then without cleaning the glucometer, placed it in the top drawer of the medication cart. 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Diabetic Neuropathy, and Chronic Viral Hepatitis C. Review of the Physician's Order dated 11/22/2024, revealed Aspart (Insulin used to treat diabetes) 100 Units/ML, inject subcutaneously per sliding scale before meals and at bedtime: For blood glucose 151-200 administer 3 units. For blood glucose 201-250 administer 6 units. For blood glucose 251-300 administer 9 units. For blood glucose 301-350 administer 12 units. For blood glucose 315-400 administer 15 units. For blood glucose less than 70 or greater than 400 notify MD. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated Resident #6 was cognitively intact. Active diagnoses included Viral Hepatitis and Diabetes Mellitus. Review of the Physician's Order dated 8/11/2025, revealed Lantus (Insulin) 100 units/ml. Inject 15 units subcutaneously at bedtime. Review of the MAR dated 8/19/2025, revealed Resident #6 received insulin before meals. Documentation on Resident #6's MAR revealed blood glucose levels were checked at 7:15 AM and 11:30 AM on the day of the surveyor's onsite survey. Review of the Care Plan with a revised date of 8/20/2025, revealed .Has Diabetes Mellitus, risk for hyper [high blood glucose]/hypoglycemia [low blood glucose].Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Fasting Serum Blood Sugar as ordered by doctor.Has a resident-assigned blood glucometer d/t [due to] communicable disease. Observation and interview on the Hall 100 on 8/19/2025 at 11:17 AM, revealed LPN A removed the same glucometer that was used to check Resident #48's blood glucose at 10:56 AM, from the top drawer, performed hand hygiene with (named) sanitizer, donned gloves, cleaned the glucometer with a 2 by (x) 2 alcohol prep pad, placed it on top of the medication cart without a barrier. LPN A gathered blood glucose monitoring supplies, entered Resident #6's room, placed a paper towel and supplies on the over bed table, cleaned the left hand first finger with a 2x2 alcohol prep pad, obtained a blood glucose specimen, exited the room, and returned to the medication cart . LPN A cleaned the glucometer with a 2x2 alcohol prep pad, doffed the gloves, performed hand hygiene, and placed the glucometer in the medication cart. LPN A confirmed she should perform hand hygiene before donning and after doffing gloves. LPN A was asked what the process was for cleaning the glucometer. LPN A stated, We clean them with alcohol pads. LPN A was asked does each resident have their own glucometer. LPN A stated, No ma'am, this is a facility used machine (used on multiple residents in the facility). LPN A confirmed that a barrier should be placed on the medication cart/table after glucometer is cleaned. During an interview on 8/19/2025 at 3:12 PM, the DON confirmed that the glucometer devices are facility used, except for the three residents that have a communicable disease (such as Hepatitis C). The DON stated she was unsure if staff was using individual glucometers for the residents with communicable diseases currently residing in the facility. The DON confirmed glucometers should be cleaned after each resident with an EPA approved disinfectant and the glucometer should be placed on a barrier after it is cleaned. The DON was asked why it was important to clean the glucometer with an EPA approved disinfectant. The DON stated, It follows policy and manufacturers instructions. The DON was asked what happens if a critical item such as a glucometer is not properly cleaned. The DON confirmed improper disinfection of glucometers could put residents at risk of contracting blood borne pathogens. During an interview on 8/21/2025 at 9:38 AM, the DON reviewed a skills check off list with her name written at the bottom indicating that she had checked off LPN A on all of the skills on 5/25/2025, including blood glucose monitoring. The DON confirmed LPN Awas hired on 5/24/2025 and trained for 4 days with different nurses who should have signed her off on her skills, but the DON did not observe her perform or check her off on blood glucose monitoring during that time. The DON stated, That is not my signature. During an interview on 8/21/2025 at 10:48 AM, the Administrator and DON confirmed the root cause of the Immediate Jeopardy was a knowledge deficit, that the facility had no documentation that LPN A had been checked off on blood glucose monitoring on hire and no audits were completed of LPN A performing blood glucose monitoring during the medication administration audits performed by the facility since 5/24/2025. The surveyors verified the Removal Plan on 8/21/2025 by review of facility documents, observations and interviews. (Named Facility) Date: 8/20/2025 F880 Removal Plan #2 1. Corrective Action accomplished for those residents found to be affected by the alleged deficient practice. Resident #48 A. Resident# 48 was admitted to the facility on [DATE] with diagnosis of diabetes, malignant neoplasm of bladder. B. 100 hall glucometer removed from use on the medication cart and replaced with new glucometer on 8/19/25 by the MDS Coordinator. C. MD notified of potential exposure with new orders received to obtain labs on 8/20/25. D. Resident Representative notified on 8/20/25 of potential exposure with new orders received. E. Resident #48 Overbed table cleaned and disinfected by Clinical Supervisors (Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, Risk Manager, Admissions Coordinator, and MDS Coordinators) on 8/19/25. F. 100 medication cart surface and glucometer storage drawer cleaned and disinfected by MDS Coordinators on 8/19/25. 2. Identify other residents who have the potential to be affected by the same deficient practice. A. All residents that reside on the 100 hall medication cart assignment that require blood glucose monitoring have the potential to be affected. B. New lab orders received from MD for residents that reside on the 100 hall medication cart assignment requiring blood glucose monitoring. Resident Representatives notified on 8/20/25 of potential exposure with new orders received. C. Residents with communicable disease assigned separate individual glucometer on 8/19/25 by the Director of Nursing. The assigned glucometers were labeled with the residents first initial and last name by the Administrator, ADON (Assistant Director of Nursing), and MDS Coordinator on 8/19/25 and 8/20/25. The individual glucose monitoring devices for residents with communicable disease will be stored in the resident room. 3. Measures/Systemic changes put in place to ensure the deficient practice does not reoccur. A. Medical Director was notified by phone on 8/19/25 by the Director of Nursing of F880 immediate jeopardy deficiency. AdHoc (as needed) QAPI (Quality Assurance and performance Improvement) Meeting to review and discuss F880 immediate jeopardy deficiency. Root Cause Analysis conducted with Knowledge Deficit identified as primary root cause. B. lnservice initiated with clinical supervisors to include Assistant Director of Nursing, Staffing Coordinator, MDS Coordinators, Admissions Coordinator and Risk Managers beginning on 8/19/25 and by the Director of Nursing and Clinical Resource, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each residents use, dedicated glucometers for residents with communicable disease diagnosis and hand hygiene. Staff educated to clean with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's (Occupational Safety and Health Administration) standards. Licensed nurses educated on utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of blood borne pathogens. Competency Check with return demonstration completed by the Director of Nursing and Clinical Supervisors. C. lnservice initiated with all licensed nurses beginning on 8/19/25 to on duty nurses and off duty nurses shall be completed at the nurses next scheduled shift by the Director of Nursing and/or clinical supervisors, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each residents use, dedicated glucometers for residents with communicable disease diagnosis and hand hygiene. Staff educated to clean with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's standards. Licensed nurses educated on utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of blood borne pathogens. Competency Check with return demonstration completed. Newly hired licensed nurses will be educated during orientation regarding equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each residents (resident's) use, dedicated glucometers for residents with communicable disease diagnosis, hand hygiene, cleaning with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's standards, utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of blood borne pathogens. Competency Check with return demonstration will be completed during orientation and training. D. DON and clinical supervisors initiated one on one licensed nurse observation of blood glucose checks including cleaning and disinfecting of glucometers on 8/19/25 at 5:30 pm and 8:00 pm. E. [Named] Glucometer Resource Binder placed at each nurses (nurses') station by the MDS Coordinators on 8/19/25. 4. Monitoring of corrective action to ensure the deficient practice will not reoccur. A. The clinical supervisors or R.N. (Registered Nurse) on duty will complete observations initiated on 8/20/25 4 times a day for 7 days, 2 times a day times x 7 days, daily x 7 days, and 5 times a week x 1 week and weekly thereafter x 2 months to ensure that all staff remain in compliance with infection control procedure for glucometer cleaning and disinfecting of blood glucose monitoring devices. Observations conducted shall include weekdays, evenings, and weekends to encompass all blood glucose monitoring administration times. B. Findings of the audit will be reported to the Administrator and Director of Nursing for compliance review. C. Failure to adhere to facility policy will be considered a violation. Violations will result in disciplinary action in accordance with the facility progressive disciplinary policy. D. A report of findings and subsequent disciplinary action, if applicable, will be reported to the facility Quality Assurance Committee consisting of Director of Nursing, Medical Director, Administrator, Risk Management, Assistant Director of Nursing, MDS Coordinator, Social Services Director, Admissions Coordinator, Staffing Coordinator, Activities Director, Dietary Manager, Business Office Manager, Maintenance Director monthly x 3 months to review the need for continued intervention. 5. Measures/Systemic changes put in place to ensure the deficient practice does not reoccur. A. Medical Director was notified by phone on 8/19/25 by the Director of Nursing of F880 immediate jeopardy deficiency. AdHoc QAPI Meeting to review and discuss F880 immediate jeopardy deficiency. Root Cause Analysis conducted with Knowledge Deficit identified as primary root cause. B. lnservice initiated with clinical supervisors to include Assistant Director of Nursing, Staffing Coordinator, MDS Coordinators, Admissions Coordinator and Risk Managers beginning on 8/19/25 and by the Director of Nursing and Clinical Resource, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each residents use, dedicated glucometers for residents with communicable disease diagnosis and hand hygiene. Staff educated to clean with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's standards. Licensed nurses educated on utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of bloodborne pathogens. Competency Check with return demonstration completed by the Director of Nursing and Clinical Supervisors. C. lnservice initiated with all licensed nurses beginning on 8/19/25 to on duty nurses and off duty nurses shall be completed at the nurses next scheduled shift by the Director of Nursing and/or clinical supervisors, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each residents. Signed by (Named Executive Director)

Based on policy review, Licensed Practical Nurse (LPN) Job Description review, Medication Administration Observation review, observations and interviews, the facility failed to ensure all licensed nurses independently demonstrated competency while providing care and services for 1of 3 Nurses (Licensed Practical Nurse (LPN) A) observed, when 2 of 6 residents (Resident #48 and #6) observed for medication administration, and when 28 of 32 nurses (LPN A, LPN B, RN C, LPN D, RN E, RN F, LPN G, LPN H, RN I, LPN J, LPN K, LPN L, LPN M, LPN N, LPN O, RN P, LPN Q, LPN R, RN S, LPN T, LPN U, RN V, LPN W, LPN X, RN Y, LPN AA, RN BB, and the DON) reviewed did not have completed competency audits for medication pass. The findings include: 1.Review of the facility policy titled, Sufficient/Competent Staff, dated 10/2023, revealed .It is the policy of this facility to provide.nursing care in a manner and in an environment which promotes each resident's physical, mental, and psychosocial well- being.The facility will ensure that licensed nurses.have the competencies and skill sets necessary to care for resident's needs . Review of the facility policy titled, New Hire Orientation, dated 1/2025, revealed .It is the policy of the company to provide a general orientation program for all new employees.to orient new employees to the company's policies.and procedures.Each new employee will attend the general orientation as part of their first day of employment.All new employees will complete the appropriate new hire documents included in the company orientation packet.The Supervisor/Department Head or their designee will check off items on the checklist as they are completed.Department specific orientation will be completed following general orientation.The Executive Director is responsible for ensuring adherence to this policy. Review of the Licensed Vocational Nurse/Licensed Practical Nurse Job Description, dated 5/28/2025, revealed .The primary purpose of your job position is to provide primary care to specific residents.with an emphasis on assessment, illness prevention, and health care management.Implement and maintain established policies, procedures.and infection control.Supervises and assists in management of the infection control program.Administer services within the applicable scope of nursing practice.Prepare and administer medications as ordered by the physician.Must be knowledgeable of nursing and medical practices and procedures.This position consistently supports and promotes compliance.to applicable Federal, State, and local laws and regulations.and licensure requirements. Review of LPN A's New Hire and Annual Skills check list-Orientation Checklist -Licensed Nurse, dated 5/25/2025, revealed that all skills including Infection control and Medication Administration was dated 5/25/2025 and Initialed by Evaluator. This skill has been demonstrated to show competency. Signed by the Director of Nursing (DON) and dated 5/25/2025. Observation during Medication Administration on 8/19/2025 at 10:55 AM, revealed LPN A removed the glucometer from the medication cart, donned gloves without performing hand hygiene, entered Resident #48's room, performed an Accu-Chek, returned the glucometer to top of medication cart without a barrier, and did not clean the glucometer or perform hand hygiene. Observation during Medication Administration on 8/19/2025 at 11:17 AM, revealed LPN A cleaned the glucometer with an alcohol pad and placed it on top of the medication cart to dry without a barrier. LPN A entered Resident #6's room, performed an Accu-Chek, returned to the medication cart, cleaned the glucometer with an alcohol pad, and placed the glucometer inside the medication cart drawer. During an interview on 8/19/2025 at 11:19 AM, LPN A was asked if hand hygiene should be performed before donning gloves. LPN A stated, Yes. LPN A was asked what the facility policy for cleaning glucometers is. LPN A stated, You clean it with alcohol. LPN A confirmed that a barrier should be used once the glucometer is cleaned. During an interview on 8/21/2025 at 9:38 AM, the DON was asked if she checked LPN A's skills off on her orientation sheet. The DON stated, No ma'am. The DON confirmed that the signature of her name on LPN A's New Hire and Annual Skills checklist was not hers. The DON was asked who checked LPN A off on the skills. The DON stated, I can not verify that. During an interview on 8/21/2024 at 11:24 AM, the DON confirmed that she didn't have any in-services or orientation skills check off for LPN A related to glucometer cleaning. Review of the facility document titled, Medication Administration Observation, for 2025, revealed 4 Nurses had completed a Medication Administration Observation audit. The facility was unable to provide a Medication Administration Observation Audit for the following nurses: a. LPN A b. LPN B c. RN C d. LPN D e. RN E f. RN F g. LPN G h. LPN H i. RN I j. LPN J k. LPN K l. LPN L m. LPN M n. LPN N o. LPN O p. RN P q. LPN Q r. LPN R s. RN S t. LPN T u. LPN U v. RN V w. LPN W x. LPN X y. RN Y z. LPN AA aa. RN BB bb. DON During an interview on 8/21/2025 at 10:48 AM, the DON was asked if having medication observation audits completed on four nurses were adequate for the total number of nurses employed. The DON stated, No.

Based on the policy review, medical record review, observation, and interview, the facility failed to provide an environment free from accident hazards for 3 of 72 (Resident #42, #51 and #60) residents when razors and a bottle of rubbing alcohol were left unsecured and unattended in in Resident's rooms. There were 7 residents with wandering behaviors in the facility. The findings include: 1. Review of the facility policy titled .Personal Property, Resident's, dated 01/2025, revealed .Facility to provide space and safety for resident's personal property.The right to retain and use personal possessions.unless to do so would infringe upon the rights or health and safety of other residents. Review of the facility policy titled, Quality of Life, dated 8/2025, revealed .It is the policy of this facility to create a safe environment for the resident.Ensure all.chemicals.and any other hazardous material are kept locked/secured. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Cognitive Communication Deficit and Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #42 had moderately impaired cognition. Observation in the Resident's room on 8/18/2025 at 10:11 AM and 4:05 PM, revealed one blue uncapped disposable razor on the back of the sink in Resident #42's bathroom unsecured and unattended. Observation in the resident's room on 8/18/2025 at 4:09 PM, revealed the Assistant Director of Nursing (ADON) confirmed Resident #42 had unsecured sharps in the bathroom and they should not be there. 3. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of the annual MDS dated [DATE], revealed a BIMS score of 12, which indicated Resident #60 had moderate cognitive impairment, without behaviors. Observation in the resident's room on 8/18/2025 at 10:24 AM and 5:30 PM, revealed three gray uncapped disposable razors inside of a gray basin, and three gray uncapped disposable razors on the back of the paper towel dispenser in Resident #60's bathroom, that were unsecured and unattended. During an interview and observation in the resident's room on 8/18/2025 at 5:35 PM, the Director of Nursing (DON) was shown the razors that were in the Resident #60's room and bathroom and confirmed Resident #60 should not have unsecured sharps in his room. During an interview on 8/20/2025 at 10:46 AM, Licensed Practical Nurse (LPN ) CC confirmed that sharps should be disposed of in the sharps container and not left in the resident's room. 4. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Hypertension and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated that Resident #51 was cognitively intact. Observation in the resident's room on 8/18/2025 at 11:15 AM, revealed one 16 ounce (oz) bottle of green 70% [percent] Isopropyl Alcohol sitting on Resident #51 nightstand. Observation and interview with the Director of Nursing (DON) on 8/18/2025 at 11:26 AM, in the Resident #51's room, the DON was shown the bottle of 70 percent (%) Isopropyl Alcohol and confirmed that it should not be in the Resident's room and should be locked on the medication cart or in the medication storage room.

