Every finding on record at Vivian Healthcare Center

Based on record reviews and interviews, the facility failed to ensure 3 (#9, #13, and #53) of 5 residents reviewed for unnecessary medications were free from chemical restraints by failing to: ensure Resident #9's GDR recommendations were implemented andensure Residents' (#9, #13, and #53) orders for PRN psychotropic medications did not exceed 14 days without a rational. Findings: Review of the facility's Psychotropic/Psychoactive Medication Policy revised 01/2025 revealed in part: Policy StatementA psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (I) Antipsychotic; (II) Anti-depressant; (III) Anti-anxiety; and (IV) Hypnotic. Other medications which affect brain activity will also be subject to psychotropic medication requirements if documented use is a substitution for a psychotropic medication rather than the approved or original indication.Psychotropic medications are used only when appropriate and at the lowest possible dose to enhance the residents' quality of life, maximize functional ability or promote overall well-being. Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and documented.Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review. An ongoing evaluation of need of the medication must be documented, as the resident has the right to be free of chemical restraints.Policy Implementation8. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications.10. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.14. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs, safely and as appropriate. Resident #9Review of Resident #9's medical record revealed an admission date of 08/28/2011 and diagnoses including Parkinson's disease, major depressive disorder, and dementia. Review of Resident #9's physician orders revealed an order dated 01/28/2025 for Quetiapine (Seroquel) Fumarate Oral Tablet 25 milligrams; Give 0.5 tablet [12.5 milligrams] by mouth two times a day related to major depressive disorder. Further review revealed Resident #9 had a PRN psychotropic medication order start date 11/18/2023 for Hydroxyzine (Vistaril) HCL Tablet 25 milligram; Give 1 tablet by mouth every 6 hours as needed for anxiety and/or itching. Further review failed to reveal a rational or a stop date of PRN psychotropic medication order over 14 days. Review of Resident #9's most recent GDR dated 01/14/2026 revealed a dose reduction recommendation for Seroquel to 12.5 milligrams once at night.Review of Resident #9's discontinued and completed orders for dates 01/14/2026 through 05/11/2026 failed to reveal implementation from GDR recommendation dated 01/14/2026 to decrease Seroquel 12.5 milligrams from twice daily to once at night. During an interview on 05/11/2026 at 10:20 a.m. S3 DON confirmed Resident #9's GDR dated 01/14/2026 recommended a decrease in Seroquel 12.5 milligrams from twice daily to once at night. S3 DON reported there was no documentation of a GDR attempt from 01/14/2026 or rational why GDR attempt was not made. Resident #13Review of resident #13's medical record revealed an admission date of 10/31/2025 and diagnoses including unspecified dementia, anxiety disorder, and altered mental status. Review of Resident #13's physician orders revealed Resident #13 had a PRN psychotropic medication order start date 10/13/2025 for Ativan (Lorazepam) Oral Tablet 0.5 milligrams; Give 1 tablet by mouth every 12 hours as needed for agitation related to anxiety disorder, unspecified. Further review failed to reveal a rational or a stop date of PRN psychotropic medication order. Resident #53Review of Resident #53's medical record revealed an admission date of 12/31/2025 and diagnoses including Alzheimer's disease, unspecified dementia, and major depressive disorder. Review of Resident #53's physician orders revealed Resident #53 had a PRN psychotropic medication order start date 01/15/2026 for Vistaril Oral Capsule 50 milligrams (Hydroxyzine Pamoate); Give 1 capsule by mouth every 4 hours as needed for anxiety related to anxiety disorder, unspecified. Further review failed to reveal a rational or a stop date of PRN psychotropic medication orders.During an interview on 05/08/2026 at 11:26 a.m., S3 DON reported PRN psychotropic medications should be reordered every 14 days or have as stop date with rational for an order lasting longer than 14 days. S3 DON confirmed residents #9, #13, and #53 had PRN psychotropic medication orders which lasted longer than 14 days without a stop date or rational for an order lasting longer than 14 days.

Based on record reviews and interviews, the facility failed to: 1. Provide written notice to residents and/or their RP which specified the reason for transfer, effective date, location and statement of the resident's appeal rights and duration of the bed hold for 3 (#6, #10, and #56) of 3 residents reviewed for hospitalizations, and 2. Update the emergency transfer log (Notice of Discharge to the Ombudsman) for 2 (#6 and #10) of 3 residents reviewed for hospitalizations. Findings: Resident #6 Review of Resident #6's medical record revealed an admission date on 11/21/2025 and diagnoses including acute respiratory failure with hypoxia and dependence on renal dialysis. Review of Resident #6's medical record revealed emergency transfers to an acute care hospital on [DATE], 12/16/2025, 03/05/2026, 03/31/2026 and 04/18/2026. Further review failed to reveal documentation Resident #6 or Resident #6's RP was given written notification of the facility's bed hold policies at the time of his transfer's to the hospital on [DATE], 12/16/2025, 03/05/2026, 03/31/2026 or 04/18/2026. Review of the facility's Ombudsman Emergency Transfer Log for dates 04/01/2025 through 03/31/2026 failed to reveal documentation the Ombudsman was notified of Resident #6's transfer to the hospital on [DATE]. Resident #10 Review of Resident #10's medical record revealed an admission date on 07/10/2025 and diagnoses including other sequelae of cerebral infarction, specified diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #10's progress notes for dates 03/02/2026 through 03/10/2026 revealed Resident #10 was sent to the hospital on [DATE] per Resident #10's request and returned to the facility 03/10/2026. Further review failed to reveal a documentation of the bed hold notification was given to Resident #10 and/or RP on 03/02/2026 at time of transfer. Review of the facility's Ombudsman Emergency Transfer Log for dates 04/01/2025 through 03/31/2026 failed to reveal documentation the Ombudsman was notified of Resident #10's transfer to the hospital on [DATE]. Resident #56 Review of Resident #56's medical record revealed an admission date of 02/24/2026 and a discharge date of 03/20/2026 with diagnoses including chronic kidney disease and unspecified dementia. Review of Resident #56's medical record revealed Resident #56 was transferred to an acute care hospital on [DATE]. Further review failed to reveal Resident #56's RP was given written notification of the facility's bed hold policies at the time of his transfer to the hospital on [DATE]. During an interview on 05/08/2026 at 8:50 a.m., S4 Business Office Manager reported she was not responsible for bed hold documentation at the time of transfer. During an interview on 05/08/2026 at 8:55 a.m., S6 Social Services reported she was not responsible for bed hold documentation at the time of transfer. During an interview on 05/08/2026 at 8:59 at a.m., S3 DON reported she was not sure who was responsible for bed hold documentation at the time of transfer. During an interview on 05/08/2026 at 9:44 a.m., S5 Corporate Nurse reported there was no documentation of the bed hold policy/notification at transfer for Residents #6, #10, and #56.During an interview on 05/08/2026 at 9:45 a.m., S1 Regional Operation Manager/Interim Administrator reported there was not documentation in the medical record of the bed hold policy/notification at time of transfer for Residents #6, #10, and #5.During an interview on 05/08/2026 at 11:00 a.m., S6 Social Services confirmed the Ombudsman was not notified of Resident #6's transfer on 03/05/2026 and Resident #10's transfer on 03/02/2026 and should have been.

Based on record review and an interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an Advance Directive for 5 (#4, #5, #10, #36, and #53) of 5 residents reviewed for Advanced Directives. Findings: Review of facility's Advance Directive Policy with latest revision date of August 2023 revealed in part;Policy Statement: Advance Directives will be respected in accordance with state law and facility policy.Policy Interpretation and Implementation:Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an Advanced Directive if he or she chooses to do so.2. Written information will include a description of the facility's policies to implement Advance Directives and applicable state law.3. If the resident is incapacitated and unable to receive information about his or her right to formulate an Advance Directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written Advance Directives.15. In accordance with current regulatory definitions and guidelines governing Advance Directives, out facility has defined Advance Directives as preferences regarding treatment options and include, but are not limited to:a. Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated. Review of Resident #4's face sheet revealed an admission date of 03/28/2023 with the following diagnoses but not limited to specified chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, dementia, and anxiety disorder. Review of Resident #4's medical record failed to reveal a consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission.During an interview on 05/06/2026 at 2:00 p.m. S2 Interim Assistant Administrator confirmed Resident #4 did not have a completed Advance Directive form that indicated Resident #4 was given written materials on how to formulate an Advance Directive. Review of Resident #5's face sheet revealed an initial admission date of 09/09/2025 and a reentry admission date of 4/29/2026 with the following medical diagnoses but not limited to aftercare following joint replacement surgery; displaced fracture of base of neck right femur, muscle weakness, lack of coordination abnormalities of gait and mobility, and unspecified dementia,Review of Resident #5's medical record failed to reveal a consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission.During an interview on 05/06/2026 at 4:20 p.m. S5 Corporate Nurse confirmed Resident #5's Advance Directives acknowledgment had not been obtained and should have been.Review of Resident #10's face sheet revealed an admission date of 07/10/2025 and readmission date of 03/10/2026 with following medical diagnoses but not limited sequelae of cerebral infarction; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, specified diabetes mellitus with diabetic polyneuropathy; chronic obstructive pulmonary disease, chronic kidney disease, stage 3 unspecified, and encounter for attention to ileostomy. Review of Resident #10's medical record failed to reveal a consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission. During an interview on 05/06/2026 2:00 PM S2 Interim Assistant Administrator confirmed Resident #10 did not have consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission. Review of Resident #36's face sheet revealed an admission date of 02/02/2024 with the following medical diagnoses but limited to spondylosis without myelopathy or radiculopathy, cervical region, pan lobular emphysema, type 2 diabetes mellitus with diabetic chronic kidney disease, apraxia following non-traumatic intracerebral hemorrhage, occlusion and stenosis of right carotid artery, atherosclerotic heart disease of native coronary artery without angina pectoris, spondylosis without myelopathy or radiculopathy, thoracolumbar region, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of Resident #36's Advance Directive Status Form dated 11/07/2023 revealed: the advance directive rights and policies been explained and written information provided to Resident and/or Responsible Party was not completed. During an interview on 05/06/2026 at 2:00 p.m. S2 Interim Assistant Administrator confirmed the Resident #36 did not have a completed advance directive form that indicated Resident #36 was given written materials on how to formulate an Advance Directive. Review of Resident #53's face sheet revealed an admission date of 12/31/2025 with the following diagnoses but not limited to Alzheimer's disease, dementia and major depressive disorder. Review of Resident #53's medical record failed to reveal a consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission.During an interview on 05/06/2026 at 2:16 PM S2 Interim Assistant Administrator confirmed Resident #53 did not have consent and/or education of Advanced Directive material given to resident/resident's responsible party upon admission.

