Every finding on record at Waldon Health Care Center

Based on interviews and record reviews, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) was documented as provided for 3 (Resident #1, Resident #2, Resident #3) of 4 sampled residents reviewed for charting completion and accuracy. Findings:Resident #1Review of Resident #1's Care Plan dated 02/18/2026 revealed, in part, Resident #1 required staff assistance with activities of daily living with staff to provide assistance with oral care, eating, and showering. Review of Resident #1's February 2026 Documentation Survey Report v2 revealed, in part, there was no documented evidence staff provided Resident #1 with bathing assistance or eating assistance on the day shift for 02/13/2026 and 02/18/2026. Review of Resident #1's March 2026 Documentation Survey Report vs revealed, in part, there was no documented evidence staff provided Resident #1 with bathing assistance or eating assistance on the day shift on 03/25/2026. Review of Resident #1's clinical record did not reveal any alternate documentation to support the above-mentioned ADLs were provided or that the facility ensured the completion of the documentation required for Resident #1's ADLs. Resident #2Review of Resident #2's care plan revised on 03/04/2026 revealed, in part, Resident #2 required staff assistance with activities of daily living, including assistance with meals, oral care, and toileting/incontinence care. Review of Resident #2's February 2026 Documentation Survey Report v2 revealed, in part, there was no documented evidence staff provided the resident with eating assistance on the day shift for 02/13/2026; the evening shift on 02/10/2026, 02/13/2026, 02/16/2026, 02/17/2026, and 02/25/2026; and the night shift on 02/10/2026, 02/16/2026, and 02/28/2026. There was also no documented evidence staff provided oral hygiene assistance on the day shift for 02/13/2026; the evening shift on 02/10/2026, 02/13/2026, 02/16/2026, 02/17/2026, and 02/25/2026; and the night shift on 02/10/2026, 02/16/2026, and 02/28/2026. Additionally, there was no documented evidence staff provided toileting assistance on the day shift for 02/13/2026; the evening shift on 02/10/2026, 02/13/2026, 02/16/2026, 02/17/2026, and 02/25/2026; and the night shift on 02/10/2026, 02/16/2026, 02/26/2026, and 02/28/2026. Review of Resident #2's clinical record did not reveal any alternate documentation to support the above-mentioned ADLs were provided or that the facility ensured the completion of the documentation required for Resident #2's ADLs. Resident #3Review of Resident #3's care plan revealed, in part, the resident required staff assistance with activities of daily living due to limited mobility, including bathing/showering, eating, oral hygiene, and toileting/incontinence care. Review of Resident #3's January 2026 documentation survey V2 report revealed no documented evidence staff provided required ADL assistance as care planned. Further review revealed there was no documented evidence of bathing on 01/22/2026 and 01/27/2026; eating assistance on the day shift on 01/22/2026, 01/23/2026, 01/26/2026, and 01/27/2026, the evening shift on 01/15/2026, and the night shift on 01/14/2026 and 01/15/2026; oral hygiene assistance on the day shift on 01/22/2026, 01/23/2026, 01/26/2026, and 01/27/2026, the evening shift on 01/15/2026, and the night shift on 01/14/2026 and 01/15/2026; and toileting assistance on the day shift on 01/22/2026, 01/23/2026, 01/26/2026, and 01/27/2026, the evening shift on 01/15/2026, and the night shift on 01/15/2026. Review of Resident #3's clinical record did not reveal any alternate documentation to support the above-mentioned ADLs were provided or that the facility ensured the completion of the documentation required for Resident #3's ADLs. In an interview on 04/14/2026 at 3:16PM, S1Administrator verified the above-mentioned findings, and indicated the ADLs were not documented by staff as having been performed and should have been. In an interview on 04/14/2026 at 3:27PM, S2Director of Nursing confirmed the above-mentioned findings, and indicated the ADLs were not documented by staff as having been performed or refused and should have been.

Based on interviews and record reviews, the facility failed to:1. Ensure the Minimum Data Set (MDS) accurately reflected the diagnosis of 1(Resident #8) of 1 resident reviewed for active diagnoses;2. Ensure the MDS accurately reflected high-risk medications for 1(Resident #8) of 1 resident reviewed for medications;3. Ensure the MDS accurately reflected a Pre-admission Screening and Resident Review (PASRR) Level II for 2 (Resident #9, Resident #67) of 2 residents reviewed for PASRR Level II; and,4. Ensure the MDS accurately reflected the tobacco status of 1(Resident #67) of 1 resident reviewed for tobacco use.Findings: 1. Review of Resident #8's medical record revealed, in part, Resident #8 was admitted to the facility on [DATE], with a diagnosis of obstructive and reflux uropathy.Review of Resident #8's admission MDS with an Assessment Reference Date (ARD) of 12/10/2025 revealed, in part, Resident #8 was assessed as having no diagnosis of obstructive and reflux uropathy. Review of Resident #8's care plan, dated 12/11/2025, revealed, in part, Resident #8 had a Foley catheter related the diagnosis of obstructive and reflux uropathy. 2. Review of Resident #8's physician orders dated 12/04/2025 revealed, in part, an order dated for Buspar (a medication used to treat anxiety). Further review revealed Resident #8 had no physician orders for an antibiotic medication or an antipsychotic medication.Review of Resident #8's admission MDS with an ARD of 12/10/2025 revealed, in part, Resident #8 was assessed for taking and having indications for an antibiotic and an antipsychotic medication. Further review revealed Resident #8 was assessed as not taking and/or having indications for an anti-anxiety medication.Review of the facility's validation report for Resident #8 dated 01/14/2026, revealed, in part, Resident #8 had a modification to his admission MDS on 12/10/2025.3. Resident #9Review of Resident #9's medical records revealed, in part, Resident #9 was admitted to the facility on [DATE]. Further review revealed Resident #9 had a diagnosis of schizoaffective disorder, bipolar type dated 02/27/2023, and psychotic disorder with delusions due to known psychological condition dated 03/18/2022.Review of the Office of Behavioral Health's PASRR Level II Evaluation Summary and Determination Notice dated 03/17/2025 revealed, in part, Resident #9 had serious mental illness present.Review of Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification revealed, in part, Resident #9 was approved for admission by Level II authority for a period of 03/17/2025 through 03/16/2026.Review of Resident #9's significant change MDS with an ARD of 12/08/2025 revealed, in part, documentation which indicated that Resident #9 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Further review revealed that Resident #9's significant change MDS with an ARD of 12/08/2025 was electronically signed by S7MDSNurse on 12/11/2025.In an interview on 01/14/2026 at 2:38PM, S1Administrator confirmed Resident #9's significant change MDS with an ARD of 12/08/2025 was completed in error when S7MDSNurse documented that Resident #9 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition as Resident #9 had received his Level II PASARR on 03/17/2025.Resident #67Review of Resident #67's medical record revealed, in part, Resident #67 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia and major depressive disorder. Further review revealed Resident #67's was approved for admission by Level II Authority for a temporary period effective 01/16/2025 through 01/15/2026.Review of Resident #67's significant change MDS with an ARD of 12/29/2025 revealed, in part, Resident #67 was assessed as not having a PASRR Level II. Review of Resident #67's care plan, dated 01/12/2025, revealed, in part, Resident #67 had a PASRR Level II.Review of the facility's validation report for Resident #67 dated 01/14/2026, revealed, in part, Resident #67 had a modification to significant change MDS on 12/29/2025.4. Review of Resident #67's medical record revealed, in part, Resident #67 had a diagnosis of nicotine dependence.Review of Resident #67's significant change MDS with an ARD of 12/29/2025 revealed, in part, Resident #67 was assessed as no tobacco use.Review of Resident #67's care plan, dated 12/30/2024 and revised on 01/10/2026, revealed, in part, Resident #67 was an active safe smoker.Review of Resident #67's smoking evaluation, dated 11/06/2025, revealed, in part, Resident #67 did utilize tobacco. Review of the facility's smoking list, dated 01/06/2025, revealed, in part, Resident #67 was listed as a safe smoker.In an interview on 01/12/2026 at 10:05AM, Resident #67 indicated that she was a smoker. In an interview on 01/14/2026 at 1:55PM, S1Administrator indicated the findings for the above-mentioned residents' assessments were completed inaccurately, and should not have been.