Based on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 6 sampled residents (Resident #24) reviewed for nutrition. The findings include: Review of the facility's policy titled, .Dietary: Weight Monitoring, dated 11/09/2023, revealed .The facility shall utilize a systemic approach to optimize a resident's nutritional status .Identifying and assessing each resident's nutritional status and risk factors .Evaluating/analyzing the assessment information .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary .The Registered Dietitian or Dietary Manager shall be consulted to assist with interventions .actions are recorded in the nutrition progress notes .Observations pertinent to the resident's weight status shall be recorded in the medical record as appropriate .The interdisciplinary plan of care shall communicate instructions to staff . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Kidney Disease, Diabetes, Malignant Neoplasm of Bone and Kidney Disease. Review of Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24's Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition, and required extensive assistance from staff for all activities of daily living (ADL's). Resident #24 was not coded for weight loss during this review period. Review of the Care Plan dated 2/19/2024, revealed Resident #24 with weight loss .5% [percent] or more in last 30 days .3/11/2024 wt [weight] loss documentation .3/21/2024 [named resident] has a SWL [significant weight loss] in 30 days . Review of the Clinical Notes Report dated 2/29/2024, revealed .WT [weight]: 226# [pounds] 2/20/2024 .will recommend glucerna 1.58 oz [ounces] BID [twice daily] between meals for additional calories . Addendum Note on 3/4/2024 revealed, .Glucerna 1.5 unavailable at this time. May use Twocal [dietary supplement] . Review of Resident #24's Dietary Progress Notes dated 3/11/2024, revealed .WT: [weight] 186# [pounds] 3/8/[2024]. Monitored on weekly wts [weights] .Significant wt [weight] loss noted in one week .Will recommend to increase Twocal [dietary supplement] to 8 oz [ounce] TID [three times a day] . Review of Resident #24's Dietary Progress Notes dated 3/21/2024, revealed .WT [weight]: 190# [pounds] 3/21/2024. 15.93% [percent] SWL [significant weight loss] in 30 days . Review of MARCH 2024 MEDICATIONS, revealed .Twocal 0.08 gram-2 k[kilo]cal[calorie]/[per] ml [milliliter] oral liquid (8 oz [ounce] LIQUID(ML) Oral Two Times Daily starting 3/1/2024 . Review of Resident #16's medical record, dated 3/11/2024, revealed no documentation or physician order for Registered Dietician's (RD ' s) recommendation for Twocal [dietary supplement] 8 ounces three times a day. During an interview on 5/15/2024 at 1:27 PM, the RD was asked did she make a recommendation for Resident #24 to increase Twocal (dietary supplement) to three times a day for weight loss. The RD stated, Yes I did and we missed doing that .he [Resident #24] has carcinoma of the bone and kidney, and has a poor appetite, but has since gained some weight back . During an interview on 5/15/2024 at 4:04 PM, the Director of Nursing (DON) was asked did the facility follow the RD recommendations for weight loss for [named resident #24]. The DON stated No. The DON was asked should the facility follow the RD recommendations for weight loss. The DON stated, Yes.

Based on policy review, medical record review, observation and interview the facility failed to revise the comprehensive care plan for 2 of 18 sampled residents (Resident #21 and #51) to reflect the residents ' status related to the use of oxygen and urinary tract infection. The findings include: 1. Review of the facility's policy titled, Comprehensive Care plan, dated 10/24/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet the resident ' s medical .needs that are identified in the resident ' s comprehensive assessment .The comprehensive care plan shall describe, at a minimum, the following .any specialized services .The comprehensive care plan shall be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . 2. Review of the medial record revealed Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Cardiorespiratory Conditions, Heart Failure, End Stage Renal Disease, and Respiratory Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, shortness of breath or trouble breathing when lying flat, oxygen and a noninvasive ventilator. Review of the Care Plan dated 11/3/2023, and revised 3/1/2024, revealed there was no documentation Resident # 21 was using oxygen. Review of the Physician Order Sheet dated April 2024, signed on 4/23/2024, revealed .Oxygen .5 liters/minute by BNC [binasal cannula] while in bed and as needed . Observation in the resident's room on 5/13/2024 at 9:23 AM, revealed Resident #21 sitting up in a wheelchair with oxygen infusing through a binasal cannula. Observation on 5/15/2024 at 8:32 AM, revealed Resident #21 in bed with oxygen infusing through a binasal cannula. During an interview on 5/15/2024 at 3:01 PM, the Director of Nursing (DON) was asked if oxygen should be on the care plan. The DON stated, .yes . 3. Review of the medical record revealed Resident # 51 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Hypertension, Hyperlipidemia, Vitamin D Deficiency, Gout and Dementia. Review of the care plan dated 11/20/2023 did not address Resident #51's history of or risk for Urinary Tract Infection. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition, and receives moderate assistance with toileting and personal hygiene. Review of the Treatment/Order Update/Change in Condition form dated 4/2/2024, revealed .nitrofurantoin [an antibiotic] .100 mg capsule: give 1 (one) tablet PO [by mouth.] BID [twice per day] x [for] 7 days for UTI. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #51 received nitrofurantoin twice daily from 4/2/2024-4/8/2024. Review of the Treatment/Order Update/Change in Condition form dated 5/7/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days . Review of the Treatment/Order Update/Change in Condition form dated 5/9/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days .x 3 more doses for 5 total days . Review of the Treatment/Order Update/Change in Condition form dated 5/14/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days . Review of the MAR dated May 2024, revealed .Rocephin 1 gram .for Three Days Starting 05/07/2024 .URINARY TRACT INFECTION .Rocephin 1 gram .for Three Days Starting 5/9/2024 .URINARY TRACT INFECTION .Rocephin 1 gram .for Three Days Starting 05/14/2024 .URINARY TRACT INFECTION . During an interview on 5/15/2024 at 3:35 PM, MDS Coordinator #1 was asked if Resident #51 was care planned for antibiotic use related to her recent Urinary Tract Infections and current use of antibiotics. MDS Coordinator #1 stated, .we would care plan her for risk for UTI. MDS Coordinator #1 confirmed Resident #51's care plan did not address the risk for Urinary Tract Infection.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately for 2 of 6 medication storage areas (200 Hall Medication Cart and the East Nurses Station) when a schedule II-V medication was open, unlabeled, and not properly secured and when an unidentified, unsecured pill was observed lying on the floor reviewed. The findings include: 1. Review of the facility's policy titled, Medication Administration, dated 8/4/2023, revealed .If medication is a controlled substance, record removal of medication and sign the Narcotic Control Record .Report and document any .refusals .Document med administrations immediately after each patient .Document refusals . Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments .Schedule II, III, IV, and V medications are stored under double lock and key . 2. Observation of the 200 Hall Medication Cart on 5/14/2024 at 11:40 AM revealed an unlabeled medication in a cup in the top drawer of the medication cart. During an interview on 5/14/2024 at 11:41 AM, Licensed Practical Nurse (LPN) A confirmed the unlabeled medication in the cup was Hydrocodone (a narcotic used to relieve pain) she had pulled for administration to Resident #26. Review of the facility ' s Controlled Drug Receipt/ Record/ Disposition Form, dated 4/29/2024, revealed Resident #26 ' s Hydrocodone/Apap (Acetaminophen) 5/325mg (milligrams) showed there were 4 pills remaining. Observation of the 200 Hall Medication Cart on 5/14/2024 at 11:42 AM, revealed Resident #26 ' s Hydrocodone/Apap 5/325 mg pill count was 3. During an observation of 200 Hall Medication Cart on 5/14/2024 at 11:42 AM, revealed a white, oblong tablet in an unlabeled medication cup sitting in top drawer of medication cart. During an interview with the Director of Nursing (DON) on 5/14/2024 at 12:09 PM, The DON confirmed that the narcotic count and the narcotic medication card should match. The DON confirmed that controlled medications should be stored under a double lock. 3. Random observation on 5/15/2024 at 12:51 PM, revealed a peach-colored pill lying on the floor, unsecured and unattended, near East Hall nurses ' station. During an interview on 5/15/2024 at 3:02 PM, the DON confirmed that there should not be medication in the floor.

Based on policy review, medical record review, observation, and interview, the facility failed to promote a resident's dignity during dining for 1 of 18 (Resident #48) residents reviewed for dignity. The findings include: The facility's .Promoting/Maintaining Resident Dignity revised 11/2017 documented, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Compliance Guidelines .When interacting with a resident, pay attention to the resident as an individual .Groom and dress residents according to resident preference . Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #48 had moderately impaired cognition, required extensive assistance of staff for dressing and personal care, and was independent when eating. Observations in Resident #48's room on 10/1/19 at 8:39 AM, revealed Resident #48 was seated in her wheelchair with her breakfast tray on the overbed table in front of her. Resident #48 was dressed in a long sleeved sweatshirt and a brief. Resident #48 stated, I need some pants on. Observations in Resident #48's room on 10/2/19 at 8:18 AM, revealed Resident #48 sitting up in bed with her breakfast tray on the overbed table in front of her. Resident #48 pulled back the sheet to reveal she was naked from the waist down. Resident #48 stated, I would sure like to have some pants on while I eat my breakfast. Interview with Certified Nursing Assistant (CNA) #1 on 10/3/19 at 11:00 AM, beside the 300 Hall Kiosk, CNA #1 was asked if she assisted Resident #48. CNA #48 confirmed that she regularly assisted Resident #48 with her care. CNA #1 confirmed Resident #48 liked to be dressed for breakfast. CNA #1 was asked if a resident should be naked or dressed in a brief from the waist down while eating breakfast. CNA #1 stated, No . Interview with the Director of Nursing (DON) on 10/3/19 at 11:26 AM, in the 200 Hall Utility Room, the DON was asked if a resident should be naked or dressed in a brief from the waist down while eating breakfast. The DON stated, They should be dressed, if that is their preference.

Based on medical record review, observation, and interview, the facility failed to provide reasonable accommodations for toilet use as ordered by the physician for 1 of 18 (Resident #72) sampled residents reviewed. The findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Bedside Commode . Review of the admission Minimum Data Set (MDS) with an assessment reference date of 9/26/19 revealed Resident #72 required extensive two person assistance for toileting, was frequently incontinent of bladder, and occasionally incontinent of bowel. Observations in Resident #72's room on 9/30/19 at 3:45 PM, on 10/1/19 at 7:56 AM, 12:54 PM, and 4:27 PM, on 10/2/19 at 7:50 AM, 10:00 AM, and 3:45 PM, and on 10/3/19 at 7:37 AM and 4:27 PM, revealed there was n o bedside commode. Interview with Certified Nursing Assistant (CNA) #2 on 10/3/19 at 8:32 AM, in the 400 hall, CNA #2 was asked if Resident #72 knew when she needed to use the bathroom. CNA #2 stated, Yesterday she did . Interview with Physical Therapy Assistant (PTA) on 10/3/19 at 8:36 AM, in the Therapy Gym, the PTA was asked if Resident #72 was able to stand and transfer. The PT stated, It takes 2 people (to assist her). The PTA was asked if he had assessed Resident #72 to be able to use a bedside commode. The PTA stated, No .That would be more for OT (Occupational Therapy) . Interview with the Occupational Therapist (OT) on 10/3/19 at 9:09 AM, in the Private Dining Room, the OT was asked if she had evaluated Resident #72 for use of a bedside commode. The OT stated, We have assessed her for transfers, and right now she is requiring the assist of 2 persons. Interview with the Assistant Director of Nursing (ADON) on 10/3/19 at 2:44 PM, in the Private Dining Room, the ADON was asked about the physician's orders [REDACTED]. The ADON stated, All I can think of is that the doctor may have made rounds and they (family) may have asked for it, and he may have just ordered it without looking at the therapy notes. The ADON was asked if he had spoken with the physician about the order. The ADON stated, No, I haven't.

Based on review of The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].#72) sampled residents reviewed for pressure ulcers. The findings include: 1. The NPUAP Prevention and treatment of [REDACTED].Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Document the results of all wound assessments .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound condition .wound edges .sinus tracts .undermining .tunneling .exudate .odor . Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Suspected Deep Tissue Injury: Depth unknown. Purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure . 2. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden scale assessments dated 9/13/19 and 9/27/19 revealed Resident #72 was at high risk for development of pressure ulcers. The Physician order [REDACTED].Skin Prep Wipes .apply skin prep to bilateral heels and cover with protective dressing daily until resolved .Order date: 9/25/2019 . The physician's orders [REDACTED].apply splint .Notes: Physical Therapist recommends that patient have B (bilateral) heel floatation soft primo boots donned when in bed and when out of bed, as much .as tolerated in order to reduce risk of wound/ulcer/skin breakdown of heels . The Care Plan dated 9/30/19 documented, .at risk of pressure ulcer related to incontinence and decreased mobility .Interventions .PT (Physical Therapy) Recommendation for B/L (bilateral) heel floatation soft primo boots as tolerated . Medical record review of the Wound Assessments dated 10/1/19 revealed Resident #72 had a Stage 2 Pressure Ulcer to the right heel and a blister that was now a Deep Tissue Injury to the left heel. Both of these pressure ulcers had an onset date of 9/23/19. There were no wound assessments prior to 10/1/19. Observations in Resident #72's room on 9/30/19 at 11:18 AM and 3:45 PM, on 10/1/19 at 7:56 AM and 4:27 PM, on 10/2/19 at 7:50 AM, 9:31 AM, and 3:25 PM, and on 10/3/19 at 3:41 PM, revealed Resident #72 was lying in bed without heel protector boots. Observations at the Nurses' Desk on 9/30/19 at 12:24 PM, revealed Resident #72 sitting in a reclined geriatric chair without heel protector boots. Observations in resident #72's room on 10/1/19 at 4:27 PM, revealed Resident #72 lying in bed. The Wound Care Nurse removed her socks and an adhesive dressing from both of her heels, which revealed a large pink wound to her right heel and a large pink wound with purple edges to her left heel. The Wound Care Nurse stated the right heel felt soft to touch. The Wound Care Nurse was asked what type of wounds they were. The Wound Care Nurse stated, I can't think off the top of my head .at first we were calling them (wounds) fluid-filled, but I will be staging them (wounds) . Interview with the Wound Care Nurse on 10/1/19 at 4:42 PM, in the Private Dining Room, the Wound Care Nurse stated, .We would not write it up .it (wound) started as a fluid-filled blister . Telephone interview with Medical Doctor (MD) #1 on 10/2/19 at 1:05 PM, MD #1 was asked if he expected nursing staff to assess wounds upon identification. MD #1 stated, Yes. MD #1 was asked what he expected nursing staff to do. MD #1 stated, Stage it (wound), measure it, do an assessment overall, why they're (wounds) there, if they (resident) ever had problems before, if they (resident) are diabetic or not, renal status, mobility of patient, everything . Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 10/3/19 at 9:34 AM, in the Sky and Ivy Room, the DON and ADON were asked what they expected staff to do upon identification of a wound. The DON stated, They (nursing staff) do a new wound process .notify the doctor and the family .put an intervention in place, and monitor it (wound) from there . The DON was asked if there should have been an assessment upon identification of Resident #72's heel wounds. The DON stated, They (staff) notified me 2 days ago of the blisters to her (Resident #72's) heels .on 9/23 they (staff) noted blisters to her (Resident #72's) heels .when they (staff) notified me that she (Resident #72) did have those (blisters) on there, I did the new wound process, we clarified with the doctor and with (Named Wound Care Nurse) that they (blisters) were pressure wounds .Therapy also initiated .the boots (heel protector boots). They (wounds) were being addressed, just not appropriately documented . The DON was asked if Resident #72 should be wearing the heel protector boots. The DON stated, I would have to look in the order. The facility was unable to provide any wound assessments for the stage 2 pressure ulcer to Resident #72's right heel and for the suspected deep tissue injury to Resident #72's left heel from the time of identification on 9/23/19 until 10/1/19, after the surveyor wound observation.