Based on record reviews, observations, and interviews the facility failed to ensure a plan of care had been developed for 4 (#13, #37, #50, #52) of 8 (#13, #18, #32, #37, #38, #50, #52, #168) residents reviewed for accidents. The facility failed to ensure a plan of care for side rail assist bars had been developed for Residents #13, #37, #50, and #52. Findings: Review of the facility's PSDs (Personal Safety Devices)-Enablers-Side Rails & Restraints policy with a revision date of February 2025 revealed in part, these devices require evaluation, resident and/or responsible party notification, an order, care planning, and routine monitoring for effectiveness and restraining effect. Resident #13 Review of Resident #13's medical record revealed in part, an original admitted [DATE] with diagnoses including, but not limited to Parkinson's without dyskinesia and dementia with agitation. Review of Resident #13's annual and state MDS (Minimum Data Set) assessments dated 12/13/2024 revealed in part, a BIMS (Brief Interview for Mental Status) score of 9 indicating moderately impaired cognition. Further review of Resident #13's annual and state MDS assessments dated 12/13/2024 revealed Resident #13 required limited assistance by one person with bed mobility and toilet use and required supervision by one person with transfers. Review of Resident #13's current physician orders revealed in part, an order dated 02/08/2024 for SRA (Side Rail Assist) bar times two for bed mobility and transfers. Review of Resident #13's comprehensive care plan failed to reveal a focus for the use of side rail assist bars and appropriate interventions. Multiple observations throughout the day on 03/17/2025 revealed Resident #13 in and out of her bed. Further observations revealed Resident #13's bed with side rail assist bars in a raised positon to each side of the HOB (Head of Bed). An observation on 03/18/2025 at 11:55 a.m. revealed Resident #13's bed with side rail assist bars in a raised positon to each side of the HOB. During an interview on 03/18/2025 at 11:55 a.m., Resident #13 reported she does use the assist bars to reposition herself while in bed and to get out of bed. During an interview on 03/19/2025 at 1:27 p.m., S4 MDS Nurse confirmed Resident #13's comprehensive care plan did not include a focus for side rail assist bars. During an interview on 03/19/2025 at 3:31 p.m., S2 DON (Director of Nursing) and S3 Corporate Nurse confirmed Resident #13's care plan did not include a focus on side rail assist bars. Resident #37 Review of Resident #37's medical record revealed in part, an admitted [DATE] with diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #37's quarterly and state MDS assessments dated 12/13/2024 revealed in part, Resident #37 required supervision with set up assist for bed mobility. Review of Resident #37's current physician orders revealed in part, an order dated 02/08/2024 for SRA bar times two for bed mobility and transfers. Review of Resident #37's comprehensive care plan failed to reveal a focus for the use of side rail assist bars and appropriate interventions. An observation on 03/18/2025 at 8:58 a.m. revealed Resident #37's bed with side rail assist bars in a raised positon to each side of the HOB. During an interview on 03/19/2025 at 9:28 a.m., S2 DON confirmed Resident #37's care plan should have a focus with appropriate interventions for side rail assist bars and did not. Resident #50 Review of Resident #50's medical record revealed in part, a readmitted [DATE] with diagnoses including, but not limited to other sequelae of cerebral infarction and dementia without behavioral disturbance. Review of Resident #50's annual MDS assessment dated [DATE] revealed in part, a BIMS score of 3 indicating severely impaired cognition. Further review of Resident #50's annual MDS dated [DATE] revealed Resident #50 required supervision or touch assist with chair/bed to chair transfers and toilet transfers. Review of Resident #50's current physician orders revealed in part, an order dated 02/07/2024 for SRA bar times two for transfers and bed mobility. Review of Resident #50's comprehensive care plan failed to reveal a focus for the use of side rail assist bars and appropriate interventions. Multiple observations throughout the day on 03/17/2025 revealed Resident #50 in her bed with side rail assist bars in a raised positon to each side of the HOB. During an interview on 03/19/2025 at 1:27 p.m., S4 MDS Nurse confirmed Resident #50's comprehensive care plan did not include a focus for side rail assist bars. During an interview on 03/19/2025 at 3:31 p.m., S2 DON and S3 Corporate Nurse confirmed Resident #50's care plan did not include a focus for side rail assist bars. Resident #52 Review of Resident #52's medical record revealed in part, an admitted [DATE] with diagnoses including, but not limited to spinal stenosis of lumbar region with neurogenic claudication and dorsalgia. Review of Resident #52's quarterly and state MDS assessments dated 02/27/2025 revealed in part, Resident #52 required limited physical assistance by one person with bed mobility. Review of Resident #52's current physician orders revealed in part, an order dated 11/20/2024 for SRA bar times two. Review of Resident #52's comprehensive care plan failed to reveal a focus with appropriate interventions for the use of side rail assist bars and appropriate interventions. An observation on 03/17/2025 at 11:33 a.m. revealed Resident #52's bed with side rail assist bars in a raised positon to each side of the HOB. During an interview on 03/19/2025 at 9:28 a.m., S2 DON confirmed Resident #52's care plan should have a focus with appropriate interventions for side rail assist bars and did not.

Based on record review, observation, and interviews, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#37) of 1 resident reviewed for dialysis by failing to assess Resident #37 upon return to the facility from dialysis treatment. Findings: Review of Resident #37's March 2025 physician orders revealed: 01/22/2025: Resident to receive dialysis 3 days a week on Monday-Wednesday-Friday at ____ dialysis center. 12/05/2025: Monitor AV (Arteriovenous) shunt pressure dressing to left arm for excessive bleeding every shift upon return from dialysis and remove dressing morning after dialysis. 12/05/2025: Monitor AV shunt site left arm for signs and symptoms infection q (every) shift. Palpate pulse(s) distal to shunt. Note changes in skin color and temp. Report changes to physician. 12/05/2025: AV shunt to left arm. Assess & palpate AV shunt q shift for thrill and bruit. Report concerns to physician. Review of Resident #37's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 12 out of 15; indicating cognitively intact. During an interview on 03/18/2025 at 9:47 a.m. Resident #37 reported upon return to the facility the nurse does not assess dialysis access site and/or obtain vital signs. Resident #37 further reported he removed his own dressing from dialysis. Observation on 03/18/2025 at 9:47 a.m. revealed Resident #37's dialysis access was in the left forearm with no dressing in place. During an interview on 03/19/2025 at 2:25 p.m. S5 RN (Registered Nurse) reported upon return from dialysis Resident #37 is not assessed and vital signs are not obtained unless Resident #37 complained of feeling bad, fatigue, weak or a headache. S5 RN reported the transport driver will leave the communication binder at the desk and S5 RN was not made aware of Resident #37's return from dialysis treatments. During an interview on 03/19/2025 at 3:00 p.m. S2 DON (Director of Nursing) reported the nursing staff should complete the dialysis checklist by assessing the resident according to the dialysis communication form and vital signs should be obtained upon return from dialysis. S2 DON reported not being aware if the facility had a policy for assessment of a resident upon return from dialysis and instructions for completing the dialysis communication form.

Based on record review, observation, and an interview, the facility failed to ensure correct use of bed rails as evidence by failing to obtain a written a physician order for side rail assist bars, obtain an informed consent from resident or resident's responsible party prior to installation, and ensure a care plan was initiated with a focus for side rail assist bars for 1 (#168) out of 8 (#13, #18, #32, #37, #38, #50, #52, and #168) residents investigated for accidents. Findings: Review of the facility's PSDs (Personal Safety Devices) -Enablers-Side Rails & Restraints Policy with a revision date of February 2025 revealed in part, These devices require evaluation, resident and/or responsible party notification, an order, care planning, and routine monitoring for effectiveness and restraining effect. Protocols for PSD-Enablers-Side Rails and Restraints I. When a resident is admitted with or is prescribed a personal safety, enabler and/or a type of side rail. The IDT (Interdisciplinary Team) will: notify resident and/or responsible party of device use and purpose in plan of care obtain and write an order update care plan and Kardex/POC (Plan of Care) to include appropriate monitoring device Review of Resident #168's face sheet revealed an admitted [DATE] with the following diagnoses but not limited to intractable epilepsy, dementia, and mild cognitive impairment. Review of Resident #168's March 2025 physician orders failed to reveal an order for hand assist rails. Review of Resident #168's care plan failed to reveal a focus on side rails/assist rails with appropriate interventions. S2 DON (Director of Nursing) presented surveyor with an electronic copy of Resident #168's Side Rail/ Assist Bar Informed Consent obtained by verbal consent on 03/18/2025. Observation on 03/17/2025 at 9:30 a.m. revealed Resident #168 had side rail assist bars to both sides of the bed. During an interview on 03/19/2025 at 9:28 a.m. S2 DON confirmed Resident #168 should have a physician order for side rail assist bars, care plan should have a focus with interventions for side rail assist bars and an informed consent should have been signed prior to installation and was not.

Based on record reviews and interviews the facility failed to ensure the resident's physician and RP (Responsible Party) were notified of a change in condition for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for resident rights. The facility failed to notify Resident #1's physician and RP when Resident #1 was involved in an investigational incident. Findings: Review of the facility's Abuse Prohibition Policy with a reviewed date of 05/17/2024 revealed in part: Policy and Procedures. Investigation . 6.) Procedure for the investigation will include, but is not limited to the following: Notification to the attending physician and family. Review of Resident #1's medical record revealed an admitted [DATE] with a readmitted [DATE]. Review of Resident #1's medical record revealed the following diagnoses in part: Major depressive disorder, delusional disorder, schizoaffective disorder, unspecified dementia, cognitive communication deficit, and behavioral disturbance. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 08/01/2024 revealed a BIMS (Brief Interview of Mental Status) of 3 indicating Resident #1 was moderately impaired. Review of Resident #1's medical record failed to reveal the physician/NP (Nurse Practitioner) and RP were notified of the incident reported to the state office on 09/03/2024. During an interview on 09/25/2024 at 9:00 a.m., S1 Administrator reported Resident #1's RP and the Physician/NP were not notified of the incident investigated and should have been.