Based on observations, interviews, and record review, the facility failed to ensure the total number and the actual hours worked for licensed and unlicensed nursing personnel was posted daily during review of nurse staffing requirements.Findings:Observation on 01/12/2026 at 8:35AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/12/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.Observation on 01/13/2026 at 10:32AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/13/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.In an interview on 01/13/2026 at 10:35AM, S5Ward Clerk indicated she entered the total number of licensed and unlicensed personnel that worked on the Daily Nursing Staffing Hours form dated 01/12/2026 and 01/13/2026. S5Ward Clerk further indicated she did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel on the above mentioned form.In an interview on 01/13/2026 at 10:40AM, S3Director of Nursing indicated the total number of hours and the total actual hours worked for licensed and unlicensed personnel per shift was not included on the Daily Nursing Staffing Hours form dated 01/12/2026 and 01/13/2026.In an interview on 01/13/2026 at 1:30PM, S1Administrator indicated the total number and the total actual hours worked for licensed and unlicensed personnel per shift was not included on the Daily Nursing Staffing Hours form dated 01/12/202 and 01/13/2026, and should have.

Based on observation, interviews, and record review, the facility failed to ensure food stored in the facility's walk-in refrigerator was properly labelled and contained with an opened date and was unavailable for resident use. Findings: Review of the facility's policy, dated 01/2026 and titled Food Receiving and Storage revealed, in part, all food stored in the refrigerator will be labeled and dated.Observation on 01/12/2026 at 9:28AM revealed the facility's walk-in refrigerator had the following opened, undated and unlabeled food items:-1 package of smoked sausage; and, -2 packages of smoked sliced turkey breast.In an interview on 01/12/2026 at 9:29AM, S8Cook confirmed the above-mentioned opened food items were not dated and labeled, and should have not been available for resident use.In an interview on 01/12/2025 at 1:55PM, S1Administrator indicated the above-mentioned undated and unlabeled opened food items should have been labeled appropriately and not available for resident use.

Based on interviews and record reviews, the facility failed to implement facility policy to ensure all witness statements received verbally were titled, and signed by both the person making the statement and the witness. Findings: Review of the facility's Abuse, Neglect, and Misappropriation of Funds Policy and Procedure, with revised date of March 2025, if only oral information can be obtained about an allegation of abuse, the following is required, in part: A statement must be documented signed and date; and, The recorder and the witness to the statement must sign, date, and title statement. Review of the facility's investigation related to an allegation of sexual abuse dated 12/04/2024, revealed S1Administrator had documented S13Housekeeper's statement regarding alleged sexual abuse; however, S13Housekeeper had not signed and dated the statement, and S1Administrator had not titled the statement. Review of S5LPN's Sexual Abuse Allegation Statement dated 03/15/2025 revealed the statement was not signed by S5LPN, nor any witness. Review of S12CNA's Sexual Abuse Allegation Statement dated 03/19/2025 revealed the statement was not signed S12CNA, nor any witness. In an interview on 03/26/2025 at 5:10PM, S3Corporate Administrator indicated he took the verbal statements from S5LPN and S12CNA with S1Administrator and S2DON present, but did not get the witnesses to write a statement, nor sign the verbal documentation of the investigation.