Based on review of the GERIATRIC MEDICATION HANDBOOK, thirteenth edition, provided by the American Society of Consultant Pharmacists, medical record review, and interview, the facility failed to ensure accurate documentation of [DIAGNOSES REDACTED].#31, #57, and #76) sampled residents reviewed for unnecessary medications. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, thirteenth edition, beginning on page 7, documented, .Medication Class (Classification) .[MEDICATION NAME]: Opioids . [MEDICATION NAME] . Antidepressants .Mirtazipine ([MEDICATION NAME]) .Anxiolytic: Benzodiazepines ([MEDICATION NAME]) .Gastrointestinal (GI) Agents: Laxative .Magnesium [MEDICATION NAME] (Milk of Magnesia) .GI Agents: Proton Pump Inhibitor .Pantoprazole .GI Agents: Stool Softener .[MEDICATION NAME] ([MEDICATION NAME]) .Respiratory Agents: Steroids (Nasal) .[MEDICATION NAME] . 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] .[MEDICATION NAME] . Related [DIAGNOSES REDACTED]. A Medication Administration Record [REDACTED].[MEDICATION NAME] .[MEDICATION NAME] . [MEDICAL CONDITION] . [MEDICATION NAME]/[MEDICATION NAME] is a drug combination used to treat pain. A physician's orders [REDACTED].[MEDICATION NAME] .Related [DIAGNOSES REDACTED]. A MAR indicated [REDACTED].[MEDICATION NAME] .Dementia . [MEDICATION NAME] is a medication used to treat anxiety. 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] .Related [DIAGNOSES REDACTED]. A MAR indicated [REDACTED].MUSCLE WEAKNESS . [MEDICATION NAME] is a medication used to treat constipation. A physician's orders [REDACTED].[MEDICATION NAME] .nasal spray .Related [DIAGNOSES REDACTED]. A MAR indicated [REDACTED].[MEDICATION NAME] .nasal spray .HYPERTENSION . [MEDICATION NAME] is a medication used to treat nasal allergy symptoms. A physician's orders [REDACTED].pantoprazole .Related [DIAGNOSES REDACTED]. A MAR indicated [REDACTED].pantoprazole .HYPERTENSION . Pantoprazole is a medication used to treat acid reflux. 4. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].pantoprazole .Related [DIAGNOSES REDACTED]. The (MONTH) MAR indicated [REDACTED].[MEDICAL CONDITION] . Pantoprazole is a medication used to treat stomach ulcers. A physician's orders [REDACTED].[MEDICATION NAME] .Related [DIAGNOSES REDACTED]. The (MONTH) MAR indicated [REDACTED].Muscle Weakness . [MEDICATION NAME] is a medication used to treat depression. Telephone interview with the Consultant Pharmacist on 10/3/19 at 8:29 AM, the Consultant Pharmacist was asked who was responsible for ensuring medications prescribed for residents in the facility had accurate diagnoses. The Consultant Pharmacist stated, .nursing, medical doctor, and pharmacist . The Consultant Pharmacist was asked if muscle weakness was an accurate [DIAGNOSES REDACTED].it's used for depression and appetite .I don't know what the logic was for that. The Consultant Pharmacist was asked if generalized weakness was an accurate [DIAGNOSES REDACTED]. The Consultant Pharmacist stated, I wouldn't think so .it's for constipation . The Consultant Pharmacist was asked if dementia was an accurate [DIAGNOSES REDACTED]. The Consultant Pharmacist stated, [MEDICATION NAME] is for anxiety. The Consultant Pharmacist was asked if he had identified incorrect [DIAGNOSES REDACTED]. The Consultant Pharmacist stated, .In the past we have asked for corrections .about 8 months ago we hit them pretty hard on [DIAGNOSES REDACTED].they are still picking the wrong [DIAGNOSES REDACTED].>

Based on policy review, medical record review, observation, and interview, the facility failed to ensure nutritional interventions were provided to prevent further weight loss for 2 of 5 (Resident #46 and 58) sampled residents reviewed for weight loss. The findings included: 1. The facility's Weight Monitoring policy dated 11/27/17 documented, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status .Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem .The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary . 2. The facility's Dietary Services Training Manual dated 10/13, documented, .In the case where fortified foods and/or extra portions of food items are provided as a result of a nutritional concern .weight loss .these items must have a physician's orders [REDACTED].oatmeal .Super Spuds .instant potatoes . 3. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 1, which indicated severe cognitive impairment, required extensive staff assistance for eating, had a weight loss of 5 percent (%) or more in the past month or 10% or more in the past 6 months, and was not on a physician-prescribed weight-loss regimen. The Care Plan dated 8/2/18 documented, .At risk for weight loss .Interventions .Dietary supplements as ordered .Weight loss; 5% or more in last 30 days or 10% or more in last 180 days .Monitor and document weight with interventions implemented as indicated . Review of the Patient Weight Report revealed a weight of 132 pounds on 5/21/18, and a weight of 109 pounds on 11/12/18, which indicated a significant weight loss of 17.42% over 6 months. The physician's orders [REDACTED].super spuds at lunch related to weight loss .First scheduled time is 11/14/2018 at 11:30 AM . Resident #46's lunch tray card documented, .Diet .Puree .super spuds . Observations in the dining room on 11/15/18 at 12:00 PM, revealed Certified Nursing Assistant (CNA) #1 seated next to Resident #46 and assisting her to eat her pureed lunch meal. CNA #1 was asked what she was having to eat. CNA #1 stated, Pinto beans, greens, and Polish sausage. There were no Super Spuds (fortified mashed potatoes) on the tray. Interview with the Registered Dietician (RD) on 11/15/18 at 2:08 PM, in the conference room, the RD was asked what interventions had been implemented to prevent further weight loss. The RD stated, .Super Spuds were ordered yesterday to provide more calories .That would have been started today at lunch. The RD was asked why Resident #46 did not receive the Super Spuds on her tray at lunch today. The RD confirmed Resident #46 should have received the Super Spuds on her lunch tray and stated, .a miscommunication . 4. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 10/11/18 documented, .At risk for wt (weight) loss .Interventions .Dietary supplements as ordered . The physician's orders [REDACTED].Super Cereal 1 Bowl .Every Morning Starting 11/07/2018 . Review of Resident #58's breakfast tray card revealed the physician's orders [REDACTED]. Observations in Resident #58's room on 11/15/18 at 10:37 AM, revealed Resident #58 was sitting in a wheelchair, and Sitter #1 was assisting her to eat her breakfast meal, which consisted of bacon, pancakes, ice cream, and orange juice. There was no Super Cereal (fortified oatmeal) on the tray. Interview with Sitter #1 in Resident #58's room on 11/15/18 at 12:18 PM, Sitter #1 was asked if Resident #58 received any cereal or oatmeal for breakfast this morning. Sitter #1 confirmed she did not. Review of the Patient Weight Report revealed a weight of 139.6 pounds on 10/3/18, and a weight of 131.2 pounds on 11/3/18, which indicated significant weight loss of 6% in 1 month. The weight for 11/13/18 was 124.5 pounds, which was a total loss of 10.8% since admission on 10/3/18. Interview with the Food Service Supervisor on 11/15/18 at 1:05 PM, in the conference room, the Food Service Supervisor was asked who was responsible for putting the Super Cereal on the breakfast tray. The Food Service Supervisor stated, Kitchen .It should print on the tray card . Interview with the RD on 11/15/18 at 1:51 PM, the RD was asked what interventions had been implemented to prevent further weight loss. The RD stated, .Super Cereal was started on 11/7. That comes out on her breakfast tray. Interview with the RD on 11/15/18 at 2:08 PM, in the conference room, the RD was asked why the Super Cereal was not documented on Resident #58's breakfast tray card as ordered, and why Resident #58 did not get the Super Cereal on her breakfast tray. The RD stated the Super Cereal was ordered by the Nurse Practitioner instead of by the weight team, who usually adds the food item on the tray card. The RD confirmed Resident #58 should have received the Super Cereal on her tray.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 1 (Licensed Practical Nurse (LPN) #1) nurse failed to perform hand hygiene or wear gloves during a blood glucose test, and failed to discard a used glucometer strip in the biohazardwaste . The findings included: 1. The facility's Hand Hygiene policy with a revision date of 4/18 documented, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection . 2. The facility's Infectious Waste policy with a revision date of 9/17 documented, .Infectious Waste will be disposed .Waste containers must be closable and ensure that waste will be contained. The design of the container must be such that it is able to retain the waste over an extended period of time between pickups by a specialized waste service .Regard non-absorbent disposable .devices that have been contaminated with blood, body fluids or blood contaminated secretions or excretions as infectious waste . 3. The facility's Glucose Monitoring inservice documented, .Perform hand hygiene .Apply gloves .Insert test strip into glucometer . Observations in Resident #40's room on 11/15/18 at 4:50 PM, revealed LPN #1 performed a blood glucose test on Resident #40 using her bare hands without performing hand hygiene, and then discarded the used blood glucose strip in the regular uncovered trash in Resident #40's bathroom. Interview with the Assistant Director of Nursing (ADON) on 11/15/18 at 5:16 PM, in the conference room, the ADON was asked if she expected nurses to wash their hands before performing an accucheck (a fingerstick blood glucose test). The ADON stated, Yes. The ADON was asked if she expected nurses to wear gloves when performing an accucheck. The ADON stated, Yes. The ADON was asked how the used blood glucose test strip should be discarded after the test. The ADON stated, .put it in the sharps.

Based on review of the Centers for Disease Control's (CDC) Management of [MEDICAL CONDITION] in Healthcare Settings, policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when isolation precautions were not initiated and maintained for 2 of 5 (Resident #20 and 75) residents reviewed with extended spectrum beta-lactamase (ESBL) urinary tract infections, and when 1 of 7 (Licensed Practical Nurse (LPN) #1) nurses failed to clean a nebulizer after a breathing treatment was administered. The findings included: 1. The CDC's Management of [MEDICAL CONDITION] in Healthcare Settings, 2006 .Last update: February 15, 2017 . documented, .MDRO ([MEDICAL CONDITION]) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents .These highly resistant organisms deserve special attention in healthcare facilities .including those producing extended spectrum beta-lactamases (ESBLs) .these pathogens are frequently resistant to most available antimicrobial agents .In LTCFs (Long Term Care Facilities) .For ill residents .those totally dependent upon healthcare personnel for healthcare and activities of daily living .use Contact Precautions in addition to Standard Precautions . 2. The facility's Isolation Precautions policy documented, .Facility Staff will apply Transmission-Based Precautions, in addition to standard precautions to residents who are known or suspected to be infected or colonized with infectious agents which require, as determined by the CDC, additional controls to effectively prevent transmission .Decisions regarding isolation will be individualized .Considerations include .behaviors or cognitive deficits that increase the resident's non-adherence to precautions . 3. The facility's .Isolation .Transmission Based Precautions documented, .The Infection Control Coordinator has the authority to order .Isolation Precautions when necessary . 4. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #20 was severely impaired for cognition, required extensive assistance from staff for activities of daily living, and was always incontinent of urine. Medical record review revealed Resident #20 had a urine culture dated 11/22/17 that had been underlined positive for ESBL. There was no documentation that isolation precautions had been initiated or maintained for Resident #20 after the facility learned that Resident #20 was positive for ESBL in the urine culture report. Observations in Resident #20's room on 12/3/17 at 10:35 AM, 12/4/17 at 8:23 AM, 12/5/17 at 8:19 AM, revealed Resident #20 did not have an indwelling urinary catheter and there was no isolation cart or signage on her door to see a nurse before entering the room. Observations in Resident #20's room on 12/6/17 at 10:58 AM, revealed Certified Nursing Assistants (CNA) #1 and CNA #3 performing perineal care for incontinence on Resident #20. After cleaning and drying Resident #20, CNA #1 did not place a new brief on Resident #20. Both CNAs were asked why they didn't place a new brief on Resident #20. Both CNAs confirmed that sometimes a new brief is not applied when residents are staying in the bed. Interview with Licensed Practical Nurse (LPN) #2 on 12/5/17 at 10:10 AM, at the west nurse's station, LPN #2 was asked if Resident #20 was currently being treated for [REDACTED].#2 stated, Yes. LPN #2 was asked if a urine culture had been done. LPN #2 stated, Yes .ESBL . Interview with CNA #1 on 12/6/17 at 8:53 AM, at the west nurse's station, CNA #1 was asked if Resident #20 was incontinent of urine. CNA #1 stated, .sometimes she is .I believe sometimes she doesn't know when she needs to go . Interview with the Assistant Director of Nursing (ADON) and the Staff Development Coordinator on 12/6/17 at 4:23 PM, in the Private Dining Room, the ADON confirmed that she was the Infection Control Coordinator. The ADON and the Staff Development Coordinator were asked how they determine when to initiate isolation precautions for a resident. The ADON stated, .results from the culture .C Diff ([MEDICAL CONDITION]) .ESBL . The Staffing Coordinator stated that if someone is placed in isolation, there is a cart containing personal protection equipment and a sign is on the door to see the nurse before entering the room. The ADON was asked if anyone in the building was in isolation precautions during the survey. The ADON stated that no one was in isolation and then stated, Resident #20 does have ESBL in her urine .she is incontinent .but it's contained because of her brief . The ADON confirmed that a brief could leak. A phone interview with the Nurse Practitioner (NP) on 12/6/17 at 4:58 PM, in the conference room, the NP was asked whether residents with a urine culture positive for ESBL should be in isolation. The NP stated, .yes . The NP was asked if the staff had notified her regarding Resident #20 having ESBL in her urine. The NP stated, Not to my knowledge . 5. Closed medical record review revealed Resident #75 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented that Resident #75 was severely impaired for cognition, required extensive assistance from staff for all activities of daily living, and was always incontinent of urine. Medical record review revealed Resident #75's urine culture dated 9/4/17 was positive for ESBL. The care plan dated 10/17/16 documented Resident #75 is always incontinent of bladder. Resident #75's Subjective Objective Assessment Plan (SOAP) note dated 9/5/17 and signed by the NP, documented, .C&S (Culture and Sensitivity) resulted showing ESBL . The facility was unable to provide documentation that isolation precautions had been initiated or maintained for Resident #75 after the facility learned that Resident #75's urine culture was positive for ESBL. 6. The facility's .Standards of Practice Manual .Aerosol Treatments . policy documented, .Nebulizer is to be rinse (rinsed) after each use with tap water or saline and allow (allowed) to air dry and store in bag . 7. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The December 2017 Physician order [REDACTED].[MEDICATION NAME] sulfate 2.5 mg (milligrams) / (per) 3 ml (milliliter) .solution for nebulization (1 vial) .THREE TIMES DAILY . Observations in Resident #63's room on 12/4/17 at 10:45 AM, revealed LPN #1 prepared to give Resident #63 the nebulizer treatment. LPN #1 poured an unknown liquid out of the nebulizer chamber into the garbage can, instilled the [MEDICATION NAME] sulfate solution into the chamber and began the inhalation therapy. After the inhalation therapy was completed, LPN #1 poured the excess liquid out of the chamber, reconnected the chamber to the inhalation tubing, and placed the inhalation kit back into the storage bag without rinsing or drying the nebulizer setup. Interview with the Director of Nursing (DON) on 12/5/17 at 10:50 AM, in the Social Worker's Office, the DON was asked what should be done when a nebulizer treatment is completed. The DON stated, .It should be rinsed out, pulled apart and rinsed out, dried and put back in the bag .