Based on observations, interviews and record reviews the facility failed to ensure necessary care and services were provided in accordance with accepted professional standards of practice for 2 (#37, #54) of 2 (#37 and #54) residents reviewed for respiratory care. The facility failed to ensure equipment was assembled correctly by not having a humidifier bottle attached to the oxygen concentrators. Findings: Review of the facility's Oxygen Administration Procedure revealed in part the following: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand); 2. Nasal cannula, nasal catheter, mask (as ordered); 3. Humidifier bottle; 4. No smoking/Oxygen in Use signs: Steps in the Procedure: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that water bubbles as oxygen flows through. Resident #37 Observation on 02/19/2024 at 8:30 a.m. revealed no humidifier bottle attached to the oxygen concentrator that was being used by resident #37. Review of resident #37's medical records revealed diagnoses that include but not limited to chronic respiratory failure with hypoxia, other poly osteoarthritis, chronic diastolic (congestive) heart failure, major depressive disorder, and chronic obstructive pulmonary disease. Review of resident #37's February 2024 Physician's orders revealed an order dated 08/30/2021 for O2 (oxygen) at 2 liters per minute via nasal cannula PRN (as needed) for SOB (shortness of breath). May titrate to 3-4 LPM (liters per minute) to keep O2 saturation >90%. Review of resident #37's Comprehensive Plan of Care revealed problems of congestive heart failure and chronic obstructive pulmonary disease and episodes of shortness of breath. Some of the interventions are O2 at 2 liters per minute via nasal cannula PRN SOB. May titrate to 3-4 LPM to keep O2 sat >90%. Oxygen settings, oxygen via nasal cannula as ordered. Observation on 02/20/2024 at 1:00 p.m. with S2 LPN (License Practical Nurse) revealed resident #37 asleep in bed with oxygen in progress with no humidifier bottle attached to the oxygen concentrator. Resident #54 Observation on 02/19/2024 at 8:30 a.m. revealed resident #54's oxygen in progress per nasal cannula by an oxygen concentrator. Further observation revealed no humidifier bottle attached to the oxygen concentrator. Review of resident #54's medical records revealed diagnoses that included but not limited to acute chronic diastolic congestive heart failure, acute pulmonary edema, other sequelae of cerebral infarction and dementia. Observation on 02/20/2024 at 1:00 p.m. with S2 LPN (License Practical Nurse) revealed resident #54 in bed with oxygen in progress with no humidifier bottle attached to the oxygen concentrator. During an interview 02/20/2024 at 1:15 p.m. S2 LPN reported she had tried to get humidifier bottles attached to the oxygen concentrators for resident #37 and #54 but she could not get it to stay connected. S2 LPN reported the oxygen would not continue to work when she attempted to connect the humidifier bottle to the oxygen concentrator.S2 LPN confirmed the humidifer bottles should have been attached to the oxygen concentrators.

Based on record reviews and an interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#54) of 21 (#1, #4, #6, #8, #14, #16, #17, #18, #24, #27, #28, #37, #39, #41, #44, #46, #49, #53, #54, #58 and #59) sampled resident's care plans reviewed. The facility failed to monitor resident #54's oxygen saturation level every shift as ordered by the physician/NP (nurse practitioner). The facility failed to have a physician order for oxygen therapy. Findings: Review of resident #54's medical records revealed she was admitted to this facility on 09/23/2023. Resident #54 had multiple diagnoses that included acute chronic diastolic congestive heart failure, acute pulmonary edema, other sequelae of cerebral infarction and dementia. Review of resident #54's physician/NP Progress notes dated 02/06/2024 revealed she was seen and evaluated on this date due to staff reported resident with increased cough and shortness of breath. Resident recently had an inpatient hospitalization for CHF (Congestive Heart Failure) exacerbation with pneumonia. The physician/Nurse Practitioner documented her plans in her progress notes for oxygen at 2 liters per nasal cannula, monitor oxygen saturation every shift and notify provider of any acute changes in condition or shortness of breath. Review of resident #54's February 2024 Physician orders with S1 DON (Director of Nursing) failed to reveal an order written for oxygen or an order to monitor the resident's oxygen saturation level. Further review of resident #54's medical records failed to reveal monitoring of resident #54's oxygen saturation level had been done as ordered. Review of the facility's Oxygen Administration Procedure presented by S1 Administrator revealed in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Assessment Before administering oxygen, and while the resident is receiving oxygen therapy, assess for - 1. Signs or symptoms of cyanosis 2. Signs and symptoms of hypoxia During an interview on 02/20/2024 at 4:00 p.m. S1 DON reviewed resident #54's clinical records and confirmed resident #54 did not have a written physician order for oxygen or to monitor O2 saturation every shift. S1 DON reviewed the plans documented on the physician/NP progress notes dated 02/06/2024 and confirmed the order for oxygen 2 liters per nasal cannula, and monitor the O2 (oxygen) saturation every shift should have been written as a physician order and implemented and it was not. S1 DON reported when physician/NP plans are written, she or one of the nurses are to make sure an order is written for the plan or the NP will write the order herself.

Based on record review and interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#58) out of 29 sampled residents reviewed. The facility failed to enter an accurate discharge status for Resident #58. Findings: Review of resident #58's electronic medical record revealed an admitted [DATE] and a discharge date of [DATE]. Review of resident #58's MDS dated [DATE] revealed a (planned) discharge with return not anticipated to a short-term General Hospital. Review of resident #58's discharge summary revealed the resident was discharged to another long-term care facility with a family member. During an interview on 02/20/2024 at 3:15 p.m. S2LPN (Licensed Practical Nurse) indicated resident #58 was discharged to another long term care facility at her family's request. During an interview on 02/20/2024 at 3:22 p.m. S3MDS Nurse confirmed resident #58's discharge MDS of 12/08/2023 was coded as a hospitalization and should have been coded as a transfer to another facility.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 10 of 25 weekend days reviewed. Findings: Review on the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 to March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 2 2023 revealed the facility provided 127.81 hours on 02/11/2023 and were required to provide 133.95 hours, provided 124.59 hours on 02/12/2023 and were required to provide 131.60 hours, provided 146.91 hours on 02/18/2023 and were required to provide 148.05 hours, provided 143.83 hours on 02/19/2023 and were required to provide 145.70 hours, provided 131.95 hours on 02/25/2023 and were required to provide 141 hours, provided 127 hours on 03/05/2023 and were required to provide 141 hours, provided 138.8 hours on 03/11/2023 and were required to provide 143.5 hours, provided 143.05 hours on 03/12/2023 and were required to provide 143.35 hours, provided 129.24 hours on 03/18/2023 and were required to provide 136.30 hours, provided 130.40 hours on 03/19/2023 and were required to provide 136.30 hours. During an interview on 08/16/2023 at 4:20 p.m. S1 Administrator reviewed the facility's staffing pattern reports for weekends from FY Quarter 2 2023, and acknowledged the facility did not provide the minimum hours required on 02/11/2023, 02/12/2023, 02/18/2023, 02/19/2023, 02/25/2023, 03/05/2023, 03/11/2023, 03/12/2023, 03/18/2023, and 03/19/2023 and should have.

Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. Findings: Record review of the facility's QAA Committee meetings revealed no documentation of a second quarter meeting was completed for the year of 2022. During an interview on 1/18/23 at 3:30 p.m., S1 Administrator confirmed a QAA Committee meeting was not held for the second quarter for the year of 2022 and a meeting should have been held.

Based on record review and interviews, the facility failed to ensure residents were free from unnecessary medication use for 4 (#1,#3, #4, #5) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure: 1. Resident #1 and Resident #3 were monitored for side effects, behaviors and interventions of anti-anxiety medication. 2. Resident #3, Resident #4, and Resident #5 were monitored for side effects, behaviors and interventions of antipsychotic medication. 3. Lab was obtained for Depakote level for Resident #5 Findings: Review of facility's policy Psychotropic/ Psychoactive Medication Management revealed in part Policy Statement: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Antipsychotic, (ii) Anti-depressant, (iii) Anti-anxiety, and (iv) Hypnotic. Other medications which affect brain activity will also be subject to psychotropic medication requirements if documented use is a substitution for psychotropic medication rather than the approved or original indication. Psychotropic medications are used only when appropriate and at the lowest possible dose to enhance the resident's quality of life, maximize functional ability or promote well-being. Policy Implementation: . 7. Residents will be monitored for behaviors to include behavior changes and for side effects and complications related to psychoactive medications, for example, sedation, lethargy, agitation, mental status changes, or behavior changes that affect ability to perform adl's (activities of daily living) . 1. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and had diagnoses that included, atherosclerotic heart disease, Type 2 Diabetes Mellitus, essential hypertension, anxiety, and depression. Review of Resident #1's physician orders revealed a 9/13/2022 order for Buspirone HCl (hydrochloride) tablet 5 mg (milligrams) - give 1 tablet by mouth three times a day for anxiety. Review of Resident #1's November 2022 MAR (Medication Administration Record) revealed Resident #1 had received Buspirone HCl 5mg tablet by mouth three times a day from 11/1/2022 to 11/27/2022. Further review of the November 2022 MAR failed to reveal anti-anxiety medication monitoring for behaviors and side effects had been conducted for Resident #1. During an interview on 1/9/2023 at 4:10 PM S2 ADON (Assistant Director of Nursing)/Interim DON (Director of Nursing) reviewed Resident #1's November 2022 MAR and reported monitoring for side effects and behaviors had not been conducted in regard to anti-anxiety medication for Resident #1 and should have. Review of Resident #3's medical diagnoses revealed Resident #3 had diagnoses that included Parkinson's disease (3/1/2017), anxiety disorder (10/17/2017), schizophrenia (3/1/2017), and delusional disorders (3/1/2017). Review of Resident #3's December 2022 Physician Orders revealed the following orders: -Buspirone HCl tablet 10 mg: Give 20 mg by mouth three times a day for anxiety dated 3/27/2022 -Side effects anti-anxiety Q shift: 0.None, 1. Dry mouth, 2.constipation, 3.blurred vision, 4.orthostatic hypotension, 5.falls, 6.sedation, 7.drowsiness, 8.behavior changes, 9.dizziness dated 9/28/2022. Review of Resident #3's December 2022 MAR failed to reveal adequate monitoring of Resident #3 behaviors, side effects and interventions for anti-anxiety medications. Review of Resident #3's December 2022 MAR with S2 ADON/ Interim DON failed to reveal adequate behavior, side effect monitoring and interventions of antianxiety medications. During an interview on 1/9/2023 at 3:00 PM S2 ADON/ Interim DON confirmed Resident #3 behaviors, side effects and interventions were not monitored adequately for anti-anxiety medications. During an interview on 1/9/2023 at 3:00 PM S3 Corporate Nurse confirmed Resident #3 behaviors and interventions were not monitored adequately using the number coded guidance for anti-anxiety medications. 2. Review of Resident #3's Medical Diagnoses revealed Resident #3 had diagnoses that included Parkinson's disease (3/1/2017), anxiety disorder (10/17/2017), cerebral infarction (3/1/2017), schizophrenia (3/1/2017), delusional disorders (3/1/2017), unspecified cataract (12/15/2019), and constipation (3/1/2017). Review of Resident #3's December 2022 Physician Orders revealed the following orders: -Seroquel tablet (Quetiapine Fumarate): Give 150 mg by mouth at bedtime for schizophrenia dated 3/27/2022 -Behavior monitoring: Antipsychotic every shift: 0.None, 1.Afraid, 2.Agitated, 3.Angry, 4.Anxious, 5.Mood change, 6.Noisy, 7.Restless, 8.Withdrawn/ crying, 9.Crying, 10.combative, 11.___ every shift dated 9/28/2021 Review of Resident #3's December 2022 MAR failed to reveal adequate monitoring of Resident #3 behaviors and side effects for an antipsychotic medication. Review of Resident #3's December 2022 MAR with S2 ADON/ Interim DON failed to reveal adequate monitoring of behaviors, side effects, and interventions of antipsychotic medications. During an interview on 1/9/2023 at 3:00 PM S2 ADON/Interim DON confirmed Resident #3 behaviors, side effects and interventions were not monitored adequately for antipsychotic medication. During an interview on 1/9/2023 at 3:00 PM S3 Corporate Nurse confirmed Resident #3 behavior monitoring and interventions were not monitored adequately using the number coded guidance for antipsychotics medications. Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease unspecified, transient cerebral ischemic attack unspecified, essential hypertension, anxiety disorder, unspecified dementia, and anxiety. Review of Resident #4's physician orders revealed an 11/3/2022 order for Seroquel tablet 25mg (Quietiapine Fumarate) Give 1 tablet by mouth two times a day related to anxiety disorder, unspecified dementia, unspecified psychotic disturbance, mood disturbance, and anxiety. Review of Resident #4's December 2022 MAR revealed Resident #4 had received Seroquel Tablet 25mg-1 tablet by mouth two times a day throughout December 2022. Further review of the December 2022 MAR failed to reveal monitoring for antipsychotic medication side effects and behaviors had been conducted. During an interview on 1/9/2023 at 4:17 PM S2 ADON/Interim DON reviewed Resident #4's December 2022 MAR and reported monitoring for antipsychotic side effects and behaviors had not been conducted for Resident #4 and should have been. Review of Resident #5's medical record revealed Resident #5 had diagnoses that included metabolic encephalopathy (11/5/2022), cognitive communication deficit (3/22/2021), and Alzheimer's dementia (9/22/2020). Review of Resident #5's November 2022 Physician Orders revealed the following: Quetiapine Fumarate tablet 25 mg; Give 2 tablets by mouth at bedtime r/t unspecified dementia, unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 12/22/2022 Review of Resident #5's December 2022 MAR failed to reveal monitoring for behaviors, effectiveness and side effects for antipsychotic medication. During an interview on 1/9/2023 at 2:30 PM S4 LPN (Licensed Practical Nurse) confirmed Resident #5 received antipsychotic medications and should have been monitored for behaviors, side effects and effectiveness of antipsychotic medications. During an interview on 1/9/2023 at 3:40 PM S2 ADON/ Interim DON confirmed Resident #5 received antipsychotic medications and should have monitored for behaviors, side effects and effectiveness of antipsychotic medications. 3. Review of Resident #5's face sheet revealed medical diagnoses: Metabolic encephalopathy (11/5/2022) Review of Resident #5's November 2022 Physician Orders revealed the following: -cbc (complete blood count), cmp (comprehensive metabolic panel), Vitamin D, B12, Depakote: October and April every 6 months starting on the 12th dated 10/9/2022 -Depakote tablet delayed release 250 mg (Divalproex sodium): Give 1 tablet by mouth one time a day for dementia dated 6/12/2022 Review of Resident #5's medical record including scanned miscellaneous documents failed to reveal Resident #5 lab was obtained for cbc, cmp, Vitamin D, B12, and Depakote. During an interview on 1/9/2023 at 2:00 PM S1 Administrator confirmed lab (cbc, cmp, Vitamin, D, B12, Depakote) were not obtained as ordered by physician.