Based on interview and record review, the facility failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors for 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) of 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) sampled staff reviewed for behavior training. Findings: Review of the facility's Facility Assessment Tool updated on 10/16/2024 revealed, in part, the facility was able to accept residents with psychiatric/mood disorders and psychiatric symptoms and behaviors would be identified and interventions implemented to help support the residents. Review of Resident #2's Minimum Data Set Assessment Reference Date 12/24/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 8 (score of 08-12 indicated moderate cognitive impairment). Review of Resident #2's care plan revealed, in part, Resident #2 had the potential to touch female peers inappropriately (touching a resident's arm without permission) initiated on 03/16/2025 Review of Resident #2's S13Housekeeper Verbal Witness Statement dated 12/04/2024 revealed, in part, Resident #2 exposed his penis to staff. Review of Resident #2's Progress Note dated 12/04/2024 revealed, in part, Resident #2 was transferred to a psychiatric facility for inappropriate sexual behavior. Review of Resident #2's Physician's Emergency Certificate (PEC) (a document used to admit a resident into a psychiatric facility) dated 12/04/2024 revealed, in part, Resident #2 had behaviors of exposing self to staff and peers and hypersexual behavior. Review of Resident #2's PEC dated 02/05/2025 revealed, in part, Resident #2 was assessed as having hypersexual behaviors and touching others inappropriately. Review of Resident #2's PEC dated 03/03/2025 revealed, in part, Resident #2 was hypersexual with staff and peers, with unwanted sexual advances to other residents. In an interview on 03/20/2025 at 10:19AM, S8Porter indicated he was assigned to provide 1:1 supervision to Resident #2. S8Porter indicated no one had explained to him the reason Resident #2 was placed on 1:1 supervision, but he was instructed he was to be with Resident #2 at all times. S8Porter further indicated he had a binder with a list of questions to fill out regarding Resident #2's behaviors for every shift. In an interview on 03/20/2025 at 3:12PM, S10Housekeeping Supervisor indicated she was assigned to 1:1 supervision of Resident #2. S10Housekeeping Supervisor further indicated she was not sure what behaviors Resident #2 displayed or how to intervene if the behavior occurred. In an interview on 03/25/2025 at 2:40PM, S9Porter indicated last night (03/24/2025) was about the third time he was assigned to 1:1 supervision of Resident #2. S9Porter further indicated he did not receive any education on Resident #2's specific behaviors or how to intervene if the behaviors occurred. Record review revealed no documented evidence and the facility was unable to present any evidence the above mentioned staff members received specific training Resident #2's behaviors or training on how to care for residents with psychosocial disorders. In an interview on 03/25/2025 at 2:58PM, S2Director of Nursing (DON) indicated the facility had no documented evidence the above mentioned staff had been trained in Resident #2's behaviors prior to being assigned one on one supervision with Resident #2. In an interview on 03/26/2025 at 2:49PM, S1Administrator confirmed the above mentioned staff provided one on one supervision for Resident #2. S1Administrator further indicated the above mentioned staff members did not receive trainings on caring for residents with mental or psychosocial disorders.

Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (Resident #R1) of 7 (Resident #2, Resident #3, Resident #4, Resident #R1, Resident #R2, Resident #R3, Resident #R4) sampled residents observed during medication administration. Findings: Review of Resident #R1's record revealed, in part, Resident #R1 had diagnoses which included chronic diastolic congestive heart failure (condition in which the heart was unable to pump blood proficiently) and sinusitis. Review of Resident #R1's March 2025 Physician Orders revealed, in part, Lasix (medication used to remove excess fluid from the body) 20 milligrams (mg) administer three tablets by mouth daily. Further review revealed an order for Flonase (medication used to treat allergies) 50 micrograms (mcg) per actuation one spray in both nostrils one time a day. Observation on 03/21/2025 at 8:15AM revealed S4Licensed Practical Nurse (LPN) was unable to locate Resident #R1's Flonase and Lasix to administer. In an interview on 03/21/2025 at 8:15AM, S4LPN indicated the facility recently had to order multiple medications from the pharmacy and was waiting for the medications to be delivered. Review of Resident #R1's March 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #R1's Flonase and Lasix were not administered as ordered on 03/21/2025. In an interview on 03/21/2025 at 11:51AM, S2Director of Nursing (DON) indicated the facility did not obtain the Lasix and Flonase medications in a timely manner.

Based on record review and interviews, the facility failed to ensure the dietary manager had completed an approved food safety program and passed the accompanying test for 1 (S13Dietary Manager) of 1 (S13Dietary Manager) sampled dietary managers employed by the facility. Findings: In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated she had been the facility's dietary manager for 2 years. S13Dietary Manager further indicated she had not taken the exam for the ServSafe course. In an interview on 01/14/2025 at 3:50 p.m., S1Administrator indicated the facility was not aware S13Dietary Manager had not completed the examination for her ServSafe course, and therefore did not have ServSafe certification. At time of exit the facility had not presented any evidence S13Dietary Manager had passed the ServSafe examination.

Based on observations, record review, and interviews, the facility failed to ensure: 1. Food items were not placed in areas in which water had accumulated on food packaging; 2. Food items were covered in the refrigerator; 3. Expired food items were discarded and not available for use; 4. Damaged food items were not stored amongst other food items; 5. Staff had all hair restrained when in the food preparation areas; 6. Chemicals were not stored in food preparation areas; 7. Food items were labeled with an opened date and labeled with the contents of the container/bag; and, 8. Staff did not store their food items with residents' food items; Findings: Review of the facility's policy titled, Food Receiving and Storage Policy and Procedure, last reviewed in ,d+[DATE] revealed, in part: -staff were to ensure refrigerated foods were labeled, dated, and monitored so they are used by their use by date, frozen, or discarded; and, -food may not be stored under leaking water lines, or under lines on which water has condensed. Observation on [DATE] at 9:46 a.m. with S13Dietary Manager revealed, in part: - ice had accumulated on the left and right side of the freezer's fan and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the box; - the facility's refrigerator had a cart with 83 uncovered containers of fruit cocktail; - the facility's refrigerator contained three one-quart containers of heavy whipping cream with an expiration date of [DATE]; -the facility's dry storage area contained a dented container of mandarin oranges on the shelf between other canned goods; and - S13Dietary Manager's hair was not fully contained by her hairnet. Observation on [DATE] at 11:15 a.m. with S13Dietary Manager revealed, in part: -S13Dietary Manager's hair was not fully contained by her hairnet; -ice had accumulated on the left and right side of the freezer's fan, and a box of cut okra, a box of ground beef, a box of chocolate pudding, and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the boxes; -two small buckets of sanitizer were stored under the facility's food preparation table; -the facility's refrigerator had two undated plastic containers that were not labeled with the contents of the containers and an undated bottle that was not labeled with the contents of the bottle; and, -the facility's refrigerator had the following: an undated half-empty one gallon container of mayo; an undated half-empty five pound container of sour cream; an undated half-empty one gallon container of yellow mustard; an undated one gallon container of sweet pickles with approximately one-fourth of the container used; and an undated half-empty one gallon container of Italian dressing. In an interview on [DATE] at 11:27 a.m., S13Dietary Manager indicated the facility had to defrost the freezer approximately every two weeks due to the accumulated ice of the freezer's fans. S13Dietary Manager confirmed the bottle and two plastic containers of prepared food observed in the facility's refrigerator on [DATE] belonged to the staff and should have not been in the facility's refrigerator with residents' food items. S13Dietary Manager further confirmed the above findings and indicated the above findings were deficient. In an interview on [DATE] at 3:50 p.m., S1Administrator confirmed the above findings were deficient.