Based on review of the Centers for Disease Control (CDC) and Prevention's website, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure accurate nutritional assessments were completed for 2 of 5 (Resident #28 and 73) residents reviewed for nutritional risk. The findings included: 1. The Centers for Disease Control and Prevention's www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html dated 8/29/17 documented, .BMI (Body Mass Index) appears to be as strongly correlated with various metabolic and disease outcome as are these more direct measures of body fatness .BMI is an inexpensive and easy-to-perform method of screening for weight category, for example underweight, normal or healthy weight, overweight, and obesity .Calculate BMI by dividing weight in pounds .by height in inches .squared and multiplying by a conversion factor of 703 . 2. The facility's Clinical Nutritional Care Procedure dated 11/28/17 documented, .All patients are assessed to identify a possible nutritional risk. The assessment provides the information needed to develop a nutritional plan of care. It is important to know the risk factors for poor nutritional status in older patients .Interventions must be completed in a timely and appropriate manner .The Nutritional Status Review is completed within specified time frames to provide a thorough nutrition screening for each patient .14-day assessment .Quarterly .Significant Change/Annual . 3. The Registered Dietician's (RD) job description signed by the RD on 10/16/17 documented, .Responsible for providing clinical expertise through assessment of patients utilizing Medical Nutrition Therapy .ESSENTIAL DUTIES AND RESPONSIBILITIES .Assess individual patients regarding appropriate nutritional care . 4. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment, required staff supervision for eating, and no weight loss. The care plan dated 10/26/17 documented, .At risk for weight loss related to disease process and medications . The NUTRITIONAL STATUS REVIEW dated 4/13/17 documented a weight of 143 pounds, a height of 63 inches, a Body Mass Index (BMI) of 22.9, and that Resident #28 had full dentures. Laboratory values were not assessed. There was no documentation that caloric, protein, or fluid needs were calculated or assessed. Based on the CDC's BMI calculation formula, the documented BMI of 22.9 was inaccurate. The correct BMI should have been documented as 25.3. The NUTRITIONAL STATUS REVIEW dated 12/5/17 documented a weight of 137 pounds, which revealed a weight loss of 4.2 percent since 4/13/17, and that Resident #28 had full dentures. Observations in Resident #28's room on 12/3/17 at 9:23 AM, revealed Resident #28 had natural teeth with missing bottom teeth. Interview with the Certified Dietary Manager (CDM) on 12/6/17 at 10:07 AM, in the private dining room, the CDM was asked whether Resident #28 had any nutritional assessments from April until 12/5/17. The CDM stated, I missed her. The CDM was asked whether she reviewed any laboratory values when she did the nutritional assessments on 4/13/17 or 12/5/17. The CDM confirmed laboratory values were not reviewed for Resident #28. The CDM was asked whether laboratory values should have been assessed. The CDM stated, I think the policy states that we are supposed to do it quarterly. Interview with the RD on 12/6/17 at 10:10 AM, in the private dining room, the RD was asked whether laboratory values should be assessed as part of a nutritional assessment. The RD stated, .we generally go back for about 3 days .don't use the [MEDICATION NAME] as much anymore .we go more by what they are eating . Interview with the MDS Coordinator on 12/6/17 at 10:15 AM, the MDS Coordinator stated, She does have her teeth . The MDS Coordinator confirmed Resident #28 had natural teeth instead of a full set of dentures. The facility was unable to provide documentation that a full and accurate nutritional assessment was conducted for Resident #28 at least quarterly per the facility's policy. 5. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #73's care plan dated 6/27/17 documented, .At risk for weight loss related to leaves uneaten food at meals .Weight loss; 5% (percent) or more in last 30 days or 10% or more in last 180 days. 9/18/17 . The ADMISSION NUTRITIONAL ASSESSMENT form dated 6/12/17 had no laboratory values assessed or that specific caloric, protein or fluid needs were calculated or assessed for Resident #73. The facility was unable to provide any nutritional assessments after the initial assessment. Interview with the RD on 12/5/17 at 4:12 PM, in the private dining room, the RD was asked about Resident #73's nutrition. The RD stated, .She has had some significant fluctuations . The RD was asked if her caloric, protein or fluid needs were assessed. The RD stated, .We only chart caloric needs if she had a weight loss .We would use the standard for her age group . The RD was asked if the standard nutritional needs were charted. The RD stated, No, it is understood, I guess. Interview with the Director of Nursing (DON) on 12/6/17 at 10:50 AM, in the private dining room, the DON was asked how often should a nutritional assessment be done by dietary. The DON stated, .quarterly . Interview with the CDM on 12/6/17 at 11:12 AM in the private dining room, the CDM was asked if other assessments should have been done. The CDM stated, Yes. The CDM was asked if Resident #73 should have also been reassessed when she returned from the hospital. The CDM stated, There should have been a reassessment.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a newly admitted resident received a meal when 1 of 69 (Resident #329) residents did not receive a lunch tray. The findings included: 1. The facility's Dining Services policy documented, .provide patients with nourishing, palatable and attractive meals .nursing staff is responsible to prepare the patient for dining service . 2. Medical record review documented Resident #329, was admitted on [DATE] with a [DIAGNOSES REDACTED]. Medical record review revealed Resident #329 was on a regular diet. Dining observations on the 400 hall on 12/3/17 at 12:21 PM, revealed the lunch tray pass started at 12:21 PM, and ended at 12:30 PM. Resident #329 did not receive a lunch tray. Interview with Certified Nursing Assistant (CNA) #2 on 12/3/17 at 12:31 PM, on the 400 hall, CNA #2 was asked if all the lunch trays had been served on the 400 hall. The CNA #2 stated Yes. Interview with the Registered Dietitian (RD) on 12/3/17 at 12:35 PM, on the 400 hall, the RD was asked if Resident #329 had received her lunch tray. The RD stated, .I thought she already ate . Interview with Resident #329 on 12/3/17 at 12:43 PM, in her room, Resident #329 stated, .getting hungry .past my lunch time . Interview with the RD on 12/5/17 at 4:51 PM, in the private dining room, the RD was asked when a resident was admitted , who was responsible for assuring residents are served a tray. The RD stated, .her card was omitted .it was an oversight .

Based on policy review, fall investigation review, medical record review, observation and interview, the facility failed to monitor and reassess pain for 1 of 3 (Resident #54) sampled residents of the 36 residents included in the stage 2 review. The failure of the facility to assess for pain resulted in actual harm when Resident #54 complained of pain and was observed to be in pain. The findings included: 1. The facility's Pain Management policy documented, .A definition for pain .'Pain is whatever the experiencing person says it is, existing whenever he says it does. It is a major symptom .interfering with a person's quality of life and general functioning .'Pain as the 5th Vital Sign' was initially promoted by the American Pain Society to elevate awareness of pain treatment. Vital signs are assessed and taken seriously by healthcare professionals. We should also assess and treat pain with the same zeal .Patients, who are cognitively impaired .should be assessed using Pain Assessment in the Cognitively Impaired grid. The patient should be scored according to their condition with a 0, 1 and 2 in each of the five (5) areas: Breathing independent of Vocalization, Negative Vocalization, Facial Expression, Body Language and Consolability .Pain Assessment .The patient is observed for signs of pain or verbalization of pain from the patient .Nurse management should review the Patient Vital Sign Report for pain levels each day . 2. Medical Record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION], Personal History of (healed) Traumatic Fracture, Chronic Pain. The October 2016 Physician order [REDACTED].[MEDICATION NAME] 5/325mg (milligrams) PO (orally) q (every) 4 hours prn (as needed) pain .Physical Monitors: Pain Level .Frequency .As Needed Every Four Hours Starting 08/10/2016 . The admission Minimum Data Set ((MDS) dated [DATE] documented, .Brief Interview for Mental Status (BIMS) .Score .2 (severe cognitive impairment) .Active [DIAGNOSES REDACTED]. The care plan dated 8/17/16 documented, .Problems .At risk for pain related to .History of Chronic Pain .Goals .Will have relief from pain and discomfort STATUS: Active (Current) GOAL DATE 12/1/16 .Interventions .Monitor pain .Pain scale and assessment . A fall investigation event note dated 9/1/16, documented, .Incident .Fall .Review factors related to the resident for possible contributing factor .Pain . Review of the October 2016 Medication Administration Record [REDACTED]. Observations in the Sky & (and) Ivy Dining Room (DR) on 10/25/16 at 5:20 PM, revealed Resident #54 sitting up in a wheelchair. Resident #54 was asked how she was feeling. Resident #54 stated, I don't feel too good .be glad when I can rest .I'm hurting in my back . Observations in the Coffee Room at the corner of 100 and 200 halls on 10/25/16 at 6:28 PM, revealed Resident #54 sitting up in a wheelchair at a table. Resident #54 complained to Licensed Practical Nurse (LPN) #3 about her back hurting. LPN #3 took the resident back to her room and stated, I think when she's sitting up in the afternoon, her back's hurting where she broke it . Resident #54 was squirming in the wheelchair at this time. Observations in the front lobby by the Magnolia DR on 10/26/16 at 1:36 PM, revealed Resident #54 sitting up in a wheelchair with her chin on her chest and her eyes closed. Observations in the Coffee Room on 10/26/16 at 3:12 PM, revealed Resident #54 sitting up in a wheelchair. Resident #54 told Certified Nursing Assistant (CNA) #4 that she wanted to lie down. CNA #4 left to tell CNA #3 of Resident #54's request to lie down. CNA #3 and CNA #4 took Resident #54 into her room. CNA #4 was heard telling CNA #3, .she is care planned to be in sight at all times . Interview with a Family Member on 10/24/16 at 3:47 PM, in Resident #54's room, the Family Member stated, .only thing I don't like is that they won't let her take a nap during the day .gets up in the morning and is up until time to go to bed .we have requested .but they say that if they put her in the bed, then she will fall .she will say she's tired and hurting . Interview with CNA #4 in the Coffee Room on 10/26/16 at 3:15 PM, CNA #4 was asked if resident was not allowed to lie down. CNA #4 stated, .has to be in sight at all times .she will fall . CNA #4 was asked if she was told that Resident #54 was care planned to be in sight at all times. CNA #4 confirmed that she was. Interview with MDS Nurse #1 on 10/27/16 at 8:16 AM, in the MDS office, MDS nurse #1 was asked if it was on Resident #54's care plan that she could not lie down in her bed during the day. MDS Nurse #1 stated, .I don't see that . There was no documentation on the care plan to keep the resident in sight at all times. Interview with the Director of Nursing (DON) on 10/27/16 at 8:37 AM, at the 100/200 Nurses' Desk, the DON was asked how pain was monitored. The DON stated, .no set way .ask if having pain .give pain med and go back to see if it is working . Interview with the DON on 10/27/16 at 9:15 AM, in the private DR, the DON was asked how Resident #54's pain was monitored. The DON stated, .she is care planned to go to activity at 3 o'clock .that's when she had falls .I don't know of anything other than that The DON was asked again how Resident #54's pain was monitored. The DON stated, .that's just general nursing assessment .the CNA goes in there and if she has facial grimacing, they will let the charge nurse know .she was brought to us since August .I haven't known about her extensively, just what I know from the referral . The DON was asked if she would expect any documentation of pain assessments on a cognitively impaired resident with a [DIAGNOSES REDACTED].can do the Wong Baker . The DON was asked if she would expect it to be documented. The DON stated, That's just nursing assessment . The DON was asked how she would know that the residents were being assessed for pain. The DON stated, It's on the care plan and on the MDS .if they didn't get any pain medicine, then they didn't have pain . Interview with CNA #5 on 10/27/16 at 9:50 AM, in the Coffee Room, CNA #5 was asked what her understanding was regarding the resident being out of bed during the day. CNA #5 stated, I know she is supposed to be in sight .fall risk . CNA #5 was asked if she had ever seen the resident asleep in her wheelchair. CNA #5 stated, Yes. CNA #5 was asked if she ever offered to put resident to bed when she has found her asleep. The CNA stated, .no . Telephone interview with the Nurse Practitioner (NP) on 10/27/16 at 5:00 PM, the NP was asked how she was made aware if the residents' pain was being monitored. The NP stated, .they do their assessment .they let me know . The NP was asked how often she saw Resident #54, the NP stated, .if nursing has concerns they will call .I know that when she first came to us, she had chronic back pain . The facility failed to implement a system that consistently monitored the resident's pain and provide interventions to ensure the resident's pain was controlled or relieved. Resident #54 complained of pain and was observed to be in pain which resulted in actual harm.

Based on medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized and developed an appropriate plan to ensure residents' pain was assessed and monitored to keep residents as free from pain as possible and failed to ensure an effective QA program that identified root cause of problems, developed appropriate plans and ensured systems processes were in place and consistently monitored and followed by staff to address quality concerns and maintain compliance as evidenced by patterns of repeat deficiencies (F282, F323, F441). The failure of the facility to ensure residents were monitored and assessed for pain resulted in actual harm to Residnet #54, when Resident #54 complained of pain and was observed to be in pain. The findings included: 1. The QA program failed to ensure the facility recognized and developed an appropriate plan to ensure care plans were followed related to pain assessments and nutritional supplements. The failure of the facility to follow the care plan for pain management resulted in actual harm to Resident #54. Refer to F282. 2. The QA program failed to ensure the facility implemented a method of identifying concerns and implementing plans of action to correct identified concerns. The failure of the QA program to identify residents in pain and implement a plan of action to ensure residents are as free of pain as possible resulted in actual harm to Resident #54. Refer to F309. 3. The QA program failed to ensure the facility was effective in preventing accident hazards as evidenced by failure to ensure staff followed policies for completion of post-fall neurochecks, and by unsecured chemical storage. Refer to F323. 4. The QA program failed to ensure the facility was effective in prevention of the potential spread of infection as evidenced by failure to ensure staff handled dirty linen per facility policy. Refer to F441.