Based on record review and interview the facility failed ensure risk for falls had been assessed for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. Facility failed to ensure a Fall Risk Assessment had been conducted quarterly for Resident #2. Findings: Review of Fall Prevention Program Policy (updated 7/20/21) revealed: Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. Definition A fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident falls off any apparatus/equipment used for transfers. Procedure 1. All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall and upon significant change in condition. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included Pick's Disease, aphasia, anxiety disorder, recurrent depressive disorders, dementia with other behavioral disturbance, essential hypertension, and other chronic pain. Review of Resident #2's 9/7/2022 Quarterly MDS (Minimum Data Set) revealed BIMS (Brief Interview Mental Status) was not conducted as resident is rarely/never understood. Further review of the MDS revealed Resident #2 was total dependence and required one person physical assist for bed mobility and toilet use and was total dependence and required two+ person physical assist with transfers. Review of Resident #2's Care Plan revealed Resident #2 was at risk for falls related to balance problems, poor communication/comprehension, psychoactive drug use, and unaware of safety needs. Review of Resident #2's medical record failed to reveal a Fall Risk Assessment had been conducted since a 2/17/2022. The 2/17/2022 Fall Risk Assessment revealed Resident #2 was at moderate risk for falling. During an interview on 1/9/2023 at 2:15 S1 Administrator reviewed Resident #2's medical record and reported quarterly Fall Risk Assessment had not been conducted since 2/17/2022 when Resident #2 had a prior fall and Fall Risk Assessments should have been conducted quarterly.

Based on record review and interviews the facility failed to adequately monitor 1 (#2) of 5 (#2, #9, #30, #37, and #53) residents reviewed for unnecessary medications. The facility failed to provide monitoring for 1 (#2) resident for [CONDITION(S)] and side effects related to diuretic medication prescribed by the physician. Findings: Review of Medical Record revealed Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -1/13/22 [MEDICATION(S)] tablet 20mg (milligram) give 1 capsule by mouth one time a day for [CONDITION(S)]. (Discontinued 1/21/22) -1/21/22 [MEDICATION(S)] tablet give 10mg by mouth one time a day every other day for bilateral lower extremity [CONDITION(S)]. Review of Resident #2's Care Plan revealed: -1/21/22 [MEDICATION(S)] as ordered, monitor/document/report changes in lung sounds on auscultation (i.e. crackles), [CONDITION(S)] and changes in weight. -Potential for fluid deficit related to lower extremity [CONDITION(S)] ([MEDICATION(S)]) with interventions that included, in part administer medications as ordered, monitor/document for side effects and effectiveness, notify Medical Doctor of significant abnormalities. Review of Resident #2's January 2022 MAR (medication administration record) revealed administration of [MEDICATION(S)] 20mg give 1 capsule by mouth one time a day for [CONDITION(S)] was administered with no monitoring for [CONDITION(S)] conducted. Review of Resident #2's January 2022 and February 2022 MARs further revealed administration of [MEDICATION(S)] 10mg give 10mg by mouth one time a day every other day for bilateral lower extremity [CONDITION(S)] was administered with no monitoring for [CONDITION(S)] conducted. During an interview on 2/16/22 at 11:40 AM, S2 ADON (Assistant Director of Nursing) reviewed Resident #2's January 2022 and February 2022 MARs and reported [MEDICATION(S)] had been administered to Resident #2 and monitoring for [CONDITION(S)] had not been conducted and should have. During an interview on 2/16/22 at 12:35pm S1 DON (Director of Nursing) reviewed Resident #2's MAR and reported monitoring for [CONDITION(S)] was not completed for Resident #2 who was receiving [MEDICATION(S)] and should have been.

FACILITY Environment Based on observations and interviews the provider failed to ensure the facility's call bell system was working properly. This deficient practice had the potential to affect all 56 residents that resided in the facility. Findings: Observation on 2/16/22 at 1:25 PM in room Resident #40 lying in bed in room A with food particles smeared on her gown. Resident #40's call bell was blinking inside of the room. During an interview on 2/16/22 at 1:26 PM, Resident #40 indicated she had pressed her call bell button and had been waiting for a good while to be cleaned up. During an interview on 2/16/22 at 1:38 PM, S4 RA (Restorative Aide) indicated that she came to remove a splint that was on Resident #37 who also resides in room A. S4 RA was notified that Resident #40's call light was blinking in the room. During an interview on 2/16/22 at 1:40 PM, S4 RA reported there should be beeping at the nurse's station when a call bell was used. S4 RA was asked to push the call bell that Resident #40 was using. Observation on 2/16/22 at 1:42 PM revealed S3 LPN (licensed practical nurse) was at the front nurse's station and no audible sound was noted. During an interview on 2/16/22 at 1:43 PM, S3 LPN was asked if a call bell was going off and S3 LPN looked at a computer screen in front of him and indicated that a call bell was on in room A. S3 LPN was asked if there should be an audible noise at the nurse's station when a call bell is used. S3 LPN indicated there is and he pulled a speaker out that was behind the computer screen and turned the speaker on an the an audible repetitive beeping was noted. S3 LPN was asked why the speaker was not on before he turned it on and S3 LPN indicated if the speaker was on he would have to hear the beeping all day. During an interview on 2/16/22 at 1:45 PM, S1 DON (Director of Nursing) was notified that the speaker for the audible beeping for call bells was not turned on and S3 LPN reasoning for the speaker not being on was because he would have to hear the beeping all day. S1 DON indicated that the audible sound should have been on and audible. Observation on 2/16/22 at 1:50 PM revealed the call bells in room B were not working at all. During an interview with an observation on 2/16/22 at 1:51 PM, S1 DON was asked to observe the call bells in room B, S1 DON verified that the call bells were not working in room B after the observation. During an interview with observation on 2/16/22 at 1:52 PM, S1 DON was asked to come to nurse's station that was closest to room B. S1 DON was asked if she noted an audible beep at the nurse's station with the call bells that were pressed in the other rooms of the same hall room B is in, S1 DON verified there was not an audible noise while the call bells were active. S1 DON then verified that the speaker that should be working was not on and after the speaker was turned on the noise was very static and the beeping was hardly audible due to the static noise. During an interview on 2/16/22 at 2:05 PM, S6 Maintenance and S7 Regional Maintenance Director verified the call bells in room B were not working due to the battery being dead for the call bells to work. During an interview on 2/16/22 at 2:15 PM, S1 DON indicated she had questioned S3 LPN about the speakers being turned off and S3 LPN indicated to S1 DON and S8 Regional Director that he would have to listen to the beeping all day. S1 DON was asked if the residents in room B were able to press the call bell if they needed assistance and she indicated that Resident #53 was able to press the call bell for assistance. Observation on 2/16/22 at 2:28 PM revealed Resident #53 sitting at a table during an activity and the resident was opening up a box of puzzle pieces to do the activity, she was also taking a drink that was in an open glass. During an interview on 2/16/22 at 2:30 PM, Resident #53 indicated that she is able to use her call bell in her room.

Based on record review and interview the facility failed to ensure care plan meetings were conducted quarterly for 1 (#41) of 31 sampled residents. Findings: Review of medical record revealed Resident #41 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/14/22 at 3:45pm Resident #41 reported the facility quit doing quarterly care plan meetings when COVID started. Review of Resident #41's medical record revealed Care Plan Conference on 7/15/21 only. No other Care Plan Conference documents were found for 2021. During an interview on 2/15/22 at 3:45pm S5 Social Services provided Resident #41's Care Plan Conference documentation for 2021 which included 4/20/21 and 7/15/21 and reported Care Plan conferences were not conducted each quarter and should have been.

Based on record review and an interview the facility failed to ensure a physician order [REDACTED].#43) of 4(#6, #33, #41, #43) residents that were reviewed for nutrition. The facility failed to complete weekly weights for Resident #43 as ordererd by physician for the month of October 2020. Findings: Record review of Resident #43's current physician's orders [REDACTED]. - Weekly weights for four weeks, every day shift on Monday until 10/26/2020 (Start date 10/5/2020). Record review of Resident #43's weights failed to reveal recorded weights for the month of October 2020. During an interview on 10/22/2020 at 10:20am S2 ADON (Assistant Director of Nursing) confirmed Resident # 43's weekly weights were not completed as ordered for the month of October 2020.