Based on observations, interviews, record reviews, the facility failed to ensure: 1. A facility-wide surveillance of resident's infections were maintained (Resident #7, Resident #12, Resident #27, and Resident #84); and, 2. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care (Resident #21). This deficient practice was identified for 4 (Resident #7, Resident #12, Resident #27, and Resident #84) of 13 (Resident #1, Resident #7, Resident #12, Resident #27, Resident #39, Resident #55, Resident #56, Resident #63, Resident #73, Resident #76, Resident #79, Resident #84, and Resident #88) sampled residents reviewed for infection surveillance; and, for 1 (Resident #21) of 2 (Resident #21 and Resident #27) residents observed during incontinence care. Findings: 1. Review of the facility's Antibiotic Stewardship- Review of and Surveillance of Antibiotic Use and Outcomes, with revised date of February 2024, revealed, in part: -as part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. -all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form, and the information gathered will include, in part: resident name, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. Review of Resident #7's July 2024's Physician Orders revealed, in part, Resident #7 was prescribed and received Levofloxacin (antibiotic medication used to treat infections) 500 milligrams (mg) one tablet by mouth daily for 10 days for a right knee infection with a start date of 07/05/2024; and Doxycycline (antibiotic medication use to treat infections) 100mg one tablet by mouth every 12 hours for right knee wound with a start date of 07/06/2024. Review of Resident #12's July 2024's Physician Orders revealed, in part, Resident #12 was prescribed Cefepime Hydrochloride (HCl) (antibiotic mediation used to treat infections) intravenous (IV) solution reconstituted (amount of medication dissolved in a solution) (medication administered directly into the vein) 2 grams (gm) IV one time a day related to acute osteomyelitis (infection of the bone) of the left ankle, with a start date of 07/04/2024. Review of the facility's Infection Surveillance Map and Infection Reports for July 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #7 and Resident #12's above mentioned antibiotics and infections as part of the facility's July 2024 infection surveillance. Review of Resident #27's August 2024's Physician Orders revealed, in part, Resident #27 was prescribed, in part, Tobradex (antibiotic medication used to treat infections) Opthalmic (medication administered into the eye) 0.3-0.1 percent ointment. Instill into left eye four times a day for 10 days with a start date of 08/01/2024 for blepharitis (inflammation and infection) of the left upper eyelid. Review of the facility's Infection Surveillance Map and Infection Reports for August 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #27's above mentioned antibiotic and infection as part of the facility's August 2024 infection surveillance. Review of Resident #84's November 2024 Physician Orders revealed, in part, Resident #84 was prescribed Augmentin (antibiotic, medication used to treat infections) 500/125mg one tablet by mouth twice a day for cellulitis (infection of the skin) with a start date of 11/18/2024. Review of the facility's Infection Surveillance Map and Infection Reports for November 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #84's above mentioned antibiotic and infection as part of the facility's November 2024 infection surveillance. In an interview on 01/16/2025 at 2:08 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) indicated the documents presented to the surveyor was all of the facility's infection surveillance for all of the facility's infections for July 2024 through January 2025. S2DON/IP further indicated after reviewing the above mentioned documents the facility was not capturing all residents' infections, and therefore the facility did not have a comprehensive facility Antibiotic Stewardship and Surveillance of Infections. 2. Review of the facility's Handwashing and Hand Hygiene policy and procedure dated October 2024 revealed, in part, hand hygiene should be performed before moving from a contaminated body site to a clean body site during resident care. Review of Resident #21's Minimum Data Set with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 was always incontinent of bowel and bladder. Further review revealed Resident #21 was dependent on staff for toileting hygiene. Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care. S11CNA and S12CNA then removed Resident #21's urine and feces soiled brief, cleaned Resident #21's buttock area of feces, and placed a clean brief on Resident #21 without changing gloves or performing hand hygiene. S11CNA then disposed of Resident #21's soiled brief into the trash. S11CNA and S12CNA then manually transferred Resident #21 from the bed to a wheelchair with the same gloves used to perform incontinence care. In an interview on 01/14/2025 at 2:25 p.m., S12CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have. In an interview on 01/14/2025 at 2:30 p.m., S11CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on a resident during incontinence care. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on resident during incontinence care. 47081

Based on observation, record reviews, and interviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #21) of 2 (Resident #21 and Resident #27) sampled residents observed during incontinence care. Findings: Review of the facility's undated Resident [NAME] of Rights revealed, in part, staff shall protect the right to privacy of the resident's body during toileting, bathing, and other activities of personal hygiene. Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated Resident #21 had severe cognitive impairment. Further review revealed Resident #21 was dependent on staff assistance for toileting hygiene. Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care while Resident #21's roommate, Resident #46, remained in the room. Further observation revealed S11CNA and S12CNA did not close Resident #21's bedside privacy curtain and proceeded to remove Resident #21's pants, remove Resident #21's incontinence diaper and start Resident #21's incontinence care. Further observation revealed Resident #21's genitalia remained uncovered during the entire incontinence care process. In an interview on 01/15/2025 at 9:05 a.m., S11CNA confirmed she did not close Resident #21's bedside curtain to ensure Resident #21's privacy during incontinence care and should have. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated the CNAs should have ensured a resident's privacy was maintained during incontinence care. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed a resident's privacy should have been maintained during incontinence care by closing the resident's privacy curtain since another resident was in the room.

Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #84) of 3 (Resident #26, Resident #64, and Resident #84) residents investigated for abuse. Findings: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Funds Program dated October 2024 revealed, in part, the facility should ensure the safety and well-being of residents was maintained at all times and was committed to zero tolerance of any form of abuse. Further review revealed, abuse was the willful infliction of injury with resulting physical harm or pain, and this applied to all residents regardless of their medical condition or mental capacity. Further review revealed, physical abuse included hitting and slapping. Review of facility's Statewide Incident Management System (SIMS) Report investigation entered on 10/01/2024 for an incident that occurred on 10/01/2024 at 2:17 p.m. revealed, in part, Resident #64 hit Resident #84 in the face with an open hand while sitting outside in the courtyard. Further review revealed, S1Administrator determined Resident #84 was the victim of resident to resident physical abuse by Resident #64. Further review also revealed S1Administrator determined physical abuse was substantiated based on Resident #64's confession and video surveillance footage of the above mentioned incident. Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #84 went to the nurse's station and reported she had been hit in the face by another resident while outside on the patio. Further review revealed, Resident #84 had a red mark/scratch noted to the left side of her eye. Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #64 had a documented incident of physical aggression. Further review revealed Resident #64 initiated a physical altercation by striking another resident in the face. Review of #84's nurse's note dated 10/01/2024 revealed, in part, Resident #84 was sent out to the hospital to be evaluated for complaints of pain to Resident #84's left side of her face and her left eye. Review of Resident #64's progress note dated 10/01/2024 revealed, in part, Resident #64 was sent out by the physician to behavioral health for an evaluation due to aggressive behavior toward another resident. In an interview on 01/15/2025 at 9:05 a.m., Resident #64 confirmed the physical altercation with Resident #84 and indicated she hit Resident #64 in the face. In an interview with 01/16/2025 at 8:55 a.m., S16Social Services confirmed the above mentioned incident between Resident #64 and Resident #84 that occurred on 10/01/2024. In an interview on 01/16/2025 at 9:00 a.m., S1Administrator acknowledged the above mentioned incident had occurred on 10/01/2024 between Resident #64 and Resident #84. S1Administrator confirmed the above mentioned incident of resident to resident physical abuse was substantiated after being investigated by the facility.