Based on policy review, fall investigation review, medical record review, observation and interview, the facility failed to follow the care plan for pain assessments and nutritional supplements for 2 of 20 (Resident #54 and 114) sampled residents of the 36 residents included in the stage 2 review. The failure of the facility to follow the care plan and assess for pain resulted in actual harm when Resident #54 complained of pain, and was observed to be in pain. The findings included: 1. The facility's Pain Management policy revealed, .A definition for pain .'Pain is whatever the experiencing person says it is, existing whenever he says it does. It is a major symptom .interfering with a person's quality of life and general functioning .'Pain as the 5th Vital Sign' was initially promoted by the American Pain Society to elevate awareness of pain treatment .Patients, who are cognitively impaired .should be assessed using Pain Assessment in the Cognitively Impaired grid. The patient should be scored according to their condition with a 0,1 and 2 in each of the five (5) areas: Breathing independent of Vocalization, Negative Vocalization, Facial Expression, Body Language and Consolability .Pain Assessment .The patient is observed for signs of pain or verbalization of pain from the patient .Nurse management should review the Patient Vital Sign Report for pain levels each day . 2. Medical Record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION], Personal History of Traumatic Fracture and Chronic Pain. Resident #54's care plan dated 8/17/16 documented, .Problems .At risk for pain related to .History of Chronic Pain .Goals .Will have relief from pain and discomfort STATUS: Active (Current) GOAL DATE 12/1/16 .Interventions .Monitor pain .Pain scale and assessment . Review of the Medication Administration Record [REDACTED]. A fall investigation event note dated 9/1/16, documented, .Incident .Fall .Review factors related to the resident for possible contributing factor .Pain . Observations in the Sky & (and) Ivy dining room (DR) on 10/25/16 at 5:20 PM, revealed Resident #54 sitting up in a wheelchair. Resident #54 was asked how she was feeling. Resident #54 stated, I don't feel too good .be glad when I can rest .I'm hurting in my back . Observations in the Coffee Room on 10/25/16 at 6:28 PM, revealed Resident #54 sitting up in a wheelchair at a table, and complained to Licensed Practical Nurse (LPN) #3 about her back hurting. LPN #3 took the resident back to her room, and stated, I think when she's sitting up in the afternoon, her back's hurting where she broke it . Resident #54 was observed squirming in her wheelchair at this time. Observations in the Coffee Room on 10/26/16 at 3:12 PM, revealed Resident #54 was sitting up in a wheelchair, and told Certified Nursing Assistant (CNA) #4 that she wanted to lie down. CNA #3 and CNA #4 took Resident #54 into her room where CNA #4 was heard telling CNA #3, .she is care planned to be in sight at all times . CNA #4 was asked if Resident #54 was not allowed to lie down. CNA #4 stated, .has to be in sight at all times .she will fall . A family interview conducted on 10/24/16 at 3:47 PM, in Resident #54's room, the Family Member stated, .only thing I don't like is that they won't let her take a nap during the day .gets up in the morning and is up until time to go to bed .we have requested, but they say that if they put her in the bed then she will fall .she will say she's tired and hurting . Interview with Minimum Data Set (MDS) Nurse #1 on 10/27/16 at 8:16 AM, in the MDS office, MDS Nurse #1 was asked if it was on the care plan that Resident #54 could not lie back down in her bed during the day. MDS Nurse #1 stated, .I don't see that . There was no documentation on the care plan to keep the resident in sight at all times. Interview with the Director of Nursing (DON) on 10/27/16 at 8:37 AM, at the 100/200 nurses' desk, the DON was asked how pain was monitored. The DON stated, .no set way .ask if having pain .give pain med and go back to see if it is working .it is care planned . Interview with the DON on 10/27/16 at 9:15 AM, in the private dining room (DR), the DON was asked how Resident #54's pain was assessed. The DON stated, .she is care planned to go to activity at 3 o'clock .that's when she had falls .I don't know of anything other than that . The DON was asked if she would expect pain assessments to be documented for a cognitively impaired resident with a [DIAGNOSES REDACTED].can do the Wong Baker . The DON was asked if she would expect it to be documented. The DON stated, That's just nursing assessment . The DON was asked how she knew that the residents were being assessed for pain. The DON stated, .if they didn't get any pain medicine then they didn't have pain . Interview with CNA #5 on 10/27/16 at 9:50 AM, in the Coffee Room, CNA #5 was asked what her understanding was regarding Resident #54 being out of bed during the day. CNA #5 stated, I know she is supposed to be in sight .fall risk . Telephone interview with the Nurse Practitioner (NP) on 10/27/16 at 5:00 PM, the NP was asked how she was able to see if the resident's pain was being monitored. The NP stated, .they do their assessment .they let me know . The NP was asked how often she saw Resident #54, the NP stated, .if nursing has concerns they will call . The NP was asked where she would find information regarding the resident's pain status, the NP stated, .if they are concerned then they can call me .I know that when she first came to us she had chronic back pain . The facility's failure to follow the care plan to assess Resident #54 for pain resulted in actual harm when the resident complained of pain and was observed to be in pain. 3. Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].Physical Monitors: % (percent) Consumed .Order Date: 7/19/2016 . The care plan dated 5/2/16 documented, .Problems .At risk for weight loss .Interventions .dietary supplements as ordered . Review of the October 2016 treatment administration report (TAR) revealed that LPN #1 had documented on 10/26/16 that Resident #114 had consumed 100% of the Magic Cup at lunch. Observations in the dining room on 10/26/2016 at 11:55 AM, revealed Resident #114 sitting in a wheelchair in the dining room being served lunch. The meal that was served to Resident #114 consisted of a piece of grilled chicken with gravy, sliced carrots, 1 roll, creamed corn and ambrosia fruit salad, tea and water. There was no Magic Cup served with the meal. Interview with the Registered Dietitian (RD) on 10/26/16 at 4:08 PM, in the private dining room, the RD was asked who provides the Magic Cups that are ordered with meals. The RD stated, It comes from the kitchen on the meal tray . Telephone interview with LPN #1 on 10/26/16 at 6:31 PM, LPN #1 was asked how she knew Resident #114 consumed 100% of the Magic Cup as documented on the TAR. LPN #1 stated, She usually eats all of it, and sometimes she brings it back (to her room). LPN #1 was asked whether she had been informed by the nurse in the dining room that Resident #114 had consumed the Magic Cup. LPN #1 stated, I assumed she ate it .Sometimes I talk to (Named dining room nurse) about how much they eat. LPN #1 was asked if she had talked to the dining room nurse today. LPN #1 stated, No. Interview with the DON on 10/27/16 at 11:51 AM, in the private dining room, the DON was asked what she expects the staff to do when a supplement is ordered with meals. The DON stated, It should be provided to the resident whether they serve it themselves, or if they need to be assisted. The nurse should check the supplement, verify the percentage and document it if it is their patient. If not, the nurse should talk to the nurse in the dining room to verify the percentage.

Based on observation and interview, the facility failed to ensure food was prepared and stored under sanitary conditions as evidenced by unrestrained hair, pots and pans stored in a dirty steam table compartment, and chemicals stored in a food prep area. The facility had a census of 78, with 78 of those residents receiving a meal tray from the kitchen. The findings included: Observations in the kitchen on 10/24/16 during initial tour beginning at 9:30 AM, revealed the following: a. The Dietary Manager (DM) had unrestrained hair around her neck, and the Registered Dietician (RD) had unrestrained hair over her left ear and around her neck. b. Two dirty dish-storage compartments underneath the steam table with a dry brown substance and white splatters. c. A red pail with liquid sitting between the juice machine and the tea machine. The DM was asked what the liquid was. The DM stated, .sanitizer. Interview with the DM on 10/27/16 at 4:15 PM, in the kitchen, the DM was asked whether it was acceptable to have exposed hair in a food service area. The DM stated, No. The DM was asked whether it was acceptable to store pots and pans in the dirty steam table compartment. The DM stated, No. The DM was asked if it was acceptable to store chemicals in a food prep area. The DM stated, No .

Based on policy review, medical record review, and interview the facility failed to ensure medical records were complete and accurate as evidenced by failure to document the correct staging of a pressure ulcer for 1 of 20 (Resident #8) sampled residents; failure to accurately document a supplement intake for 1 of 20 (Resident #114) sampled residents; and failure to document narcotic medications were administered to residents after being signed out on the narcotic sheet for 3 of 20 (Resident #24, 54 and 117) sampled residents of the 36 residents included in the stage 2 review. The findings included: 1. The POCKET GUIDE TO PRESSURE ULCERS Third Edition page 5 documented, .Pressure ulcers do not heal in a reverse sequence as the body does .For example, once an ulcer is Stage 4, it remains Stage 4 even as it is healing . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/8/16 documented, .Problem .Pressure Ulcer R (right) buttock 9/6/16 .9/12/16 .Stage lll .R Thigh stage lll .9/6/16 .R ear stage lII .9/11/16 . The weekly skin report dated 9/12/16 documented, .Location R upper buttocks .Onset Date 09/06/16 .Stage lll .Length 1 cm (centimeter) .Width 1 cm .Depth 0.2 .Location R ear .Onset Date 09/11/16 .Stage ll .Length 0.7 cm Width 1 cm .Depth 0.1 . The weekly skin report dated 9/19/16 documented, .Location R upper buttocks .Onset Date 09/06/16 .Stage ll .Length 0.6 cm Width 0.5 cm .Depth 0.2 .Location R ear .Onset Date 09/11/16 .Stage l .Length 0.5 cm .Width 0.5 cm .Depth 0 . The skin reports documented the pressure ulcers healed in reverse sequence. The weekly skin report dated 10/3/16 documented, .Location thigh inner Right .Onset Date 9/1/16 .Stage lll .Length 0.8 cm .Width 0.8 cm .Depth 0.1 . The weekly skin report dated 10/10/16 documented, .Location thigh inner Right .Onset Date 9/1/16 .Stage ll .Length 0.5 cm .Width 0.7 cm .Depth 0.1 . Interview with the Wound Nurse (WN) on 10/26/16 on 2:45 PM, in the private dining room, the WN was asked if Resident #8 was admitted with any pressure ulcers. The WN stated, .didn't have any sores when he came in .I was off a few days and when I came back those places were there .I staged them as a 2, the left and right upper buttocks . The WN was asked whether a pressure ulcer can go from a stage 3 to a stage 2. The WN stated, .I'm new at this .I didn't know I couldn't do that. I'm learning . Interview with the Director of Nursing (DON) on 10/26/16 at 5:31 PM, in the private dining room, the DON was asked whether a pressure ulcer could go from a stage 3 to a stage 2. The DON stated, .pressure ulcer can progress from stage 1 to a stage 2 but cannot digress to a stage 2 to a stage 1 . The DON was asked would that be considered inaccurate medical records. The DON stated, Yes . 2. The facility's Weight Loss policy documented, .Nutritional Interventions Guidelines for Weight Loss .3. Provide oral nutrition supplement .The percentage of intake of ALL nutritional interventions by mouth must be documented on the MAR (Medication Administration Record) and monitored for effectiveness . Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Resident has had weight loss -on a physician prescribed weight loss regimen. A care plan dated 5/2/16 documented, .Problems .At risk for weight loss related to leaving uneaten food at meals .Interventions .dietary supplements as ordered . A physician order [REDACTED].% (percent) consumed .order date 7/19/16 . The treatment administration report (TAR) dated October, 2016 revealed Licensed Practical Nurse (LPN) #1 had documented on 10/26/16, Resident #114 had consumed 100% of the magic cup at lunch. Observations in the dining room on 10/26/16 at 11:55 AM, revealed Resident #114 sitting in a wheelchair in the dining room being served lunch. The meal that was served to Resident #114 did not include a magic cup. Resident #114 was eating independently. Resident #114 had a piece of grilled chicken with gravy, sliced carrots, 1 roll, creamed corn and ambrosia fruit salad, tea and water. Resident #114 ate approximately 1/2 of the cream corn, and 3 to 4 bites of the ambrosia salad. She ate 1 bite of the roll. She asked the resident sitting next to her if the resident wanted her chicken. The resident stated yes, so Resident #114 let the resident take it off her plate. Resident #114 did not eat any of the carrots, and she did drink all her tea and water. At 12:25 PM, Resident #114 was pushed back to her room. Resident #114 was not served nor did she consume a magic cup during her lunch meal. Interview with the Registered Dietitian (RD) on 10/26/16 at 4:08 PM, in the private dining room, the RD was asked who gives the resident the magic cup and when is it given to them. The RD stated, It comes from the kitchen on the meal tray . Telephone interview with LPN #1 on 10/26/16 at 6:31 PM, LPN #1 was asked how she knew Named Resident #114 ate 100% of her magic cup that she documented on the TAR. LPN #1 stated, She usually eats all of it, and sometimes she brings it back (to her room). LPN #1 was asked was she told by the nurse in the dining room that she ate it (the magic cup) or did she assume she ate it. LPN #1 stated, I assumed she ate it .Sometimes I talk to (Named Nurse) about how much they eat. LPN #1 was asked if she had talked to (Named Nurse) today. LPN #1 stated, No. Interview with the Director of Nursing (DON) on 10/27/16 at 11:51 AM, in the private dining room, the DON was asked what she expects the staff to do when a supplement is ordered with meals. The DON stated, It should be provided to the resident whether they serve it themselves or if they need to be assisted, the nurse should check the supplement and verify the percentage and document it if it is their patient, if not the nurse should talk to the nurse in the dining room to verify the percentage. 3. The facility's CONTROLLED MEDICATIONS policy documented, .CONTROLLED DRUG ACCOUNTABILITY PROCEDURE .2. Each dose administered is to be signed out be the nurse on the controlled drug record and on the patient's eMAR . A. Medical Record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #24 had a BIMS of 3 which indicated severe cognitive impairment. Resident #24 received PRN (as needed) pain medication or was offered and declined. Resident #24 had frequently experienced pain in the last 5 days. The care plan dated 1/27/16 and reviewed on 8/1/16 documented, .Problems .risk for pain related .has a history of multiple fractures and a [DIAGNOSES REDACTED].Interventions .Administer medications as ordered . The physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] 10-325mg ([MEDICATION NAME]) (milligrams) one po (by mouth) every 6 hrs (hour) prn (as needed) . The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 8/30/16 through 8/31/16 revealed 5 [MEDICATION NAME] were signed out for Resident #24 (The facility was unable to provide the narcotic sheets for 8/1/16 to 8/29/16). The MAR dated 8/30/16 through 8/31/16 revealed 2 [MEDICATION NAME] were documented as administered to Resident #24. (3 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 9/1/16 through 9/30/16 revealed 54 [MEDICATION NAME] were signed out for Resident #24. The MAR dated 9/1/16 through 9/30/16 revealed 18 [MEDICATION NAME] were documented as administered to Resident #24. (36 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 10/1/16 through 10/27/16 revealed 62 [MEDICATION NAME] were signed out for Resident #24. The MAR dated 10/1/16 through 10/27/16 revealed 19 [MEDICATION NAME] were documented as administered to Resident #24. (43 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) From August 30, 2016 through October 27, 2016, a total of 121 [MEDICATION NAME] were signed out, and a total of 39 [MEDICATION NAME] were documented as administered on the MAR. (68% were NOT documented as administered on the MAR.) B. Medical Record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION], Personal History of (healed) Traumatic Fracture, Chronic Pain. The admission MDS dated [DATE] documented, .Cognitive Patterns .BIMS .Summary Score .2 (severe cognitive impairment) .Pain Assessment Interview .Have you had pain or hurting at any time in the last 5 days .No . Review of the August 2016 MAR revealed Resident #54 had received pain medication on 8/13/16 with a pain rating of 6, 8/15/16 with a pain rating of 8, 8/16/17 in the morning with a pain rating of 8, 8/16/16 in the afternoon with a pain rating of 7, 8/17/16 in the morning with a pain rating of 7, 8/17/16 in the afternoon with a pain rating of 9, and 8/17/16 at night time with a pain rating of 9. Resident #54's care plan dated 8/17/16 documented, .Problems .At risk for pain .History of Chronic Pain .Goals .Will have relief from pain and discomfort STATUS: Active (Current) GOAL DATE 12/1/16 .Interventions .Monitor pain .Pain scale and assessment . Review of the October 2016 Physician order [REDACTED].#54 documented, .[MEDICATION NAME] 5/325mg PO (by mouth) q (every) 4 hours prn (as needed) pain .Physical Monitors: Pain Level .Order Date .8/10/2016 . The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 8/18/16 through 8/31/16 revealed 16 [MEDICATION NAME] were signed out for Resident #54 (The facility was unable to provide the narcotic sheets for 8/10/16 to 8/18/16). The MAR dated 8/18/16 through 8/31/16 revealed 13 [MEDICATION NAME] were documented as administered to Resident #54. (3 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 9/1/16 through 9/30/16 revealed 37 [MEDICATION NAME] were signed out for Resident #54. The MAR dated 9/1/16 through 9/30/16 revealed 31 [MEDICATION NAME] were documented as administered to Resident #54. (6 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 10/1/16 through 10/23/16 revealed 29 [MEDICATION NAME] were signed out for Resident #54. The MAR dated 10/1/16 through 10/23/16 revealed 24 [MEDICATION NAME] were documented as administered to Resident #54. (5 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) From August 18, 2016 through October 23, 2016, a total of 82 [MEDICATION NAME] were signed out, and a total of 68 [MEDICATION NAME] were documented as administered on the MAR. (17% were NOT documented as administered on the MAR.) C. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed Resident #117 had a BIMS score of 5, indicating severe cognitive impairment, and received PRN pain medication for occasional mild pain in the last 5 days. A care plan dated 7/7/16 documented, .Problems .At risk for pain .history of chronic pain .Interventions .Administer medications as ordered . A physician order [REDACTED]. The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 8/23/16 through 8/31/16 revealed 9 [MEDICATION NAME] were signed out for Resident #117 (The facility was unable to provide the narcotic sheets for 8/1/16 to 8/22/16). The MAR dated 8/23/16 through 8/31/16 revealed 7 [MEDICATION NAME] were documented as administered to Resident #117. (2 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 9/1/16 through 9/30/16 revealed 19 [MEDICATION NAME] were signed out for Resident #117. The MAR dated 9/1/16 through 9/30/16 revealed 11 [MEDICATION NAME] were documented as administered to Resident #117. (8 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) The CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM sheet beginning 10/1/16 through 10/25/16 revealed 8 [MEDICATION NAME] were signed out for Resident #117. The MAR dated 10/1/16 through 10/25/16 revealed 4 [MEDICATION NAME] were documented as administered to Resident #117. (4 [MEDICATION NAME] were signed out on the narcotic sheet and NOT documented as administered on the MAR.) From August 23, 2016 through October 25, 2016, a total of 36 [MEDICATION NAME] were signed out and a total of 22 [MEDICATION NAME] were documented as administered on the MAR. (39% were NOT documented as administered on the MAR.) Telephone interview with the Pharmacy Consultant on 10/27/16 at 4:25 PM, the Pharmacy Consultant was asked about what his role is when he is in the facility. The Pharmacy Consultant stated, I mainly look at the narcotic sheets during drug destruction to make sure they match the cards. The Pharmacy Consultant was asked if he reviews the MARs with the narcotic sheets to verify the counts taken out and the counts administered. The Pharmacy Consultant stated, I look at the MARs sometimes, not every month, but maybe 4-5 months ago. I did a spreadsheet and calculated all the [MEDICATION NAME] for each resident. But it would be hard to do a MAR review every single month. The DEA (Drug Enforcement Agency) considers the narcotic sheet binding. I also have looked at the number of cards and the number of sheets that are logged in the front of the narcotic book. But unless the nurses are paying attention, a whole card and sheet can be taken. They have to be paying attention .