Based on observations and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain proper grooming and personal hygiene for 2 of 2 (#33, #30) residents reviewed for activities of daily living. Findings: Resident #33 Observation on 10/20/2020 at 1:30 pm revealed resident #33's fingernails on both hands protruded past nail beds and had brown colored residue under each nail. Review of resident #33's Comprehensive Plan of Care revealed the problem of Resident has an ADLS (activities of daily living) self-care performance deficit related to dementia and bilateral above the knee amputation with an intervention of total dependence for ADLS and nail care as needed. During an interview on 10/21/2020 at 10:15 am resident #33 stated, I don't mind my nails being cut; I just want some left to scratch with, just trim don't cut them down to the skin. During an interview on 10/21/2020 at 11:20 am S6LPN (License Practical Nurse) confirmed resident #33's nails had not been trimmed. S6LPN further confirmed resident #33 should have had nail care done. Resident #30 Observation on 10/19/2020 at 10:03 am revealed Resident #30's toe nails were very long and had grown over the nail bed. Observation on 10/21/2020 at 2:30 pm with S6LPN revealed Resident #30's toe nails were very long and had grown over the nail bed. Review of Care Plan revealed Resident #30 was at risk for ADL (Activities of Daily Living) self-care performance deficit and loss of ROM related to muscle weakness, history of [MEDICAL CONDITION], lack of coordination with approaches for nail care as needed. During an interview on 10/19/2020 at 10:03 am Resident #30 stated her toe nails were long and had not been trimmed in a while. During an interview on 10/21/2020 at 12:30 pm S6LPN stated nail care is done along with ADL (Activity of Daily Living) and for residents that have diabetes the nurse or wound care would perform nail care. During an interview on 10/21/2022 at 2:30 PM S6LPN confirmed Resident #30 toe nails were long and should have nail are done.

Based on observations, interviews and record reviews the facility failed to ensure necessary care and services had been provided in accordance with professional standards of practice, and a resident's choices for 1 (#7)of 5 ( #7, #30, #33, #40 and #48 ) residents reviewed for ADL's (Activities of Daily Living) and repositioning. Findings: Review of resident # 7's clinical records revealed [DIAGNOSES REDACTED]. During an interview on 10/22/2020 at 10:30 AM resident #7 expressed she felt so much better being out of bed and sitting up in the wheelchair. She confirmed she was hoping they would be able to roll her to the door so she could see her daughter. Review of resident #7 most recent MDS (Minimum Data Set) dated July 23, 2020: Section C- Cognitive Pattern: BIMS (Brief Interview of Mental Status) Score of 15 (cognitive intact) Section E- Behavior, Rejection of Care coded as (0) behavior not exhibited. Review of resident 7's Plan of Care revealed the following problems with some of the objectives: 1. Skin Break down, potential for, related to [DIAGNOSES REDACTED]. Some approaches are administer meds as ordered. Assist reposition with INC (incontinence care) rounds as tolerated. Braden every quarter and prn. Cleanse perineal area with soap and water following INC episodes 2. Altered bowel elimination AEB I am incontinent of bowel. Some approaches are allow much privacy and quiet environment as possible for bowel evacuation. Encourage intake of fluids. 3. Loss of ROM (range of motion) AEB (as evidenced by). I have a [DIAGNOSES REDACTED]. Some approaches are consult PT (physical therapy)/OT (occupational therapy) when/if change in present ROM(range of Motion) change occurs. Encourage and assist with PROM (passive range of motion)/AROM (assistive range of motion) during care. 4. Requires extensive assist of one with bed mobility. Some approaches are assist with dressing; ensure clothing is clean, in good repair and seasonally appropriate. Assist/encourage oral care bid and prn. Bed bath/shower Tuesday/Thursday/Saturday, sponge bath on alternate days and prn. Encourage and assist with AROM/PROM with care. I require use of mechanical lift and two staff for transfers. I use a w/c for my mobility needs when out of bed- I prefer to stay in bed most days. Apply moisture barrier after INC care. Weekly body audit per protocol. 5. Urinary continence altered AEB, I am always incontinent of bladder. Some approaches are I do not wear briefs. I use a bed pan at times. Observation on 10/19/2020 at 11:00 AM resident #7 awake and alert lying flat on her back in bed. Resident #7 had gray thick curly facial hair on her chin and jawline. Food crumbs were on resident #7's bed linens and on her chest area while she was still in bed. During an interview on 10/19/2020 at 11:00 AM resident #7 confirmed she had not been bathed today. Resident #7 confirmed she did not know the last day she had a bath. Observation on 10/19/2020 at 2:16 PM resident #7 remained in bed in the same position. Food crumbs still remained on resident #7's bed linens and gown. During an interview on 10/19/20 at 2:16 PM resident #7 complained of pain and discomfort to her left foot, buttocks and a headache. Resident #7 confirmed staff does not get her out of bed. Resident #7 confirmed staff had told her she was too big, the lift is not working or the lift is broken. Resident #7 stated she does not know the last time she had been out of the bed. Resident #7 confirmed she would love to get out of bed. Observation on 10/19/2020 at 2:30 PM when S7LPN (License Practical Nurse) came into resident #7 room and asked what was wrong. Resident #7 told S7LPN she had left foot, buttock pain and a headache. S7LPN explained to resident #7 she had her pain med [MEDICATION NAME] at around 8:45 am, she confirmed she could not have anything else. Surveyor asked if resident #7 had anything for breakthrough pain and if she gets out of bed. S7LPN confirmed resident #7 did not have medication for breakthrough pain. S7LPN confirmed resident #7 is not gotten out of bed. S7LPN indicated she would phone the Nurse Practitioner and get an order to give her some Tylenol. Observation on 10/19/2020 at 2:35 PM revealed S8CNA (Certified Nursing Assistant) entered resident #7's room she indicated she was going to check and see if resident #7 was wet. Observation of resident #7's skin was done at this time while she was being changed by S8CNA. Observation revealed resident #7's left foot and leg, left arm and left hand very swollen. Extremities were not elevated. Resident 7's lower legs and feet dry and scaly, skin unopened. Observation of resident #7's skin to her buttock pink granulated tissue. Observation on 10/20/2020 at 9:15 AM resident #7 in bed asleep, positioned flat in bed on her back. Observation 10/20/2020 at 11:30 AM resident #7 awake and alert in bed positioned flat on her back. Observation on 10/20/2020 at 12:30 PM revealed Resident #7 awake and alert in bed positioned flat on her back. Resident #7 had food crumbs on herself, bed linens and in her bed. Observation on 10/21/2020 at 9:25 AM resident #7 lying flat in bed waiting for assistance after turning on her call light. Resident #7 confirmed she was wet and needed to be changed. Resident #7 confirmed she had an adult diaper on she stated staff do not fasten it. Resident #7 still had the facial hair, asked if she like it, she stated no. She confirmed S12CNA is the only CNA that will keep the hair shaved off her face. Resident #7confirmed she had a large wheel chair when she came here she doesn't know what happen with it. Resident #7 indicated she would ask some of the CNAs if she could use the bedpan and she was refused. During an interview on 10/21/2020 at 9:35 am S13Restorative CNA confirmed resident # 7 haven't been up out of bed in a while. She confirmed when she use to work with resident #7 all the time it takes 2 people to get her up in the lift. Observation on 10/21/2020 at 9:50 AM body audit done with S12CNA and S14CNA. Observation revealed pink granulated tissue on resident #7's buttock, small open areas to right side of buttocks, coccyx area and upper dorsal side of left thigh area. During an interview on 10/21/2020 at 9:50 AM S12CNA confirmed it had been a year since resident #7 had been up in a wheelchair. She confirmed she did not know where resident #7's wheelchair was. S12CNA confirmed resident #7 had not been up out of bed in a years. S12CNA confirmed the other CNAs will not shave the hair from resident #7's face. S12CNA confirmed resident #7 left arm and leg should be elevated on a pillow due to the [MEDICAL CONDITION]. During an interview on 10/21/2020 at 11:30 am S15LPN confirmed resident #7 had not been up out of bed in a wheel chair for months. S15LPN confirmed resident #7 never gets up out of bed due to her complaint of pain. During an interview on 10/21/2020 at 12:30 PM S6Infection Control Prevention (interim wound care nurse) confirmed and presented the most recent skin-wound, total body skin assessment date 10/15/2020. S6Infection Control Prevention Nurse confirmed resident #7 did not have any open wounds. S6Infection Control Prevention Nurse confirmed if the CNAs noted any open wounds they would notify the nurse. During an interview on 10/21/2020 at 12:30 PM S2ADON (Assistant Director of Nursing) confirmed the last time she can remember resident #7 being out of bed was not this past Thanksgiving but he Thanksgiving before that, about 2 years. S2ADON confirmed she is in resident #7's room all the time and she has never told her she wanted to be out of bed. Surveyor asked for documentation of resident #7 refusing care and other measures that had been used. During an interview on 10/21/2020 at 1:30 PM S1DON (Director of Nursing) confirmed resident #7 had been known to tell stories. S1DON stated I am in that room all the time and if resident #7 wanted to get up we would have gotten her up. S1DON confirmed they did not have documentation of resident #7 refusing care. During an interview on 10/21/2020 at 3:00 PM S1DON confirmed resident #7 did have 2 open areas to her buttocks that was not there during the previous skin assessment. S1DON confirmed if the CNAs had seen the open areas on resident #7 buttocks it should have been report to a nurse. . .