Based on interviews and record reviews, the facility failed to ensure a resident, with a new diagnosis of Schizoaffective Disorder, was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 3 (Resident #12, Resident #63, and Resident #84) sampled residents reviewed for PASARR. Findings: Review of Resident #63's medical record revealed, in part, Resident #63 was readmitted to the facility on [DATE]. Further review revealed Resident #63 was diagnosed on [DATE] with Schizoaffective Disorder. Further review revealed no documented evidence a PASARR Level II evaluation was completed for Resident #63. Review of Resident #63's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed, in part, Resident #63's active diagnoses included Schizoaffective Disorder-Bipolar Type. In an interview on 01/15/2025 at 11:20 a.m., S3Admissions Coordinator indicated a PASARR Level II evaluation was not completed for Resident #63 after Resident #63's new diagnosis of Schizoaffective Disorder on 02/27/2023. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed Resident #63 did not have a PASARR Level II submitted after a new diagnosis of Schizoaffective Disorder was determined on 02/27/2023 and should have.

Based on record reviews, interviews, and observations the facility failed to: 1. Develop a person-centered care plan for a resident with dialysis and, 2. Implement interventions per the resident's plan of care. This deficient practice was identified for 1 (Resident #27) of 1 (Resident #27) residents investigated for dialysis. Findings: Review of Resident #27's electronic medical record (EMR) revealed, in part, Resident #27 was admitted to the facility on [DATE] and had diagnoses, which included, in part, Diabetes Mellitus, Sacral pressure ulcer, and renal insufficiency. Review of Resident #27's January 2025 Physician's orders revealed, in part, an order for Resident #27 to receive dialysis. Review of Resident #27's care plan dated 07/21/2024, revealed, in part, Resident #27 received dialysis three times per week, and the facility would monitor Resident #27's intake and output. 1. In an interview on 01/14/2025 at 9:50 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated Resident #27's care plan was generated from the dialysis care plan template and the intervention to monitor intake and output should not have been on it. 2. In an interview on 01/14/2025 at 8:50 a.m., S2DON/Infection Preventionist indicated the facility's staff should document a resident's intake and output in the care task section of the resident's EMR. Review of Resident #27's completed tasks revealed, in part, no documented evidence Resident #27's intake and output were monitored. There was no documented evidence, and the facility did not present any documented evidence the facility monitored Resident #27's intake and output. In an interview on 01/14/2025 at 9:42 a.m., S17Medical Director indicated the intervention on the care plan should have been followed as documented in the specific approaches as noted on the dialysis plan of care, he expected the facility to follow Resident #27's care plan. In an interview on 01/14/2025 at 9:50 a.m., S2DON/Infection Preventionist confirmed the facility did not have documentation Resident #27's intake and output was required.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's blister was evaluated and treated for 1 (Resident #79) of 2 (Resident #12 and Resident #79) residents investigated for skin conditions. Findings: Observation on 01/13/2025 at 9:22 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/14/2025 at 9:05 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/15/2025 at 9:09 a.m., had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/15/2025 at 12:20 p.m., revealed the blister to Resident #79's right lower leg blister had opened, Resident #79's skin was no longer intact, and a clear liquid drainage was observed. Review of Resident #79's medical record revealed no documented evidence, and the provider did not present any documented evidence, an evaluation/assessment of Resident #79's right lower leg blister had been completed. In an interview on 01/15/2025 at 12:30 p.m., S19Certified Nursing Assistant (CNA) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S19CNA further indicated she had not noticed the blister to Resident #79's lower right leg. In an interview on 01/15/2025 at 2:30 p.m., S15Licensed Practical Nurse (LPN) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S15LPN further indicated she was unaware and was not made aware by any of the CNAs caring for Resident #79 that there were any blisters to Resident #79's 70 right lower leg. S15LPN further indicated the facility's CNA were supposed to notify the nurse of any changes in a resident's skin condition. In an interview on 01/15/2025 at 2:45 p.m., S20LPN/Charge Nurse indicated if the above mentioned blister was present on Resident #79's right lower leg since 01/13/2025, the facility's CNAs and/or nurses should have noted and reported Resident #79's blister. S20LPN/Charge Nurse further indicated the CNAs should have noted Resident #79's right lower leg blister during his bath/shower on 01/15/2025 and reported the blister to the nurse for evaluation/assessment. In an interview on 01/16/2025 at 11:15 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated the blister on Resident #79's right lower leg was not reported to the nurse or wound care nurse until 01/15/2025 after it had opened. S2DON/Infection Preventionist further acknowledged Resident #79's blister should have been noticed and reported to her so an evaluation/assessment could be completed but it was not.