Based on medical record review, review of the facility's daily census, review of time cards, review of January 2012 staffing schedule and interview, it was determined the facility failed to ensure sufficient staff for all residents and failed to ensure residents at risk for elopement were adequately supervised to prevent elopement for 1 of 1 (Resident #3) sampled resident who had eloped. The facility's failure to provide adequate supervision to prevent an elopement placed Resident #3 in immediate jeopardy when the resident eloped during the early morning hours of 1/13/12 that required medical intervention for hypothermia. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. This resident was assigned to a room on the 400 hall. Review of the facility's nurse patient daily census dated January, 2012 documented there were 95 residents in the facility. There were 39 residents on the 400 hall, 9 residents on the 300 hall, 32 residents on the 200 hall and 15 residents on the 100 hall on 1/12/12, the night that Resident #3 eloped from the building. Review of the time card report for 1/12/12 documented two Licensed Practical Nurses and four Aides were clocked into the facility for the 11 PM to (-) 7 AM shift. Review of the schedule sheet for January, 2011 (should be dated 2012) documented two Aides assigned to the 200 hall (32 residents) with one of the Aides assigned to 1/2 of the 100 hall, one Aide assigned to the 100 and 300 hall (24 residents) and one Aide assigned to the 400 hall (39 residents). During an interview via telephone in the MDS office on 1/19/12 at 5:20 PM, Nurse #6 assigned to work the 400 hall on 1/12/12 stated, "came in and started on paper work, not assigned as many CNA's (certified nurses assistants) that night... had CNA on 400 hall, one on 100 hall, she (one on 100 hall) was suppose to check on 300 hall. Forty-eight patients on my end. Usually have 4 (CNA's) for my end if fully staffed." Nurse #6 confirmed the Assistant Director of Nursing (ADON) was aware of lack of adequate staffing. Review of the nurses' progress notes dated 1/13/12 for Resident #3 documented, "...1230 am - resident eloped from building, went to (name of another nursing facility located on a street behind this facility), when they found him, they called police dept. (department) and Hospital, resident was carried to (name of local hospital) to get checked out, family notified..." Review of Resident #3's emergency room record dated 1/13/12 documented, "...Presentation time: 0107 (1:07 AM)... Chief Complaint: Exposure to cold unknown amt (amount) of time... Rectal temperature: 95 (degrees)... all extremities cool... disoriented to person, place, time... Broke out of nursing home. Escaped x (for) 30 minutes. Hypothermic when found... Clinical impression: Hypothermia - mild..." The lack of adequate staff available in the facility on the night shift of 1/12/12 (shift on duty when Resident #3 eloped) resulted in an immediate jeopardy situation when Resident #3 eloped from the facility without the staff's knowledge and required medical intervention for hypothermia. The Immediate Jeopardy was effective from 1/13/12 through 1/19/12. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated on-site by the survey team on 1/19/12. Non compliance of the immediate jeopardy still continues at a "D" level for monitoring of corrective actions.

A. Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the care plan to address elopement and implement measures to prevent future elopements for 1 of 1 (Resident #3) sampled resident who had eloped. The failure to revise the care plan to prevent elopement resulted in an immediate jeopardy to Resident #3 as evidenced by Resident #3 exited the building a second time without staff knowledge and required medical intervention for hypothermia. The findings included: Review of the facility's "Wander Guard System" policy documented, "...All wander guard doors will disengage whenever continuous pressure is applied to the door for fifteen (15) seconds...most demented patients will try the door briefly and turn away when it is locked..." Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. The MDS did not assess Resident #3 as a wander risk. Resident #3's plan of care dated 11/16/11 documented problem of "Needs wanderguard due to history of wandering." The goal for this problem was documented as "Will not wander out of facility over next assessment period." Interventions documented, "...Visual check of Wanderguard placement q (every) shift... Monitor resident location with visual checks at least every two hours... See Wanderguard transmitter testing log..." Review of Resident #3's nurses' notes documented the following: a. 11/8/11 - "...States wants to leave, go home. Up and down hallways in other resident rooms trying to find a way out... Wanderguard placed on left ankle..." b. 11/11/11 - "...Wants to go home res (resident) to sit by door and slip out when someone enters/departs Wanderguard on..." c. 11/18/11 - "...attempted to elope out door at end of 400 Hall. Immediately brought back in. Staff alerted... resident on 15 min. (minute) Vs (symbol for checks) continuously..." d. 11/19/11 - "...attempted to elope X (times) 3 from door at end of hall..." e. 11/20/11 - "...wanders...continues to attempt to elope... Wanderguard intact and functioning properly..." f. 11/22/11 - "...wander guard on...must be supervised..." g. 11/23/11 and 11/24/11 - "...wanders..." h. 11/25/11 - "...10:40 pm- Pt (patient (Resident #3)) went out through kitchen door... leading outside and was walking down side street. Pt now inside in Rm (room), This is the first time on this shift Pt attempted to go outside..." Review of care plan documented no updates or interventions related to this event. Review of medical record documented no investigation of this event. Review of subsequent nursing notes documented no additional assessment or supervision following this event. i. 11/28/11, 11/30/11 and 12/1/11 - "...wanders..." j. 12/4/11 - "...wanderguard on... wanders a lot. Forgets where room is..." k. 12/6/11, 12/9/11, 12/12/11, 12/15/11, 12/17/11 - "...wanders..." l. 12/18/11 - "...Pull switch implemented & (and) encouraged to use w/c (wheelchair) at all X's..." Review of care plan documented no updates or interventions; subsequent nursing notes documented no additional assessment or supervision. m. 12/21/11, 12/23/11, 1/4/12, 1/7/12, 1/8/12, 1/9/12 - "...wanders..." n. 1/13/12 - "...1230 am - resident eloped from building, went to (name of another nursing facility located on a street behind this facility), when they found him they called police dept. (department) and Hospital, resident was carried to (name of local hospital) to get checked out, family notified..." The facility was unable to provide documentation of monitoring wanderguard placement each shift or monitoring resident location with visual checks at least every two hours, as per Resident #3's plan of care dated 11/16/11. Review of Resident #3's hospital emergency record dated 1/13/12 documented, "...Presentation time: 0107 (1:07 AM)... Chief Complaint: Exposure to cold unknown amt (amount) of time... Rectal temperature: 95 ...(symbol for degree) all extremities cool... disoriented to person, place, time... Broke out of nursing home. Escaped x 30 minutes. Hypothermic when found... Clinical Impression: Hypothermia - mild..." Further review of Resident #3's nurses notes for the nursing home dated 1/13/12 documented, "...4a (AM) returned to facility, 0 (no) n.o. (new orders) noted, will monitor..." Review of subsequent nursing notes documented no additional assessment or supervision until 6:00 PM on 1/13/12, when hourly visual checks were initiated. Review of care plan documented no updates or interventions. Observation on 1/17/12 at 1:00 PM, revealed Resident #3 standing at the 400 hall nurse's station with a wanderguard bracelet in place to his left ankle. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) in the private dining room on 1/19/12 at 9:00 AM, the DON was asked to provide documentation for nursing assessments and interventions following Resident #3's elopements of 11/25/11 and 1/13/12. The DON stated, "It's not there." The DON was asked to provide documentation of wanderguard checks for Resident #3. The DON stated, "It's not there." During an interview with the Regional Administrator, Administrator, and Administrator in Training on 1/19/12 at 10:00 AM, the Regional Administrator stated, "...we were not informed of the elopement attempt on 11/25/11..." The facility's failure to ensure Resident #3 received adequate supervision by not monitoring wanderguard placement each shift or monitoring Resident #3's location with visual checks at least every two hours as care planned resulted in an immediate jeopardy when Resident #3 exited the building a second time without staff knowledge and required medical intervention at the local hospital for hypothermia. Refer to the initial comments for the allegation of compliance of corrective actions put in place on 1/19/12, which removed the immediate jeopardy. Noncompliance of the immediate jeopardy continues at the lower scope and severity of "D" level for monitoring of corrective actions. B. Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the care plan to reflect the resident's current status for falls, oxygen therapy and/ or discharge from therapy services for 6 of 19 (Residents #3, 8, 10, 16, 7, and 12) sampled residents. The findings included: 1. Review of the facility's "Fall Risk/Fall Prevention Guidelines" policy documented, "...Develop an individualized interdisciplinary care plan... the Fall Focus Team will evaluate Nurse Event Notes on all patient falls for appropriate intervention making recommendations for changes as needed... A care plan will be developed by the interdisciplinary team specific to the patient assessment, interventions and goals..." 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. Resident #3's plan of care dated 11/16/11 documented problem of "Risk for falls r/t (related to) poor balance; medication use... Goal: No falls qd (every day) over next assessment period..." Review of Resident #3's nurse event notes documented the following: a. 12/15/11 - "...6:45 PM... fall with no injury on 400 Hall... told CNA's (certified nursing assistants) to watch pt in shoes and make sure they are tied..." The plan of care documented, "...PT (Physical Therapy) screen... Make sure shoes are tied..." b. 12/16/11 - "...7:00 PM... found pt in floor with eyes closed... hematoma in middle of forehead... when notifying family she stated pt (patient) had hematoma... from fall on 12-15-11... replaced shoes..." The plan of care documented, "...PT screen- replaced shoes, sitting and standing BP (blood pressure) q shift X (times) 24 hrs..." c. 12/18/11 - "...8:30 AM... Found by another resident sitting in floor of west lobby... opposite end of building... pull switch alarm..." The plan of care documented, "...PT screen... pull switch... medication review..." d. 12/20/11 - "...10:20 PM... Observed fall in hallway by 300-400 Hall Nurse's Station... Advised resident when tired to ride in his W/C (wheelchair) Res (resident) in W/C c (symbol for with) pull switch alarm..." The plan of care documented, "...Pull switch... D/C (discontinued) r/t (related to) ability to self remove. Encourage to use w/c when tired..." e. 1/2/12 - "...2:00 PM... Patient fell at the end of 200 hallway... instructed patient to be careful when ambulating by himself..." The plan of care documented, "...Pt. teaching regarding pt safety, pt status and encourage to use W/C when feeling weak..." f. 1/15/12 - "...5:00 PM... Heard alarm going off went to check pt was sitting in floor 0 (symbol for no) injury noted... told cna's to check on pt q (every) 30 min (minutes)..." The facility was unable to provide documentation of the care plan interventions of q 30 min checks and medication reviews. Observation on 1/17/12 at 1:00 PM, revealed Resident #3 standing at 400 hall nurses' station with wanderguard bracelet in place to the left ankle. Resident #3 was wearing slipper type houseshoes, with the left shoe's sole completely separated from shoe down half of shoe length. The shoe sole was flapping upon movement. During an interview with the DON and ADON in the private dining room on 1/19/12 at 9:00 AM, the DON was asked to provide documentation for nursing assessments and interventions including medication reviews following each of Resident #3's six falls. The DON stated, "It's not there." The DON was asked to clarify documentation of pull switch use and discontinuation. The DON stated, "I can't find it..." 3. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan dated 12/6/10 to present documented, "...med (medication) review..." as an intervention on 11/1/11 and 12/19/11. The facility was unable to provide documentation of medication review on 11/1/11 and 12/19/11. Review of the nurses event notes dated from 10/28/11 to 1/16/12 documented the resident had 18 falls without injuries. Review of the fall care plan dated 12/6/10 to present had no new interventions documented for falls on 11/11/11 at 11:00 AM, on 11/23/11 at 5:30 PM, and on 1/11/12 at 12:45 PM. During an interview in the private dining room on 1/19/12 at 8:50 AM the DON was asked where the medication review was documented. The DON stated, "...no formal documentation of medication review..." The DON was asked if a pharmacist was involved in the medication review. The DON stated, "...pharmacist is not involved in the med review..." The DON was asked about who did the medication review. The DON stated, "...I do..." The DON was asked about what interventions were care planned for the falls on 11/11/11 at 11:00 AM, on 11/23/11 at 5:30 PM, and on 1/11/12 at 12:45 PM. The DON stated, "...no documentation (interventions)..." 4. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurses' event notes documented the following falls without interventions documented: a. 1/6/11 - "...Resident said she got a little light headed and her legs gave way... immediate steps implemented, Instructed resident to put her light on when she needs to get up..." The care plan revised 1/6/11 documented, "...PT screen safety instructions..." The therapy fall screen dated 1/7/11 documented, "...Pt (patient) refuses therapy. Not appropriate. Edu (educate) pt to use call light..." b. 3/18/11 - "...Observed pt on bathroom floor. Pt stated she got up to go to bathroom... immediate steps implemented, instructed pt to use call light when needing to get ^ (up) and to go to bathroom using w/c (wheelchair)..." The care plan revised 3/18/11 documented, "...PT screen..." The therapy fall screen dated 3/21/11 documented, "...Advised and educated pt regarding use of call light and using wc..." c. 5/11/11 - "...Pt was going to bathroom, legs got weak so she slide down to floor... immediate steps implemented, informed pt to use call light before getting up so CNA can at least walk with her..." The care plan revised 5/11/11 documented, "...PT screen..." The therapy fall screen dated 5/12/11 documented, "...Pt refused to participate in therapy stated she just needed to be aware..." d. 5/15/11 - "...Observed (Resident #10's name) sitting in floor by bed... stated my legs gave out and I sat in the floor... immediate steps implemented, use call light when needing assistance to get out of bed..." The care plan revised 5/15/11 documented, "...PT screen/staff assist..." The therapy fall screen dated 5/15/11 documented, "...educated pt regarding risk for falls and to ask for asst. ^ (increase) checks for restroom during overnight hours..." e. 6/22/11 - "...Res (resident) stated my foot slipped when I was trying to get off the toilet... emergency call light was on in bathroom... immediate steps implemented, instructed to pull light prior to getting off toilet to avoid accidents..." The care plan revised 6/22/11 documented, "...PT screen, non skid socks when transferring..." The facility was unable to provide documentation of a PT screen. f. 12/7/11 - "...Observed pt sitting in bathroom floor... Res stated I felt dizzy and sit down in the floor... immediate steps implemented, instructed pt to use call light when needing assistance..." The care plan revised 12/7/11 documented, "...PT screen..." The therapy fall screen dated 12/8/11 documented, "...Edu (educate) pt re: (regarding) use of call light..." During an interview in the private dining room on 1/19/12 at 8:15 AM, the DON were asked to review Resident #10's medical record. The DON stated, "...Instructed her (Resident #10) to use the call light... that is all we have done for her..." 5. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] and 1/5/12 documented a BIMS score of 0 and 1, indicating severe cognitive impairment. Review of the plan of care initiated 7/13/11 and revised 1/13/12 documented, "...compromised short-term memory... compromised long-term memory... difficulty understanding others... difficulty making self understood..." Review of Resident #16's nurses' event notes during the time period of 9/13/11 through 1/16/12 documented a total of 25 falls without injuries. The plan of care initiated 7/13/11 documented the following interventions: a. "...PT screen... 9/13/11, 10/17/11, 10/19/11, 10/25/11, 10/29/11, 10/31/11, 11/1/11, 11/2/11, 11/5/11, 11/6/11, 11/7/11, 11/13/11, 11/14/11, 11/30/11, 12/4/11, 12/18/11, 12/23/11, 12/31/11, 1/6/12..." b. "...Restorative (nursing program) ...9/13/11, 10/31/11, 11/1/11, 11/6/11, 11/12/11, 11/30/11..." c. "...Chairseat alarm... 10/19/11, 10/25/11, 10/31/11, 11/1/11, 1/16/12..." d. "...Toileting plan... 11/14/11, 11/30/11, 12/23/11, 12/28/11..." e. "...Nonskid socks... 10/17/11, 12/4/11..." f. "...Nonskid strips... 11/2/11, 12/18/11..." g. "...Pull switch... 1/6/12, 1/16/12..." There were no new interventions documented on the following dates: 10/25/11, 10/31/11, 11/1/11, 11/5/11, 11/6/11, 11/30/11, 12/4/11, 12/18/11, and 1/9/12. During an interview in the private dining room on 1/19/12 at 9:00 AM, the DON was asked to provide documentation of the fall interventions for Resident #16. The DON stated, "...It is not there..." The DON was asked about medication review documentation. The DON stated, "...We don't document that..." The DON was asked how she could verify that the correct interventions were in place to prevent fall-related injuries for Resident #16. The DON stated, "...We can't...We identified about a week ago that we were having problems with our falls..." 6. During an interview in private dining room on 1/19/12 at 8:15 AM, the DON was asked what is the process when a resident falls. The DON stated, "...Have stand up meeting every morning with PT (physical therapy) and we give them the event form and they perform a screen and they have not been giving the screen to me they are putting it on the chart... PT should give us a copy of the screen and we make sure of the intervention... We are not following through..." The DON stated that there was no documentation of the stand-up meeting conducted each morning. 7. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].< (less than) 92% (percent)..." Review of the care plan updated 12/10/11 was not revised to reflect the oxygen therapy. Observations in Resident #7's room on 1/17/12 at 9:35 AM, revealed an oxygen concentrator with nasal cannula attached flowing at 2 liters per minute. The nasal cannula was laying on the bed. During an interview in Resident #7's room on 1/17/12 at 9:35 AM, Resident #7 stated, "...I use oxygen when I lay down to sleep, I have sleep apnea..." During an interview in the private dining room on 1/19/12 at 9:05 AM, the ADON was asked to review Resident #7's care plan. The ADON stated, "...No, I don't see oxygen therapy on the care plan..." 8. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care dated 11/1/11 documented, "GOALS: Will show increase in ADL (activities of daily living) abilities as therapy works with res. (resident) over next assessment period-AEB (as evidenced by) Res. Will be more highly involved in ADL skills qd (every day) over the next assessment period. INTERVENTIONS: Encourage resident for rehabilitation." Review of the Physical Therapy discharge summary dated 11/28/11 documented the resident had met maximum potential at this time. Review of the Occupational Therapy discharge summary dated 12/5/11 documented the resident had an established treatment plan completed and had met maximum potential at this time. The plan of care was not revised to reflect the residents discharge from therapy services.