Based on observations, interviews, record reviews, and review of the facility's Policy and Procedures the facility failed to ensure adequate supervision was provided for 1(#1) of 5 ((#1, #2, #3, #4, #5) sampled residents who were determined to be at risk for elopement out of a total sample of 16 residents residing in the facility who were determined to be at risk for elopement. The facility failed to have a system in place to: 1. Ensure that all staff was aware of all residents at risk for elopement; 2. Ensure staff supervised and assisted Resident #1 back into the facility after he went out of a secure door that alarmed; 3. Ensure staff followed the facility's policy for Resident Elopement related to the provision of adequate supervision of residents. The Immediate Jeopardy began for Resident #1 on 10/11/17 at 1:00 p.m. when he was knowingly left unattended outside the facility. The LPN (Licensed Practical Nurse) was aware Resident #1 followed the Fed Ex man out the door. She asked two CNAs (Certified Nursing Assistants) to stay with the resident and they said that they could not. The LPN closed the door leaving the resident outside. The LPN checked on Resident #1 approximately 30 minutes later and discovered Resident #1 was missing from the facility's grounds. The facility is located in a rural area and is surrounded by trees and bushes. The resident was found on 10/12/17 at approximately 9:30 a.m. in some bushes lying in a ditch. Resident #1 was transported to a local hospital where he was admitted for treatment of [REDACTED]. S1Administrator and S2DON (Director of Nursing) were notified on 10/16/17 at 4:20 p.m. of the Immediate Jeopardy situation regarding the elopement of Resident #1 that began on 10/11/17 at 1:00 p.m. The Immediate Jeopardy was removed on 10/17/17 at 1:00 p.m. when the Administrator provided a plan of removal which reads as follows: A. The three identified staff members who left the resident unattended without bringing him to safety have been addressed and appropriate training provided to prevent recurrence. B. Staff have been inserviced on the facility's procedures on wander prevention to ensure that all 15 residents who are at risk remain safe. Staff, who was unable to be reached, will be trained before being able return to work. A review, has been completed on all current residents at risk to ensure that all have appropriate measures in place to remain safe, and staff has been informed about plans. The aforementioned review entailed checking the wander guard system, bracelets and identifying logos outside of resident rooms. C. ADON (Assistant Director of Nursing) or designee will review wandering documentation routinely to ensure that interventions are in place and appropriate for residents at risk. All Staff will be informed of resident changes that would place them at risk for being wanderers. All employees will be informed of specific resident changes and training will be provided to staff before working their assigned shifts. ADON or designee will ensure that all appropriate documentation and updates have been completed to reflect resident current status. D. The DON or designee will review documentation monthly to ensure continued compliance. Results of this review will be discussed with QA (Quality Assurance) Team monthly. The QA team will provide feedback as the team deems appropriated to meet the resident's needs. The deficient practice remains at a level of harm for Resident #1 and at a potential for more than minimal harm for the remaining 15 residents. Findings: Review of the facility's Resident Elopement Policy (May 2001) revealed the following: Standard: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All resident will be assessed for behaviors or conditions that may place them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility: All staff is responsible to ensure resident safety. Further review of the Facility's Incidents and Accidents Prevention System Policy revealed: 10. An Elopement Binder will be maintained in a centrally located nurse's station. A duplicate Elopement Risk Binder will be kept in the DON/designee office. Both Elopement Risk binders will contain a current picture of the resident and a current face sheet. Review of Resident #1's Facility Face Sheet revealed he was admitted to the Nursing Home facility on 8/28/17 with the following Diagnoses: [REDACTED]. Review of Resident #1's MDS dated [DATE] revealed the following: Section C Cognitive Pattern: BIMS (Brief Interview for Mental Status) Score 12 (00-15) which is moderately impaired. Section E Behavior: Wandering - Presence and Frequency (behavior did not occur in the 7 day look back period). Review of Resident #1's Hospital Discharge Summary at the time of admitted d 8/25/17 revealed the following: Family reports the patient has been wondering away from home and getting lost. Family further reports resident has been showing signs of dementia. Patient apparently has been walking out of the house at night in the middle of the night leaving the doors open. He'd become lost after walking from home and was found down on the side of the road several times after walking for several hours. Review of Resident #1's Care Plan revealed the following problems/approaches: I have potential to wander into unsafe situations, wandered prior to arrival, requires WanderGuard - place me in an area where frequent observation is possible, place monitoring device on me that sounds alarms when I leave the building, check function as ordered, alert staff to my wandering behavior, provide diversional activities for me as needed, approach me positively and in calm, accepting manner, if I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them, observe and document my behavior. Review of Resident #1's physician progress notes [REDACTED]. Resident #1 was admitted here after a brief hospital stay when he was brought in by family for mental status changes, confusion and inability to function on his own apparently becoming lost and walking around the neighborhood at all hours of the night and occasionally starting fires in his kitchen in his attempts to cook . Review of Resident #1's Initial Social Service History form dated 8/29/17 revealed the following: Family states resident has been wandering off and having periods of confusion and could no longer live alone. Review of Resident #1's Physician order [REDACTED]. 8/29/17 WanderGuard to lower extremity to prevent elopement; monitor for placement every shift. 8/29/17 WanderGuard function test QWeek to assure proper working order and check expiration date. Review of Resident #1's Nursing Notes revealed the following: 10/11/17 6:14 p.m. Around 1:00 p.m. today the alarm to the front door sounded so I went to check it and realized the Fed Ex man let Resident #1 out. I went after him and ran into S5 CAN and S4 CNA and asked them to lead him back into the building. At that time, they informed me that he sits outside by himself all the time. About 30 minutes later, I went to check on him and he was gone. I alerted the rest of the staff and we all searched the entire grounds. During this time the family and police departments of (town) and (neighboring town) were notified as well as (local hospital). Afterwards several employees got into their vehicles and searched all around (town) for him with no luck S3 LPN 10/12/17 .resident found by another staff member and 911 was called and resident was transported to .(local hospital) ER for evaluation .Family notified .S16 Social Services Director Review of Resident #1's Hospital Record revealed Resident #1 was admitted on [DATE] at 9:54 a.m. with a [DIAGNOSES REDACTED]. Resident #1's Total CK (Creatine Kinase) Level on admission was >1000 unit/liter (normal range 52 - 336 units/liter). Chief Complaint: Patient found in bushes in a ditch. Missing from Nursing Home since yesterday afternoon. History of Present Illness: 63 y/o male nursing home patient with past medical history of [REDACTED]. Patient was found this morning, approximately 20 hours since his departure complaint of being cold and hungry. Patient was admitted through the Emergency Department after patient was found to have a severely elevated CPK. Patient has no obvious signs of trauma. Patient is cold to touch with an initial temperature of 36.6 C at time of arrival. Patient was warmed with a bear hugger and had intravenous normal saline initiated before being admitted to the floor. Observation on 10/16/17 at 9:00 a.m. the facility's Main West and Main South entrances opened without a code being entered. Observation on 10/16/17 at 9:20 a.m. the door to the smoking patio (Holland Hall) was locked. Observation on 10/16/17 at 11:00 am with S15 Maintenance Supervisor revealed the following: Main West, Main South and Holland (smoking area) exit doors would lock when Wanderguard was in immediate proximity and alarms were activated if the doors were open and the Wanderguard was in immediate proximity of the doorways. The kitchen, Ewall and Patterson hallways had locked and secure doorways with coded keypad locking mechanisms. During an interview on 10/16/17 at 11:30 a.m. S2DON stated during her investigation S3LPN (Licensed Practical Nurse) stated she heard the door alarm go off when a delivery driver exited the building. S2DON stated S3LPN reported Resident #1 followed the delivery driver out the door. S2DON further stated S3LPN saw S4CNA and S5CNA walking back into the building and the CNAs said Resident #1 was allowed to be outside unsupervised. S2DON acknowledged S3LPN, S4CNA and S5CNA did not follow the facility policy for supervision of residents at risk for elopement. S2DON stated Resident #1 should not have been left outside unsupervised. During an interview on 10/16/17 at 11:50 a.m. S3LPN stated she heard the door alarm go off and went to the door and saw Resident#1 had exited through the door. S3LPN stated she saw S4CNA and S5CNA returning into the building from lunch and she asked them to bring Resident #1 back inside the building. S3LPN stated S4CNA and S5CNA stated Resident #1 is outside all the time by himself. S3LPN stated she depends on the nursing assistant's in dealing with residents. S3LPN stated she then closed the door and left Resident #1 outside alone. S3LPN stated normally residents at risk for elopement are not allowed outside by themselves. S3LPN stated the Resident #1 is mainly at the facility due to being confused. S3LPN stated it was her responsibility to assess whether a resident is at risk for elopement. S3LPN stated she had seen Resident #1 outside one other time but he was not alone. S3LPN stated she went outside to check on Resident #1 approximately 30 minutes after leaving him outside alone and discovered Resident #1 was missing from the facility grounds. S3LPN stated at that point the facility and grounds were searched for Resident #1 and he was not located. S3LPN stated Resident #1 had been in the facility for a little over a month and she cared for him since his admission. S3LPN acknowledged because Resident #1 was new to the facility he should have been monitored more closely and was not. S3LPN acknowledged the Resident #1 was Care Planned as an elopement risk and had a WanderGuard Bracelet in place. S3LPN stated she received training for residents at risk for elopement. S3LPN stated residents at risk for elopement were not allowed to go outside by themselves without a staff member or family member. S3LPN stated the CNAs rotate throughout the facility and should be aware of each resident's needs. During an interview on 10/16/17 at 12:00 p.m. S8CNA stated she was in-serviced on the facility policy for residents at risk for elopement. S8CNA stated for new residents the nurses will verbally tell the CNAs if the resident has a WanderGuard in place or is at risk for elopement. S8CNA stated it is not always communicated to the CNA if residents are at risk for elopement or have WanderGuards in place. S8CNA stated CNAs sometimes only become aware during resident care when they see the WanderGuard in place or if they hear the door alarm go off when the resident gets close to it. During an interview on 10/16/17 at 12:12 p.m. S4CNA stated she was working the day Resident #1 eloped from the facility. S4CNA she was returning from her lunch break when S3LPN said you're not going to bring him (Resident #1) back inside the building. S4CNA stated she was not aware Resident #1 was an elopement risk with a WanderGuard bracelet in place. S4CNA stated she told S3LPN that she was going to clock back in from lunch and do her last round. S4CNA stated residents at risk for elopement with WanderGuard bracelets in place are not allowed to go outside without a staff or family member. S4CNA stated S5CNA stated Resident #1 comes out in the mornings on his own. S4CNA stated CNAs (Certified Nursing Assistants) are not always told when residents are at risk for elopement or have a WanderGuard bracelet in place. S4CNA stated when she approached the building Resident #1 was already outside the building and S3LPN was standing in the doorway. S4CNA stated she did not know Resident #1 was not allowed to be outside on his own. S4CNA stated after Resident #1's elopement, she has not received any training regarding resident elopement. During an interview on 10/16/17 at 12:15 p.m. S8CNA stated he was in-serviced on the facility policy for WanderGuards after Resident #1 eloped. S8CNA stated the nurses usually let the CNA know if a new resident is admitted with a WanderGuard in place or is at risk for elopement. During an interview n 10/16/17 at 12:18 p.m. S7CNA stated sometimes the CNAs find out the resident has a WanderGuard in place during care or if the door alarm goes off. During an interview on 10/16/17 at 12:30 p.m. S5CNA stated she was working the day Resident #1 eloped. S5CNA stated she was coming back from lunch and was stopped by S3LPN to see if she could watch Resident #1. S5CNA stated she told S3LPN she could not watch Resident #1 she had to make her last rounds and clock out. S5CNA stated she did not know Resident #1 was an elopement risk and had a WanderGuard bracelet in place. S5CNA stated she told S3LPN she was unaware Resident #1 was an elopement risk because she had seen Resident #1 outside alone before. S5CNA stated the nurse was aware she and S4CNA were coming back in the building and Resident #1 was outside alone. S5CNA stated when herself and S4CNA entered the building S3LPN remained in the doorway and Resident #1 remained unattended outside. S5CNA stated CNAs are not informed when WanderGuard bracelets are placed, the CNAs sometimes find the WanderGaurd on the patient during care or hear the alarm go off when the residents approach an exit. S5CNA stated the facility does not have a formal process in place to let CNAs know if a resident is at risk for elopement or has a WanderGuard in place. S5CNA stated staff was in-serviced the next day after Resident #1 eloped. S5CNA stated she had not worked with Resident #1 in the past. S5CNA stated during the in-service residents that wander were not identified. S5CNA stated a nurse had never asked her if it was okay for a resident to go outside alone, she stated the nurse would determine if the resident could go outside. S5CNA stated she works with female residents and had never worked with Resident #1. S5CNA stated the in-service went over the policy for wandering residents and the staff were not made aware of the residents that wander or were at risk for elopement. During an interview on 10/16/17 at 4:20 p.m. S2DON acknowledged six employees worked after Resident #1's elopement without being In-Serviced on the following facility policies: Elopement and Supervision of Residents at Risk; Incident and Accident Prevention System. S2DON acknowledged the employees that worked without being In-Serviced were S9CNA, S10CNA, S11Dietary Worker, S12Dietary Worker, S13Dietary Worker and S14Dietary Worker. During an interview on 10/17/17 at 11:10 a.m. S6Interim Administrator, stated she was in the facility the day Resident #1 eloped. S6Interim Administrator stated she was in the Director of Nursing's office when S3LPN reported Resident #1 was missing from the facility. S6Interim Administrator stated facility staff immediately started searching the building and grounds for Resident #1. S6Interim Administrator further stated the police and fire department were notified. S6Interim Administrator stated she was not aware of any other elopements at this facility. S6Interim Administrator stated S3LPN said Resident #1 followed the delivery driver out the door and the alarm sounded. S6Interim Administrator stated S3LPN did not say why the resident was not immediately brought back in to the facility. S6Interim Administrator stated Resident #1 should have been brought back into the facility immediately. S6Interim Administrator stated any resident with at risk for elopement should not be allowed outside on their own. S6Interim Administrator stated staff in-servicing was started to ensure the incident did not happen again.