Based on record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart c, and Medication Cart d) medication carts observed for expired medications. Findings: Review of the facility's policy titled, Storage of Medication Policy and Procedure, dated 10/2024, revealed, in part, expired drugs or biologicals should be returned to the dispensing pharmacy or destroyed. Observation of Medication Cart c on 01/15/2025 at 8:39 a.m. revealed a bottle of Meclizine Hydrochloride (HCl) 12.5 milligram (mg) caplets with an expiration date of 12/2024 was available for resident use. In an interview on 01/15/2025 at 8:41 a.m., S22Licensed Practical Nurse (LPN) confirmed the bottle of Meclizine HCl 12.5 mg caplets found stored in Medication Cart c was expired, and available for resident use, and should not have been. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist confirmed an expired medication should not have been stored in the Medication Cart c and available for resident use. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator indicated an expired medication should not have been stored in the Medication Cart c and available for resident use.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error was not greater than 5% for 2 (Resident #R3 and Resident #R4) of 10 (Resident #1, Resident #3, Resident #R1, Resident #R2, Resident #R3, Resident #R4, Resident #R5, Resident #R6, Resident #R7, and Resident #R8) sampled residents observed during medication administration. Findings: Review of the facility's undated Medication Pass Administration policy and procedure revealed, in part, medications were to be administered within 60 minutes before or after scheduled time. Review of Resident #R3's December 2024 Physician's Orders and electronic Medication Administration Record (eMAR) revealed Resident #R3 had an order for Sodium Bicarbonate (medication used to treat low sodium levels) 650 milligrams (mg), administer one tablet by mouth three times a day at 5:00 AM, 11:00 AM, and 8:00 PM. Observation on 12/26/2024 at 1:17 PM revealed S3Licensed Practical Nurse (LPN) administered Sodium Bicarbonate 650 mg one tablet by mouth to Resident #R3. Review of Resident #R4's December 2024 Physician's Orders and eMAR revealed Resident #R4 had the following orders, in part: Furosemide (medication used to remove excess fluid from the body) 20 mg, administer one tablet by mouth daily at 8:00 AM; Potassium Chloride (CL) Extended Release (ER) 20 milliequivalents (meq) (medication used to replace low potassium levels), administer one tablet by mouth daily at 8:00 AM; Oxycodone-Acetaminophen (APAP) (medication used to treat pain) 7.5/325 mg, administer one tablet by mouth three times a day at 8:00 AM, 2:00 PM, and 8:00 PM; Albuterol Sulfate (medication used to open the airway) 90 micrograms (mcg) per actuation (pump of inhaler), administer two actuations every six hours as needed for wheezing; and, Budesonide-Fumoterol Fumarate Aerosol (medication used to treat constricted airways) 106-4.5 mg/actuation, administer one puff two times a day at 8:00 AM and 4:00 PM. Observation on 12/27/2024 at 9:29 AM revealed S4LPN administered Resident #R4 the following medication, in part: Furosemide 20mg one tablet by mouth; Potassium CL ER 20 meq one tablet by mouth; Oxycodone-APAP 7.5/325 mg one tablet by mouth; Albuterol Sulfate 90 mcg two inhalations. Further observation revealed S4LPN did not administer Resident #R4's Budesonide-Fumoterol Fumarate. There were 27 medication administration opportunities for error, with 6 observed errors for a medication administration error rate of 22%. In an interview on 12/27/2024 at 11:27 AM, S4LPN indicated she administered Resident #R4 an Albuterol inhaler today and had not administered the Budesonide-Formoterol inhaler today as ordered. S4LPN further indicated she had not assessed Resident #R4 for wheezing nor had Resident #R4 requested the as needed Albuterol inhaler prior to administration. In an interview on 12/30/2024 at 11:46 AM, S2Director of Nursing (DON) indicated medications should be administered within one hour prior to or one hour after the physician ordered medication time, and it was not for neither Resident #R3 nor Resident #R4. In an interview on 12/30/2024 at 11:47 AM, S1Administrator confirmed Resident #R3 and Resident #R4's medications were not administered as per the physician's orders. In an interview on 12/30/2024 at 12:43 AM, S4LPN indicated she had residents on two halls and was not sure which medication were scheduled for 8:00 AM and which medications were scheduled for 9:00 AM. S4LPN further indicated she was late with medication administration for Resident #R4.

Based on interviews and record review, the facility failed to deliver care per professional standards by failing to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); and, 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate. S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to all 110 residents that were reported to reside in the facility on 08/30/2024. Findings: Review of Louisiana's R.S. 37:961, last amended in 2020, revealed, in part, the practice of practical nursing means the performance for compensation of any acts, in the care, treatment, or observation of persons who are ill, injured, or infirm and for the maintenance of the health of others and the promotion of health care, including the administration of medications. Review of the Louisiana State Board of Practical Nurse Examiners Scope of Practice revealed, in part, practical nursing is the performance, for pay, of acts in the care, treatment or observation of the ill and for the maintenance of the health of others and the promotion of health care. Review of the facility's undated Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards, and the facility's policies and procedures. Review also revealed the nurse's responsibility was to routinely make rounds to observe and evaluate residents' physical and emotional status. 1. Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a short term hospital stay with diagnoses, which included, unspecified dementia of an unspecified severity (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), major depressive disorder, and unspecified alcohol abuse. Review of Resident #1's Psychiatric Progress note dated 10/03/2023 revealed, in part, Resident #1 continued with intermittent confusion and continued to be fixated with leaving the facility. Further review revealed Resident #1 continued to appear anxious, restless, and wanted to leave the facility. Further review revealed Resident #1 had poor insight and was disoriented to time, place, and situation. Review of Resident #1's Psychiatric Progress note dated 03/20/2024 revealed, in part, Resident #1 continued with fixation about leaving the facility. Review of Resident #1's Psychiatric Progress note dated 05/22/2024 revealed, in part, Resident #1 was documented to have a bizarre affect with thought blocking, and refused medications and treatment over the previous few weeks. In addition, it was documented that Resident #1 reported he thought he should drink alcohol more to relax, had poor insight, and judgement with impaired memory. Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to being an elopement risk, and census checks to be conducted on Resident #1 every two hours. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part, Resident #1 had fluctuating disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) present. Review of Resident #1's most recent Care Plan revealed, in part, Resident #1 had impaired cognition. Further review revealed an intervention to observe Resident #1's whereabouts and document per the physician's orders initiated on 08/07/2024. Further review revealed a goal with a target date of 11/05/2024 that Resident #1 would not leave the facility unattended. Review of Resident #1's progress note dated 08/29/2024 at 8:33 a.m. revealed, in part, a Certified Nursing Assistant (CNA) alerted S24Licensed Practical Nurse (LPN) at 8:31 a.m. that Resident #1 was not in his room. Further review revealed S24LPN entered Resident #1's room and noted Resident #1's bed was empty and his bedding was neatly arranged. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, S4LPN was assigned to the care of the residents in Room Assignment u (where Resident #1 resided) from the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u (where Resident #1 resided) for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m. Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4 LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed S3LPN looked into Resident #1's room on 08/29/2024 at 12:04 a.m. and 6:15 a.m. Further review revealed S3LPN entered Resident #1's room at 6:04 a.m., 6:14 a.m., and 6:35 a.m. on 08/29/2024. The facility was unable to provide any evidence S3LPN and/or S4LPN rounded (performed a visual inspection of Resident #1) on Resident #1 every 2 hours as per the physician's orders on 08/28/2024 and 08/29/2024. In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 until 7:00 a.m. on 08/29/2024. S3LPN further indicated she had looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the oncoming nurse, and / or Certified Nursing Assistant (CNA) she was working with. In an interview on 08/30/2024 at 12:18 p.m., S24LPN (the on-coming assigned shift nurse for Resident #1 on 08/29/2024) indicated S3LPN had not reported that she had not been able to visualize Resident #1 during her shift, nor that she was unable to locate Resident #1 at 6:00 a.m. for medication administration. S24LPN further indicated S3LPN should have reported Resident #1's absence. In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so. In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders. In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders. 2. Review of Resident #1's August 2024 physician's orders revealed, in part, orders to administer Resident #1 Atorvastatin Calcium (a medication used to manage cholesterol) 10 mg tablet daily at bedtime, Quetiapine Fumarate (a medication used to treat depression) 25 mg tablet daily at bedtime, Mirtazapine Tartrate (a medication used to treat depression) 15 mg tablet daily, and to check for placement of Resident #1's wander guard bracelet every shift. Review of Resident #1's August 2024 electronic Medication Administration Record revealed, in part, S4LPN documented she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:00 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:00 p.m. on 08/28/2024, and one Quetiapine Fumarate 25 mg tablet at 8:00 p.m. on 08/28/2024. Further review revealed, S3LPN documented she checked placement of Resident #1's wander guard bracelet on the night shift of 08/28/2024. Review of the facility's Medication Administration Audit Report from 08/27/2024 to 08/28/2024 for Resident #1 revealed, in part, S4LPN documented that she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:23 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:23 p.m. on 08/28/2024, one Quetiapine Fumarate 25 mg tablet at 8:23 p.m. on 08/28/2024. Further review revealed S3LPN documented that she checked placement of Resident #1's wander guard bracelet on 08/29/2024 at 1:49 a.m. Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4 LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed no other evidence S4LPN entered Resident #1's room at any other time during her shift. In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was did not visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 to 7:00 a.m. on 08/29/2024. The facility was unable to produce any evidence that S4LPN administered Resident #1's medications as documented above. In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time. S2DON further indicated that S3LPN should not have documented she checked the placement of Resident #1's wander guard when she had never visualized Resident #1.