A. Based on policy review, review of the weather channel temperature, medical record review, observation and interview, it was determined the facility failed to provide adequate supervision for 1 of 1 (Resident #3) sampled resident who had eloped. The failure to provide adequate supervision to prevent elopement resulted in an immediate jeopardy when Resident #3 exited the building a second time without staff knowledge and required medical intervention for hypothermia. The findings included: Review of the facility's "Wander Guard System" policy documented, "...All wander guard doors will disengage whenever continuous pressure is applied to the door for fifteen (15) seconds...most demented patients will try the door briefly and turn away when it is locked..." Review of the monthly weather channel temperatures observed in Union City, Tennessee on the night of 1/12/12, revealed a low temperature of "25" degrees Fahrenheit. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. The MDS did not assess Resident #3 as a wander risk. Resident #3's plan of care dated 11/16/11 documented problem of "Needs wanderguard due to history of wandering." The goal for this problem was documented as "Will not wander out of facility over next assessment period." Interventions documented, "...Visual check of Wanderguard placement q (every) shift... Monitor resident location with visual checks at least every two hours... See Wanderguard transmitter testing log..." Review of Resident #3's nurses' notes documented the following: a. 11/8/11 - "...States wants to leave, go home. Up and down hallways in other resident rooms trying to find a way out... Wanderguard placed on left ankle..." b. 11/11/11 - "...Wants to go home res (resident) to sit by door and slip out when someone enters/departs Wanderguard on..." c. 11/18/11 - "...attempted to elope out door at end of 400 Hall. Immediately brought back in. Staff alerted... resident on 15 min. (minute) Vs (symbol for checks) continuously..." d. 11/19/11 - "...attempted to elope X (times) 3 from door at end of hall..." e. 11/20/11 - "...wanders...continues to attempt to elope... Wanderguard intact and functioning properly..." f. 11/22/11 - "...wander guard on...must be supervised..." g. 11/23/11 and 11/24/11 - "...wanders..." h. 11/25/11 - "...10:40 pm- Pt (patient (Resident #3)) went out through kitchen door... leading outside and was walking down side street. Pt now inside in Rm (room), This is the first time on this shift Pt attempted to go outside..." Review of care plan documented no updates or interventions related to this event. Review of medical record documented no investigation of this event. Review of subsequent nursing notes documented no additional assessment or supervision following this event. i. 11/28/11, 11/30/11 and 12/1/11 - "...wanders..." j. 12/4/11 - "...wanderguard on... wanders a lot. Forgets where room is..." k. 12/6/11, 12/9/11, 12/12/11, 12/15/11, 12/17/11 - "...wanders..." l. 12/18/11 - "...Pull switch implemented & (and) encouraged to use w/c (wheelchair) at all X's..." Review of care plan documented no updates or interventions; subsequent nursing notes documented no additional assessment or supervision. m. 12/21/11, 12/23/11, 1/4/12, 1/7/12, 1/8/12, 1/9/12 - "...wanders..." n. 1/13/12 - "...1230 am - resident eloped from building, went to (name of another nursing facility located on a street behind this facility), when they found him they called police dept. (department) and Hospital, resident was carried to (name of local hospital) to get checked out, family notified..." The facility was unable to provide documentation of monitoring wanderguard placement each shift or monitoring resident location with visual checks at least every two hours, as per Resident #3's plan of care dated 11/16/11. Review of Resident #3's hospital emergency record dated 1/13/12 documented, "...Presentation time: 0107 (1:07 AM)... Chief Complaint: Exposure to cold unknown amt (amount) of time... Rectal temperature: 95... (symbol for degree) all extremities cool... disoriented to person, place, time... Broke out of nursing home. Escaped x 30 minutes. Hypothermic when found... Clinical Impression: Hypothermia - mild..." Further review of Resident #3's nurses notes for the nursing home dated 1/13/12 documented, "...4a (AM) returned to facility, 0 (no) n.o. (new orders) noted, will monitor..." Review of subsequent nursing notes documented no additional assessment or supervision until 6:00 PM on 1/13/12, when hourly visual checks were initiated. Review of care plan documented no updates or interventions. Observations on 1/17/12 at 1:00 PM, revealed Resident #3 standing at the 400 hall nurse's station with a wanderguard bracelet in place to his left ankle. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) in the private dining room on 1/19/12 at 9:00 AM, the DON was asked to provide documentation for nursing assessments and interventions following Resident #3's elopements of 11/25/11 and 1/13/12. The DON stated, "It's not there." The DON was asked to provide documentation of wanderguard checks for Resident #3. The DON stated, "It's not there." During an interview with the Regional Administrator, Administrator, and Administrator in Training on 1/19/12 at 10:00 AM, the Regional Administrator stated, "...we were not informed of the elopement attempt on 11/25/11..." The facility's failure to ensure Resident #3 received adequate supervision by not monitoring wanderguard placement each shift or monitoring Resident #3's location with visual checks at least every two hours as care planned resulted in an immediate jeopardy when Resident #3 exited the building without staff knowledge and required medical intervention at the local hospital for hypothermia. An Allegation of Compliance (AOC) was received from the facility on 1/19/12 at approximately 9:30 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Maintenance Supervisor inspected the kitchen doors and repaired the doors to ensure the doors latched properly when shut. 2. The Wanderguard installers will install the Wanderguard system on both kitchen doors on 1/24/12. 3. A staff monitor will be placed at the kitchen doors continuously until the Wanderguard system has been installed and document monitoring via the kitchen door monitoring log. In the event the Wanderguard system is not completed by this date, the staff monitor will continue to monitor both kitchen doors and the kitchen door monitoring log will be continued. 4. The Administrator or the Maintenance Supervisor will monitor the log daily to ensure the doors are monitored continuously. 5. Facility staff was inserviced by the Administrator and Regional Registered Dietician on 1/19/12 beginning at 6:20 PM regarding the facility's Maintenance Request Protocol. Each employee that is not working will be inserviced on the Maintenance Request Protocol policy prior to working a shift and inservices will continue until all facility staff are inserviced. 6. Dietary staff was inserviced on 1/19/12 beginning at 6:20 PM by the Regional Registered Dietician to ensure the dietary staff lock the kitchen door prior to leaving the facility at night. This task was added to the Dietary Job Descriptions by the Dietary Manager on 1/19/12. 7. Facility staff were inserviced by the Administrator, Administrator in Training, and Assistant Director of Nursing on 1/19/12 at 6:20 PM regarding the facilities wandering/elopement policy. Each employee that is not working will be inserviced on the wandering/elopement policy prior to working a shift and continue until all facility staff are inserviced. 8. On 1/19/12 at 6:30 PM, the Minimum Data Set (MDS) Coordinator completed a wandering assessment on the Resident who eloped (Resident #3). The resident's care plan was updated to reflect current interventions to prevent further elopements. This patient will be monitored hourly for location by the staff with documentation on the wandering patient log. The Wanderguard ankle bracelet will be checked every shift by the Charge Nurse for proper placement and documented on the Medication Administration Record (MAR). The Wanderguard ankle bracelet will be tested daily on 11-7 shift for proper functioning and documented on the Wanderguard transmitter testing log. The Maintenance Supervisor will monitor patient bracelets, magnetic locks, and bracelet controlled doors weekly and document on the wandering control device log. All other residents with Wanderguard ankle bracelets were assessed for risk for elopement with care plans updated to reflect the current intervention. These patients will be monitored for location every hour and documentation will be noted on the monitoring tool. 9. The Quality Assurance (QA) committee consisting of Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Risk Management Nurse, MDS Coordinators, Staffing Coordinator, Medical Records, Bookkeepers, Food Service Supervisor, Social Worker, Admissions Coordinator, Maintenance Supervisor, Activities Coordinator, will monitor for compliance through the use of the QA Audit Tool. If compliance is not met, the facility staff will be re-inserviced and re-evaluated for additional interventions and audits will continue until substantial compliance is achieved. Different members of the committee will participate depending on the nature of the audit. The findings of the audit will be reported to the QA committee during the morning standup meetings and the quarterly QA and A meeting. The Medical Director will attend the Quarterly QA and (&) A meeting. Observation in the dining room of the left side kitchen entrance door on 1/19/12 at 4:35 PM, revealed that when the door was opened 16 inches wide or less and released the door would not latch shut. During an interview in the dining room at the left side kitchen entrance door on 1/19/12 at 4:35 PM, the Regional Administrator confirmed the door did not latch when tested . During an interview in the dining room of the left side kitchen entrance door on 1/19/12 at 4:50 PM, the Regional Administrator stated, "...The maintenance supervisor fixed the door and will continue to monitor it daily..." Observations in the dining room on the left side kitchen entrance door on 1/19/12 at 4:50 PM, revealed that when the door was opened 16 inches wide or less and released the door would now latch shut. During an interview in the private dining room on 1/19/12 at 9:35 PM, the Regional Administrator explained the AOC actions and plan, explained the Kitchen Door Monitor Log, Maintenance Request Protocol, Maintenance report log, Wandering patient log, Wanderguard transmitter testing log, QA & A Audit tool, and the Wandering Control device weekly test log. The Regional Administrator reviewed and discussed inservices given and documentation of the inservices with employee names (all staff on duty) on the Inservice training sign in sheets for residents with Wanderguards, wandering patients being monitored every hour, protocol for testing Wanderguards with the secure care tester, visual checks, visual checks on Resident #3, the wandering patient log, missing person procedure, maintenance request protocol, kitchen door lock, kitchen door monitor log, tested closing and latching of kitchen doors, revised job duties for dietary staff, maintenance log, wandering policy, and the charge nurse responsibilities of notification of administration. The Quality Assurance Registered Nurse discussed and reviewed the care plan for Resident #3 and the update dated 1/19/12 documented, "...Risk for elopement due to history of elopement 11/25/11 and 1/13/12 and history of wandering..." An exit conference was conducted with the Regional Administrator, Administrator, Administrator in training, the Assistant Director of Nursing, and the Quality Assurance Registered Nurse in the private dining room on 1/19/12 at 9:45 PM. The facility staff were informed of the survey findings of the Immediate Jeopardy identified on 1/19/12 and the Immediate Jeopardy being removed as of 1/19/12 when the Allegation of Compliance (AOC) was put in place at 9:30 PM. The Immediate Jeopardy was effective from 1/13/12 through 1/19/12. An acceptable AOC, which removed the Immediate Jeopardy, was received and corrective actions were validated on-site by the survey team on 1/19/12. Non compliance of the immediate jeopardy still continues at a "E" level for monitoring of corrective actions. B. Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure residents at risk for falls were adequately supervised and had interventions implemented after each fall for 5 of 13 (Residents #3, 7, 8, 10 and 16) sampled residents identified with falls. The findings included: 1. Review of the facility's "Fall Risk/Fall Prevention Guidelines" policy documented, "...Develop an individualized interdisciplinary care plan.. .the Fall Focus Team will evaluate Nurse Event Notes on all patient falls for appropriate intervention making recommendations for changes as needed... A care plan will be developed by the interdisciplinary team specific to the patient assessment, interventions and goals..." 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. Resident #3's plan of care dated 11/16/11 documented problem of "Risk for falls r/t (related to) poor balance; medication use... Goal: No falls qd (every day) over next assessment period..." Review of Resident #3's nurse event notes documented the following: a. 12/15/11 - "...6:45 PM... fall with no injury on 400 Hall... told CNA's (certified nursing assistants) to watch pt (patient) in shoes and make sure they are tied..." The plan of care documented, "...PT (Physical Therapy) screen... Make sure shoes are tied..." b. 12/16/11 - "...7:00 PM...found pt in floor with eyes closed... hematoma in middle of forehead... when notifying family she stated pt had hematoma... from fall on 12-15-11... replaced shoes..." The plan of care documented, "...PT screen- replaced shoes, sitting and standing BP (blood pressure) q (every) shift X (times) 24 hrs..." c. 12/18/11 - "...8:30 AM... Found by another resident sitting in floor of west lobby... opposite end of building... pull switch alarm..." The plan of care documented, "...PT screen... pull switch... medication review..." d. 12/20/11 - "...10:20 PM... Observed fall in hallway by 300-400 Hall Nurse's Station... Advised resident when tired to ride in his W/C (wheelchair) Res (resident) in W/C c (symbol for with) pull switch alarm..." The plan of care documented, "...Pull switch... D/C (discontinued) r/t (related to) ability to self remove. Encourage to use w/c when tired..." e. 1/2/12 - "...2:00 PM... Patient fell at the end of 200 hallway... instructed patient to be careful when ambulating by himself..." The plan of care documented, "...Pt. teaching regarding pt safety, pt status and encourage to use W/C when feeling weak..." f. 1/15/12 - "...5:00 PM... Heard alarm going off went to check pt was sitting in floor 0 (symbol for no) injury noted... told cna's (certified nursing assistants) to check on pt q 30 min (minutes)..." The plan of care documented, "...Medication review..." as intervention. The facility was unable to provide documentation of q 30 min checks or review of medications. The resident was assessed to be too cognitively impaired to remember instructions to use the wheelchair when feeling weak or remember to be careful when ambulating by himself. Observations on 1/17/12 at 1:00 PM, revealed Resident #3 standing at 400 hall nurse's station with wanderguard bracelet in place on his left ankle. Resident #3 was wearing slipper type house shoes, with the left shoe's sole completely separated from shoe down half of shoe length. The shoe sole was flapping upon movement. During an interview in the private dining room on 1/19/12 at 9:00 AM, with the DON and ADON present. The DON was asked to provide documentation for nursing assessments and interventions including medication reviews following each of Resident #3's six falls. The DON stated, "It's not there." The DON was asked to clarify documentation of pull switch use and discontinuation. The DON stated, "I can't find it..." 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's nurse event notes documented the following falls: a. 8/27/11 - "...Resident sitting in floor beside bed, resident stated his socks slipped on the floor when he was trying to get into bed... immediate steps implemented, instructed resident to be more careful when ambulating..." The care plan revised 8/27/11 documented, "...Interventions: PT Screen..." The therapy fall screen dated 8/29/11 documented, "...Nursing reports no decline and no recommendation for therapy skills at this time..." b. 11/10/11 - "...Resident stated he was sitting too close to edge of bed et (and) slipped to floor... immediate steps implemented, instructed resident before sitting up, be sure he is sitting back further in bed..." The care plan revised 11/10/11 documented, "...PT screen..." The PT screening form dated 11/15/11 documented, "...no (triangle symbol) change in status..." c. 11/30/11 - "...Resident was sitting in floor... he said... sat down and the mattress slid... immediate steps implemented, encouraged to call for assistance..." The care plan revised 11/30/11 documented, "...PT screen, non skid socks..." The therapy fall screen dated 12/1/11 documented, "...May benefit from dicom under mattress..." d. 12/28/11 - "...I was going to slide on the bed and I slid down on floor... immediate steps implemented, encouraged to call for assistance..." The care plan revised 12/28/11 documented, "...non skid strips beside bed..." e. 1/3/12 - "...Resident sitting in floor in front of bed with pillows behind him... states he was getting in bed and slide out of it... immediate steps implemented, told resident to move pillows away from edge of bed..." The care plan revised 1/3/12 documented, "...PT screen, safety instruction regarding body mechanics and use of bed and assistive devices..." The therapy fall screen dated 1/4/12 documented, "...consider new mattress if nursing deems appropriate..." Observations in Resident #7's room on 1/19/12 at 8:00 AM, revealed no non skid strips on floor and no diacom under the mattress. During an interview in Resident #7's room on 1/19/12 at 8:00 AM, Resident #7 was asked if he had fallen. Resident #7 stated, "...Yes, I kept sliding out of bed..." 4. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan dated 12/6/10 to present documented, "...med (medication) review..." as an intervention on 11/1/11 and 12/19/11. The facility was unable to provide documentation of medication review on 11/1/11 and 12/19/11. Review of the nurses event notes dated from 10/28/11 to 1/16/12 documented the resident had 18 falls without injuries. Review of the fall care plan dated 12/6/10 to present had no new interventions documented for falls on 11/11/11 at 11:00 AM, on 11/23/11 at 5:30 PM, and on 1/11/12 at 12:45 PM. During an interview in the private dining room on 1/19/12 at 8:50 AM the DON was asked where the medication review was documented. The DON stated "...no formal documentation of medication review..."The DON was asked if a pharmacist was involved in the medication review. The DON stated, "...pharmacist is not involved in the med review..." The DON was asked about who did the medication review. The DON stated, "...I do..." The DON was asked about what interventions were care planned for the falls on 11/11/11 at 11:00 AM, on 11/23/11 at 5:30 PM, and on 1/11/12 at 12:45 PM. The DON stated, "...no documentation (interventions)..." There were no new interventions implemented after each fall. 5. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurses' event notes documented the following falls without interventions documented: a. 1/6/11 - "...Resident said she got a little light headed and her legs gave way... immediate steps implemented, Instructed resident to put her light on when she needs to get up..." The care plan revised 1/6/11 documented, "...PT screen safety instructions..." The therapy fall screen dated 1/7/11 documented, "...Pt (patient) refuses therapy. Not appropriate. Edu (educate) pt to use call light..." b. 3/18/11 - "...Observed pt on bathroom floor. Pt stated she got up to go to bathroom... immediate steps implemented, instructed pt to use call light when needing to get ^ (up) and to go to bathroom using w/c (wheelchair)..." The care plan revised 3/18/11 documented, "...PT screen..." The therapy fall screen dated 3/21/11 documented, "...Advised and educated pt regarding use of call light and using wc..." c. 5/11/11 - "...Pt was going to bathroom, legs got weak so she slide down to floor... immediate steps implemented, informed pt to use call light before getting up so CNA can at least walk with her..." The care plan revised 5/11/11 documented, "...PT screen..." The therapy fall screen dated 5/12/11 documented, "...Pt refused to participate in therapy stated she just needed to be aware..." d. 5/15/11 - "...Observed (Resident #10's name) sitting in floor by bed... stated my legs gave out and I sat in the floor... immediate steps implemented, use call light when needing assistance to get out of bed..." The care plan revised 5/15/11 documented, "...PT screen/staff assist..." The therapy fall screen dated 5/15/11 documented, "...educated pt regarding risk for falls and to ask for asst. ^ (increase) checks for restroom during overnight hours..." e. 6/22/11 - "...Res (resident) stated my foot slipped when I was trying to get off the toilet... emergency call light was on in bathroom... immediate steps implemented, instructed to pull light prior to getting off toilet to avoid accidents..." The care plan revised 6/22/11 documented, "...PT screen, non skid socks when transferring..." The facility was unable to provide documentation of a PT screen. f. 12/7/11 - "...Observed pt sitting in bathroom floor... Res stated I felt dizzy and sit down in the floor... immediate steps implemented, instructed pt to use call light when needing assistance..." The care plan revised 12/7/11 documented, "...PT screen..." The therapy fall screen dated 12/8/11 documented, "...Edu (educate) pt re: (regarding) use of call light..." There were no new interventions implemented after each fall. During an interview in the private dining room on 1/19/12 at 8:15 AM, the DON were asked to review Resident #10's medical record. The DON stated, "...Instructed her (Resident #10) to use the call light... that is all we have done for her..." 6. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] and 1/5/12 documented a BIMS score of 0 and 1, indicating severe cognitive impairment. Review of the plan of care initiated 7/13/11 and revised 1/13/12 documented, "...compromised short-term memory... compromised long-term memory... difficulty understanding others... difficulty making self understood..." Review of Resident #16's nurses' event notes during the time period of 9/13/11 through 1/16/12 documented a total of 25 falls without injuries. The plan of care initiated 7/13/11 documented the following interventions: a. "...PT (Physical Therapy) screen... 9/13/11, 10/17/11, 10/19/11, 10/25/11, 10/29/11, 10/31/11, 11/1/11, 11/2/11, 11/5/11, 11/6/11, 11/7/11, 11/13/11, 11/14/11, 11/30/11, 12/4/11, 12/18/11, 12/23/11, 12/31/11, 1/6/12..." b. "...Restorative (nursing program) ...9/13/11, 10/31/11, 11/1/11, 11/6/11, 11/12/11, 11/30/11..." c. "...Chairseat alarm... 10/19/11, 10/25/11, 10/31/11, 11/1/11, 1/16/12..." d. "...Toileting plan... 11/14/11, 11/30/11, 12/23/11, 12/28/11..." e. "...Nonskid socks... 10/17/11, 12/4/11..." f. "...Nonskid strips... 11/2/11, 12/18/11..." g. "...Pull switch... 1/6/12, 1/16/12..." There were no new interventions documented for the following dates: 10/25/11, 10/31/11, 11/1/11, 11/5/11, 11/6/11, 11/30/11, 12/4/11, 12/18/11, and 1/9/12. During an interview in the private dining room on 1/19/12 at 9:00 AM, the DON was asked to provide documentation of the fall interventions for Resident #16. The DON stated, "...It is not there..." The DON was asked about medication review documentation. The DON stated, "...We don't document that..." The DON was asked how she could verify that the correct interventions were in place to prevent fall-related injuries for Resident #16. The DON stated, "...We can't...We identified about a week ago that we were having problems with our falls..." 7. During an interview in private dining room on 1/19/12 at 8:15 AM, the DON was asked what is the process when a resident falls. The DON stated, "...Have stand up meeting every morning with PT and we give them the event form and they perform a screen and they have not been giving the screen to me they are putting it on the chart... PT should give us a copy of the screen and we make sure of the intervention... We are not following through..." The DON stated that there was no documentation of the stand-up meeting conducted each morning.