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that used resources effectively and efficiently for (#1) of 5 (#1, #2, #3, #4, #5) sampled residents who were determined to be at risk for elopement out of a total sample of 16 residents currently residing in the facility who were determined to be at risk for elopement. The facility further failed: 1. Failed to ensure a system was in place to identify residents at risk for elopement. 2. Ensure Resident #1 was free from neglect by failing to supervise/monitor him when he was outside the building. 3. Ensure that all staff was aware of residents at risk for elopement. 4. Ensure staff supervised and assisted Resident #1 back into the facility after he went out of a secure door that alarmed. 5. Ensure staff followed the facility's Policy for Resident Elopement for residents at risk of elopement. 6. Ensure all staff was trained to identify which residents were at risk of elopement. The Immediate Jeopardy began for Resident #1 on 10/11/17 at 1:00 p.m. when he was knowingly left unattended outside the facility. The LPN (Licensed Practical Nurse) was aware that resident #1 followed the Fed Ex man out the door. She asked two CNAs (Certified Nursing Assistants) to stay with the resident and they told her that they could not. The LPN closed the door leaving the resident outside. The LPN checked on Resident #1 approximately 30 minutes later and discovered Resident #1 was missing from the facility's grounds. The facility is located in a rural area and is surrounded by trees and bushes. The resident was found on 10/12/17 at approximately 9:30 a.m. in some bushes lying in a ditch. Resident #1 was transported to a local hospital where he was admitted for treated for [REDACTED]. S1Administrator and S2DON (Director of Nursing) were notified on 10/16/17 at 4:20 p.m. of the Immediate Jeopardy situation regarding the elopement of Resident #1 that began on 10/11/17 at 1:00 p.m. The Immediate Jeopardy was removed on 10/17/18 at 1:00 p.m. when the administrator provided a plan of removal that reads as follows: A. The three identified staff members who left the resident unattended without bringing him to safety have been addressed and appropriate training provided to prevent recurrence. B. Staff have been inserviced on the facility's procedures on wander prevention to ensure that all 15 residents who are at risk remain safe. Staff, who was unable to be reached, will be trained before being able return to work. A review, has been completed on all current residents at risk to ensure that all have appropriate measures in place to remain safe, and staff has been informed about plans. The aforementioned review entailed checking the wander guard system, bracelets and identifying logos outside of resident rooms. C. ADON (Assistant Director of Nursing) or designee will review wandering documentation routinely to ensure that interventions are in place and appropriate for residents at risk. All Staff will be informed of resident changes that would place them at risk for being wanderers. All employees will be informed of specific resident changes and training will be provided to staff before working their assigned shifts. ADON or designee will ensure that all appropriate documentation and updates have been completed to reflect resident current status. D. The DON or designee will review documentation monthly to ensure continued compliance. Results of this review will be discussed with QA (Quality Assurance) Team monthly. The QA team will provide feedback as the team deems appropriated to meet the resident's needs. The Immediate Jeopardy was lifted on 10/17/17 at 1:30 p.m. The deficient practice remains at a level of harm for Resident #1 and a potential of more than minimal harm for the remaining 15 residents at risk for elopement. Findings: 1. Cross refer to F223. 2. Cross refer to F323 Review of the facility's Resident Elopement Policy (May 2001) revealed the following: Standard: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All resident will be assessed for behaviors or conditions that may place them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility: All staff is responsible to ensure resident safety. Further review of the Facility's Incidents and Accidents Prevention System Policy revealed: 10. An Elopement Binder will be maintained in a centrally located nurse's station. A duplicate Elopement Risk Binder will be kept in the DON/designee office. Both Elopement Risk binders will contain a current picture of the resident and a current face sheet. During an interview on 10/16/17 at 11:30 a.m. S2DON stated during her investigation S3LPN (Licensed Practical Nurse) stated she heard the door alarm go off when a delivery driver exited the building. S2DON stated S3LPN reported Resident #1 followed the delivery driver out the door. S2DON further stated S3LPN saw S4CNA and S5CNA walking back into the building and the CNAs said Resident #1 was allowed to be outside unsupervised. S2DON acknowledged S3LPN, S4CNA and S5CNA did not follow the facility policy for supervision of residents at risk for elopement. S2DON stated Resident #1 should not have been left outside unsupervised. During an interview on 10/16/17 at 11:50 a.m. S3LPN stated she heard the door alarm go off and went to the door and saw Resident#1 had exited through the door. S3LPN stated she saw S4CNA and S5CNA returning into the building from lunch and she asked them to bring Resident #1 back inside the building. S3LPN stated S4CNA and S5CNA stated Resident #1 is outside all the time by himself. S3LPN stated she depends on the nursing assistant's judgement in dealing with residents. S3LPN stated she then closed the door and left Resident #1 outside alone. S3LPN stated normally residents at risk for elopement are not allowed outside by themselves. S3LPN stated the Resident #1 is mainly at the facility due to being confused. S3LPN stated it was her responsibility to assess whether a resident is at risk for elopement. S3LPN stated she had seen Resident #1 outside one other time but he was not alone. S3LPN stated she went outside to check on Resident #1 approximately 30 minutes after leaving him outside alone and discovered Resident #1 was missing from the facility grounds. S3LPN stated at that point the facility and grounds were searched for Resident #1 and he was not located. S3LPN stated Resident #1 had been in the facility for a little over a month and she cared for him since his admission. S3LPN acknowledged because Resident #1 was new to the facility he should have been monitored more closely and was not. S3LPN acknowledged the Resident #1 was Care Planned as an elopement risk and had a WanderGuard Bracelet in place. S3LPN stated she received training for residents at risk for elopement. S3LPN stated residents at risk for elopement were not allowed to go outside by themselves without a staff member or family member. S3LPN stated the CNAs rotate throughout the facility and should be aware of each resident's needs. During an interview on 10/16/17 at 4:20 p.m. S2DON acknowledged six employees worked after Resident #1's elopement without being In-Serviced on the following facility policies: Elopement and Supervision of Residents at Risk; Incident and Accident Prevention System. S2DON acknowledged the employees that worked without being In-Serviced were S9CNA, S10CNA, S11Dietary Worker, S12Dietary Worker, S13Dietary Worker and S14Dietary Worker. During an interview on 10/17/17 at 11:10 a.m. S6Interim Administrator, stated she was in the facility the day Resident #1 eloped. S6Interim Administrator stated she was in the Director of Nursing's office when S3LPN reported Resident #1 was missing from the facility. S6Interim Administrator stated facility staff immediately started searching the building and grounds for Resident #1. S6Interim Administrator further stated the police and fire department were notified. S6Interim Administrator stated she was not aware of any other elopements at this facility. S6Interim Administrator stated S3LPN said Resident #1 followed the delivery driver out the door and the alarm sounded. S6Interim Administrator stated S3LPN did not say why the resident was not immediately brought back in to the facility. S6Interim Administrator stated Resident #1 should have been brought back into the facility immediately. S6Interim Administrator stated any resident with at risk for elopement should not be allowed outside on their own. S6Interim Administrator stated staff in-servicing was started to ensure the incident did not happen again.

Based on observations, interviews and record reviews the facility failed to ensure a resident was free from neglect by failing to provide supervision/monitoring to 1 (#1) of 5 ((#1, #2, #3, #4, #5) sampled residents who were determined to be at risk for elopement out of a total sample of 16 residents residing in the facility who were determined to be at risk for elopement. The facility's failure resulted in actual harm. The Immediate Jeopardy began for Resident #1 on 10/11/17 at 1:00 p.m. when he was knowingly left unattended outside the facility. The LPN (Licensed Practical Nurse) was aware that Resident #1 followed the Fed Ex man out the door. She asked CNAs (Certified Nursing Assistants) to stay with the resident and they told her they could not. The LPN closed the door leaving the resident outside. The LPN checked on Resident #1 approximately 30 minutes later and discovered Resident #1 was missing from the facility's grounds. The facility is located in a rural area and is surrounded by trees and bushes. The resident was found on 10/12/17 at approximately 9:30 a.m. in some bushes lying in a ditch. Resident #1 was transported to a local hospital where he was admitted for treatment of [REDACTED]. S1Administrator and S2DON (Director of Nursing) were notified on 10/16/17 at 4:20 p.m. of the Immediate Jeopardy situation regarding the elopement of Resident #1 that began on 10/11/17 at 1:00 p.m. The Immediate Jeopardy was removed on 10/17/17 at 1:00 p.m. when the administrator provided a plan of removal which reads as follows: A. The three identified staff members who left the resident unattended without bringing him to safety have been addressed and appropriate training provided to prevent recurrence. B. Staff have been inserviced on the facility's procedures on wander prevention to ensure that all 15 residents who are at risk remain safe. Staff, who was unable to be reached, will be trained before being able return to work. A review, has been completed on all current residents at risk to ensure that all have appropriate measures in place to remain safe, and staff has been informed about plans. The aforementioned review entailed checking the wander guard system, bracelets and identifying logos outside of resident rooms. C. ADON (Assistant Director of Nursing) or designee will review wandering documentation routinely to ensure that interventions are in place and appropriate for residents at risk. All Staff will be informed of resident changes that would place them at risk for being wanderers. All employees will be informed of specific resident changes and training will be provided to staff before working their assigned shifts. ADON or designee will ensure that all appropriate documentation and updates have been completed to reflect resident current status. D. The DON or designee will review documentation monthly to ensure continued compliance. Results of this review will be discussed with QA (Quality Assurance) Team monthly. The QA team will provide feedback as the team deems appropriated to meet the resident's needs. The deficient practice continued at a level of harm for Resident #1 and a potential for more than minimal harm for the remaining 15 residents. Findings: Review of the facility's Resident Elopement Policy (May 2001) revealed the following: Standard: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All resident will be assessed for behaviors or conditions that may place them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility: All staff is responsible to ensure resident safety. Further review of the Facility's Incidents and Accidents Prevention System Policy revealed: 10. An Elopement Binder will be maintained in a centrally located nurse's station. A duplicate Elopement Risk Binder will be kept in the DON/designee office. Both Elopement Risk binders will contain a current picture of the resident and a current face sheet. Review of Resident #1's Facility Face Sheet revealed he was admitted to the Nursing Home facility on 8/28/17 with the following Diagnoses: [REDACTED]. Review of Resident #1's Initial Social Service History form dated 8/29/17 revealed the following: Family states resident has been wandering off and having periods of confusion and could no longer live alone. Review of Resident #1's physician progress notes [REDACTED].#1 was admitted here after a brief hospital stay when he was brought in by family for mental status changes, confusion and inability to function on his own apparently becoming lost and walking around the neighborhood at all hours of the night and occasionally starting fires in his kitchen in his attempts to cook . Review of Resident #1's Physician order [REDACTED]. 8/29/17 WanderGuard to lower extremity to prevent elopement; monitor for placement every shift. 8/29/17 WanderGuard function test QWeek to assure proper working order and check expiration date. Review of Resident #1's MDS dated [DATE] revealed the following: Section C Cognitive Patterns - BIMS (Brief Interview For Mental Status) Score 12 (00-15) which is moderately impaired. Section E Behavior: Wandering - Presence and Frequency (behavior did not occur in the 7 day look back period). Review of Resident #1's Care Plan revealed the following problems/approaches: I have potential to wander into unsafe situations, wandered prior to arrival, requires WanderGuard - place me in an area where frequent observation is possible, place monitoring device on me that sounds alarms when I leave the building, check function as ordered, alert staff to my wandering behavior, provide diversional activities for me as needed, approach me positively and in calm, accepting manner, if I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them, observe and document my behavior. Review of Resident #1's Nursing Notes revealed the following: 10/11/17 6:14 p.m. Around 1:00 p.m. today the alarm to the front door sounded so I went to check it and realized the Fed Ex man let Resident #1 out. I went after him and ran into S5 CNA and S4 CNA and asked them to lead him back into the building. At that time, they informed me that he sits outside by himself all the time. About 30 minutes later, I went to check on him and he was gone. I alerted the rest of the staff and we all searched the entire grounds. During this time the family and police departments of (town) and (neighboring town) were notified as well as (local hospital). Afterwards several employees got into their vehicles and searched all around (town) for him with no luck S3 LPN 10/12/17 .resident found by another staff member and 911 was called and resident was transported to .(local hospital) ER for evaluation .Family notified .S16 Social Services Director Review of Resident #1's Hospital Record revealed Resident #1 was admitted on [DATE] at 9:54 a.m. with a [DIAGNOSES REDACTED]. Resident #1's total CK ([MEDICATION NAME] Kinase) level on admission was greater than 1000 units/liter (normal range 52 - 336 units/liter). Chief Complaint: Patient found in bushes in a ditch, missing from nursing home since yesterday afternoon. History of Present Illness: [AGE] year old male nursing home patient with past medical history of [REDACTED]. Patient was found this morning approximately 20 hours since his departure complaint of being cold and hungry. Patient was admitted through the emergency department after patient was found to have a severely elevated CPK. Patient has no obvious signs of trauma. Patient is cold to touch with an initial temperature of 36.6 C at time of arrival. Patient was warmed with a bear hugger and had intravenous normal saline initiated before being admitted to the floor. During an interview on 10/16/17 at 11:50 a.m. S3LPN stated she heard the door alarm go off and went to the door and saw Resident#1 had exited through the door. S3LPN stated she saw S4CNA and S5CNA returning into the building from lunch and she asked them to bring Resident #1 back inside the building. S3LPN stated S4CNA and S5CNA stated Resident #1 is outside all the time by himself. S3LPN stated she depends on the nursing assistant's in dealing with residents. S3LPN stated she then closed the door and left Resident #1 outside alone. S3LPN stated normally residents at risk for elopement are not allowed outside by themselves. S3LPN stated the Resident #1 is mainly at the facility due to being confused. S3LPN stated it was her responsibility to assess whether a resident is at risk for elopement. S3LPN stated she had seen Resident #1 outside one other time but he was not alone. S3LPN stated she went outside to check on Resident #1 approximately 30 minutes after leaving him outside alone and discovered Resident #1 was missing from the facility grounds. S3LPN stated at that point the facility and grounds were searched for Resident #1 and he was not located. S3LPN stated Resident #1 had been in the facility for a little over a month and she cared for him since his admission. S3LPN acknowledged because Resident #1 was new to the facility he should have been monitored more closely and was not. S3LPN acknowledged the Resident #1 was Care Planned as an elopement risk and had a WanderGuard Bracelet in place. S3LPN stated she received training for residents at risk for elopement. S3LPN stated residents at risk for elopement were not allowed to go outside by themselves without a staff member or family member. S3LPN stated the CNAs rotate throughout the facility and should be aware of each resident's needs. During an interview on 10/16/17 at 12:12 p.m. S4CNA stated she was working the day Resident #1 eloped from the facility. S4CNA she was returning from her lunch break when S3LPN said you're not going to bring him (Resident #1) back inside the building. S4CNA stated she was not aware Resident #1 was an elopement risk with a WanderGuard bracelet in place. S4CNA stated she told S3LPN that she was going to clock back in from lunch and do her last round. During an interview on 10/16/17 at 12:30 p.m. S5CNA stated she was working the day Resident #1 eloped. S5CNA stated she was coming back from lunch and was stopped by S3LPN to see if she could watch Resident #1. S5CNA stated she told S3LPN she could not watch Resident #1 she had to make her last rounds and clock out. S5CNA stated she did not know Resident #1 was an elopement risk and had a WanderGuard bracelet in place. S5CNA stated she told S3LPN she was unaware Resident #1 was an elopement risk because she had seen Resident #1 outside alone before.

Based on observation, record review, and staff interviews the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (#4) of 6 (#1, #2, #3, #4, #5, #6,) sampled residents reviewed for accident hazards and supervision out of a total sample of 8. The facility failed to: 1. Ensure a resident assessed as requiring supervision with meals received adequate supervision while consuming hot liquids. 2. Formulate a plan of care for a resident with a history of burns from hot liquids. 3. Communicate with CNA staff to ensure a resident was monitored while consuming hot liquids. 4. Plan and implement recommended interventions as documented on an incident/accident report. Resident #4 suffered actual harm when she sustained an avoidable 2nd degree burn to her right inner thigh due to a hot coffee spill. Findings: Observation on 8/9/11 at 2:40 p.m. revealed resident #4 receiving wound care performed by S3 ADON (Assistant Director of Nursing) and S14 LPN (Licensed Practical Nurse) treatment nurse. Resident #4 was observed to be tolerating procedure well with no signs of pain. Further observation of resident #4 during wound care revealed a small area of 1st degree burns to the left inner thigh and right inner wrist and a larger area of 1st and 2nd degree burns to the right inner thigh. Observation of resident #4's left inner thigh revealed a reddened area approximately 3 centimeters in diameter. Observation of resident #4's right inner thigh revealed a reddened area approximately 6 centimeters in diameter with 3 linear blisters approximately 1 centimeter long. Review of the Face Sheet for resident #4 revealed a [AGE] year old female with an admitted [DATE]. Further review revealed accumulative [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS (Minimum Data Set) for resident #4 dated 7/27/11 revealed in Section B (hearing, speech, vision) resident #4 has some difficulty understanding and making herself understood. Review of Section G (functional status) revealed resident #4 requires 1 person physical assistance for most ADLs (activities of daily living), set-up and supervision for meals, and uses a wheelchair for locomotion. Review of the Incident/Accident Report for resident #4 dated 12/18/10 at 10:30 a.m. revealed resident #4 was sitting at the dining room table and spilled coffee in her lap. Further review revealed, under Investigation Follow-up (New Interventions), to place a pad in resident #4's lap while drinking coffee. During an interview on 8/12/11 at 9:45 a.m. S13 LPN stated she was the nurse on duty when resident #4 spilled coffee on herself in December 2010. S13 LPN further stated she was alerted to the spill by a CNA and did not witness the incident. During an interview on 8/9/11 at 2:25 p.m. S5 CNA stated resident #4 spilled her coffee about 6 months ago after she had just placed it in front of her and turned her back. S5 CNA further stated resident #4 did not have a pad in her lap and was burned by the hot coffee. Review of the December 2010 In-Services failed to reveal an in-service on resident safety. Review of the Incident/Accident report for resident #4 dated 8/6/11 at 10:30 a.m. revealed a CNA gave resident #4 a cup of coffee which she spilled in her lap. Further review revealed resident #4 had burns to both inner thighs and her right wrist which were treated with cold compresses. Review of the Investigation Follow-Up section under Past Interventions Attempted revealed to evaluate location of coffee pot in December of 2010. Further review revealed no new interventions recommended. During an interview on 8/10/11 at 11:25 a.m. S7 LPN stated she was working on the day resident #4 spilled coffee on her lap 8/6/11. When asked if she was aware resident #4 had a previous injury from coffee, S7 LPN stated "yes." S7 LPN further stated she was not working the day of resident #4's previous coffee burn back in December 2010. When asked if the facility conducted an In-Service following either incident or if any new interventions were being implemented, S7 LPN stated "no." During an interview on 8/10/11 at 10:40 a.m. S6 CNA stated she was making hydration rounds the day resident #4 spilled her coffee. S6 CNA further stated she remembers giving coffee to resident #4 then reminded her to not spill it. S6 CNA stated just a few minutes later she heard the ward clerk yell out resident #4 had spilled coffee on herself. When asked if she placed ice in resident #4's coffee or placed a blanket in her lap, S6 CNA stated "no." Review of the facility In-Service Log failed to reveal any in-service training for August 2011. Review of the Plan of Care for resident #4 last reviewed on 7/13/11 failed to reveal a plan for consumption of hot liquids or a lap pad during meals. During an interview on 8/11/11 at 9:30 a.m. S1 Administrator stated resident #4 was not care planned for accidents involving the consumption of hot liquids after the December 2010 coffee spill and no in-service was conducted. S1 Administrator further stated she did not even recall being alerted to the incident. S1 Administrator stated she was alerted to the most recent coffee spill 8/6/11 on the Monday after the incident. When asked if any new plans were put into place to prevent future coffee spills or if any in-services were conducted, S1 Administrator stated, "if I'm being completely honest, no."