Based on review of the Wanderguard Transmitter Testing Log, medical record review and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) was accurate for wandering behavior for 1 of 1 (Resident #3) sampled resident who had eloped. The failure to accurately assess Resident #3's wandering/elopment behavior resulted in an immediate jeopardy when Resident #3 eloped on 1/13/12 which required a medical intervention for hypothermia. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's admission MDS dated [DATE] had no documentation of any wandering behavior under "Section E". Review of the "Wanderguard Transmitter Testing Log" for 11/11/11, 12/11/11, and 1/12/12 documented Resident #3 had a wanderguard on from 11/8/11 through (-) 1/18/12. Review of Resident #3's nurses' notes documented the following: a. 11/8/11 - "...states wants to leave, go home. Up and down hallway in other residents rooms trying to find a way out. family @ (at) bedside at this time. Wanderguard placed an on left ankle. Will cont. (continue) to monitor..." b. 11/9/11 - "wanderguard intact @ all x's (times)..." c. 11/10/11 - "...Resident ambulated in hallway throughout this shift. Will monitor..." d. 11/11/11 - "...Wants to go home res (resident) to sit by door and slip out when someone enters/departs Wanderguard on..." e. 11/18/11 - "...attempted to elope out door at end of 400 Hall. Immediately brought back in. Staff alerted... resident on 15 min. (minute) Vs (symbol for checks) continuously..." f. 11/19/11 - "...attempted to elope X (times) 3 from door at end of hall..." g. 11/20/11 - "...wanders...continues to attempt to elope... Wanderguard intact and functioning properly..." h. 11/22/11 - "...wander guard on...must be supervised..." i. 11/23/11 and 11/24/11 - "...wanders..." j. 11/25/11 - "...10:40 pm- Pt (patient (Resident #3)) went out through kitchen door... leading outside and was walking down side street. Pt now inside in Rm (room), This is the first time on this shift Pt attempted to go outside..." Review of care plan documented no updates or interventions related to this event. Review of medical record documented no investigation of this event. Review of subsequent nursing notes documented no additional assessment or supervision following this event. k. 11/28/11, 11/30/11 and 12/1/11 - "...wanders..." l. 12/4/11 - "...wanderguard on... wanders a lot. Forgets where room is..." m. 12/6/11, 12/9/11, 12/12/11, 12/15/11, 12/17/11 - "...wanders..." n. 12/18/11 - "...Pull switch implemented & (and) encouraged to use w/c (wheelchair) at all X's..." Review of care plan documented no updates or interventions; subsequent nursing notes documented no additional assessment or supervision. o. 12/21/11, 12/23/11, 1/4/12, 1/7/12, 1/8/12, 1/9/12 - "...wanders..." p. 1/13/12 - "...1230 am - resident eloped from building, went to (name of another nursing facility located on a street behind this facility), when they found him they called police dept. (department) and Hospital, resident was carried to (name of local hospital) to get checked out, family notified..." Review of Resident #3's hospital emergency record dated 1/13/12 documented, "...Presentation time: 0107 (1:07 AM)... Chief Complaint: Exposure to cold unknown amt (amount) of time... Rectal temperature: 95... (symbol for degree) all extremities cool... disoriented to person, place, time... Broke out of nursing home. Escaped x 30 minutes. Hypothermic when found... Clinical Impression: Hypothermia - mild..." Further review of Resident #3's nurses notes for the nursing home dated 1/13/12 documented, "...4a (AM) returned to facility, 0 (no) n.o. (new orders) noted, will monitor..." Review of subsequent nursing notes documented no additional assessment or supervision until 6:00 PM on 1/13/12, when hourly visual checks were initiated. Review of care plan documented no updates or interventions. During an interview in the private dining room on 1/19/12 at 3:00 PM, the MDS nurse was asked about the failure to document wandering behavior on the 11/11/11 MDS for Resident #3. The MDS Nurse stated, "...we missed it (assessing wandering behavior)..." Refer to the initial comment for the allegation of compliance of corrective actions put in place on 1/19/12, which removed the immediate jeopardy. Noncompliance of the immediate jeopardy continues at the lower scope and severity of "D" level for monitoring of corrective actions.

Based on policy review, review of the weather channel temperature, medical record review, observation, review of the facility's daily census, review of time cards, review of January 2012 staffing schedule and interview, it was determined the facility failed to be administered in a manner maintaining the highest practical physical and psychosocial well-being for all residents by failing to ensure a resident at risk for elopement was adequately supervised to prevent further elopement for 1 of 1 (Resident #3) sampled resident who had eloped. The facility's failure to provide adequate supervision to prevent an elopement placed Resident #3 in immediate jeopardy when the resident eloped during the early morning hours on 1/13/12 that required medical intervention for hypothermia. The facility failed to be administered in a manner to prevent further falls for 5 of 13 (Residents #3, 7, 8, 10 and 16) sampled residents identified with falls. The findings included: The administration failed to ensure adequate supervision for Resident #3 when the resident eloped from the facility without staff knowledge, requiring medical intervention for mild hypothermia. Refer to F323 and F353. The administration also failed to identify and address staff competency in developing and implementing interventions after each fall for residents identified as being at risk for falls. Resident #3 sustained 6 falls from 12/15/11 through (-) 1/15/12. Resident #7 sustained 5 falls from 8/27/11- 1/3/12. Resident #8 sustained 18 falls from 10/28/11 - 1/16/12. Resident #10 sustained 6 falls from 1/6/11 - 12/7/11. Resident #16 sustained 26 falls from 9/13/11 - 1/16/12. Refer to F323. The facility's administration, including the Administrator and the Director of Nursing, failed to effectively and efficiently ensure that all residents were maintained at their highest practical well-being. The administrative staff failed to ensure that the facility identified, monitored, and followed up on quality of care issues of resident wandering/elopement and falls. Refer to F323. The Immediate Jeopardy was effective from 1/13/12 through 1/19/12. An acceptable Allegation of compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated on-site by the survey team on 1/19/12. Non compliance of the immediate jeopardy still continues at a "E" level for monitoring of corrective actions.