Based on observations, interviews, and record reviews, the facility failed to ensure staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate. S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the remaining 2 residents (#2, #3) who resided in the facility, were identified as a wandering/elopement risks, and were physically able to open and climb out of a window. Findings: Review of the facility's policy titled, Wandering and Elopements, last revised in 03/2019, revealed, in part, if a resident was missing, staff should initiate the missing resident emergency procedure. Further review revealed the staff should determine if the resident was out on an authorized leave or pass, and if the resident was not authorized to leave, staff would initiate a search of the building and premises. Further review revealed if resident was not located, staff should notify the Administrator, the Director of Nursing (DON), the resident's legal representative, the resident's attending physician, and law enforcement as necessary. Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a short term hospital stay with diagnoses, which included, unspecified dementia of an unspecified severity (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), major depressive disorder, and unspecified alcohol abuse. Review of Resident #1's Psychiatric Progress note dated 10/03/2023 revealed, in part, Resident #1 continued with intermittent confusion and continued to be fixated with leaving the facility. Further review revealed Resident #1 continued to appear anxious, restless, and wanted to leave the facility. Further review revealed Resident #1 had poor insight and was disoriented to time, place, and situation. Review of Resident #1's Psychiatric Progress note dated 03/20/2024 revealed, in part, Resident #1 continued with fixation about leaving the facility. Review of Resident #1's Psychiatric Progress note dated 05/22/2024 revealed, in part, Resident #1 was documented to have a bizarre affect with thought blocking, and refused medications and treatment over the previous few weeks. In addition, it was documented that Resident #1 reported he thought he should drink alcohol more to relax, had poor insight, and judgement with impaired memory. Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to being an elopement risk, and census checks to be conducted on Resident #1 every two hours. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part, Resident #1 had fluctuating disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) present. Review of Resident #1's most recent Care Plan revealed, in part, Resident #1 had impaired cognition. Further review revealed an intervention to observe Resident #1's whereabouts and document per the physician's orders initiated on 08/07/2024. Further review revealed a goal with a target date of 11/05/2024 that Resident #1 would not leave the facility unattended. Review of Resident #1's progress note dated 08/29/2024 at 8:33 a.m. revealed, in part, a Certified Nursing Assistant (CNA) alerted S24Licensed Practical Nurse (LPN) at 8:31 a.m. that Resident #1 was not in his room. Further review revealed S24LPN entered Resident #1's room and noted Resident #1's bed was empty and his bedding was neatly arranged. In an interview on 08/30/2024 at 8:28 a.m., S1Administrator indicated Resident #1 entered his room on 08/28/2024 at 5:17 p.m. and never exited his room per her review of the facility's surveillance footage. S1Administrator further indicated she believed Resident #1 exited through his bedroom window because of the missing window screen and dirty windowsill. S1Administrator further indicated by interviewing staff and review of the facility's surveillance footage, she was able to determine that resident was last seen by S6CNA at 4:41 a.m. on 08/29/2024. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u (where Resident #1 resided) for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 time sheet reports, revealed, in part, S3LPN clocked in at 11:30 p.m. on 08/28/2024 and clocked out at 7:15 a.m. on 08/29/2024. Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m. Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 until 7:00 a.m. on 08/29/2024. S3LPN further indicated she had looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the oncoming nurse, and / or Certified Nursing Assistant (CNA) she was working with. In an interview on 08/30/2024 at 12:18 p.m., S24LPN (the on-coming assigned shift nurse for Resident #1 on 08/29/2024) indicated S3LPN had not reported to her that she had not been able to visualize Resident #1 during her shift, nor that she was unable to locate Resident #1 at 6:00 a.m. for medication administration. S24LPN further indicated S3LPN should have reported Resident #1's absence. In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so. In a telephone interview on 08/30/2024 at 12:29 p.m., S6CNA (Resident #1`s CNA scheduled from 11:00 p.m. on 08/28/2024 to 7:00 a.m. on 08/29/2024) indicated Resident #1 was to have visual checks every 2 hours. S6CNA further indicated S3LPN did not notify her when she was unable to visualize Resident #1 during her rounds. S6CNA further indicated S3LPN should have notified staff when she was unable to locate Resident #1 so all staff could have been notified by an announcement overhead of a wandering resident being missing, and ensure S1Administrator was notified. In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1. In a telephone interview on 08/30/2023 at 7:14 p.m., S38LPN indicated on 08/29/2024 at 6:00 a.m., she was following S3LPN during medication administration rounds. S38LPN indicated she had not visualized Resident #1 during medication rounds. S38LPN indicated she was unaware S3LPN did not visualize Resident #1 during her shift. S38LPN further indicated, if she would have been aware Resident #1 was unable to be located she would have notified other facility staff to assist with attempts to locate Resident #1. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders. In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders. Resident #2 Review of Resident #2's record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of, in part, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and syncope and collapse (condition where the resident loses consciousness briefly). Review of Resident #2's MDS with an ARD dated 06/25/2024 revealed, in part, Resident #2 was assessed with a Brief Interview for Mental Status (BIMS) score of 13 (score of 13-15 indicated Resident #2 was cognitively intact). Review of Resident #2's Elopement Risk Assessment completed on 03/23/2024 revealed, in part, Resident #2 was documented as cognitively impaired with poor decision making skills and had pertinent diagnoses. Further review revealed Resident #2 ambulated independently. Review of Resident #2's Elopement Risk Assessment summary/conclusions revealed wander guard placement. Review of Resident #2's nurse's note dated 06/25/2024 revealed, in part, Resident #2 had a wander guard on which was to be checked daily. Further review revealed Resident #2 was sometimes confused and was observed going to the exit doors. Review of Resident #2's most recent Care Plan revealed a focus of Resident #2 had exit seeking behaviors and was considered an elopement risk and had a wander guard with a focus onset date of 07/23/2021 and a target date of 09/2/2024. Further review revealed interventions included, in part, monitor Resident #2 every 2 hours and as needed; apply a wander guard to Resident #2; check Resident #2's wander guard placement every shift; photographic documentation of Resident #2 in the elopement binder; and alert staff of Resident #2's high risk for elopement. Review of Resident #2's August 2024 Physician's Orders revealed, in part, the following: check Resident #2's wander guard every day for proper operation; wander guard for safety with visual checks every 2 hours and as needed daily due to Resident #2's poor impulse control; and, visual checks every hour and as needed daily due to Resident #2 wandered in other residents rooms. Observation on 08/30/2024 at 9:36 a.m. revealed Resident #2's two windows in his room were able to be unlocked and fully opened. Observation further revealed Resident #2's window opened into the facility's outdoor courtyard. In an interview on 08/30/2024 at 9:40 a.m., S35Certified Nursing Assistant (CNA) Supervisor confirmed Resident #2 ambulated without assistance or assistive devices. In an interview on 08/30/2024 at 9:41 a.m., S9Licensed Practical Nurse (LPN) confirmed Resident #2 was able to walk independently. Observation on 08/30/2024 at 9:42 a.m. revealed Resident #2 ambulated in his room independently without staff assistance or mobility devices. In an interview on 08/30/2024 at 9:44 a.m., S15LPN indicated Resident #2 was independent with ambulation. S15LPN further confirmed Resident #2 had a wander guard bracelet present. In an interview on 08/30/204 at 11:32 a.m., S37CNA confirmed she was assigned to Resident #2. S37CNA failed to identify Resident #2 as an elopement risk and was unsure if Resident #2 wore a wander guard. S37CNA indicated if Resident #2 was an elopement risk, they would check on Resident #2 often and round at least every 2 hours. Resident #3 Review of Resident #3's record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, major depressive disorder; pseudobulbar affect (condition characterized by episodes of sudden uncontrollable inappropriate laughing or crying); bipolar disorder (condition characterized by unusual shifts in a person's mood); and traumatic brain injury (condition caused by injury to the brain). Review of Resident #3's MDS with an ARD dated 06/12/2024 revealed, in part, Resident #3 was assessed with a BIMS of 6 (a score of 00-07 indicated a severe cognitive impairment). Further review revealed Resident #3 required partial to moderate assistance with dressing the lower half of her body; and, Resident #3 required partial to moderate assistance with walking 10 feet in the room or corridor. Review revealed Resident #3 used a wander/elopement alarm daily. Review of Resident #3's Psychiatric Progress Note dated 02/21/2024 revealed, in part, Resident #3 was fixated on returning home. Review of Resident #3's Elopement Risk assessment dated [DATE] revealed, in part, Resident #3 was cognitively impaired due to traumatic brain injury. Further review revealed Resident #3 was an elopement risk due to unsuccessful attempts to enter codes on exit doors. Review of Resident #3's Elopement Risk Assessment further revealed interventions of wander guard personal safety alarm device applied; photo of Resident #3 on the wander list, and staff were aware of Resident #3's wander risk. Review of Resident #3's most recent Care Plan revealed a focus of Resident #3 was at risk for elopement with a target date of 09/10/2024. Further review revealed interventions of, in part, apply wander guard as ordered; notify staff Resident #3 was at risk for elopement; observe Resident #3's whereabouts and safety every shift and as needed; and obtain a physician order and written family consent for wander guard. Review of Resident #3's August 2024 and September 2024 Physician's Orders revealed, in part, Resident #3 was to have a wander guard bracelet to her left wrist with placement check every shift, Resident #3 was to have a census check every 2 hours, and wander guard check every day for proper operation. Observation on 08/30/2024 at 9:38 a.m. revealed Resident #3's bed was next to the window which was capable of being unlocked and fully opened to the outside. Further observation revealed Resident #3's windows exited to an unsecured location outside of the facility. In an interview on 08/30/2024 at 9:40 a.m., S35Certified Nursing Assistant (CNA) Supervisor confirmed Resident #3 ambulated without assistance or assistive devices. In an interview on 08/30/2024 at 9:46 a.m., S15Licensed Practical Nurse (LPN) confirmed Resident #3 was independent with ambulation. S15LPN indicated she was not sure if Resident #3 wore a wander guard bracelet and would have to check the elopement risk binder. In an interview on 08/30/2024 at 11:11 a.m., Resident #3 indicated she did not want to be at the facility and if she could leave right now she would. Observation on 08/30/2024 at 11:19 a.m. revealed Resident #3 walked independently up and down the hall near her room with a steady gait. In an interview on 08/30/2024 at 12:14 p.m., S36CNA indicated Resident #3 was fully independent with ambulation. S36CNA further indicated she was unsure if Resident #3 was at risk for wandering but would have to check the elopement binder.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents; and, 3. Staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision; 4. The facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024, 08/14/2024, and 08/21/2024): and, 5. A nurse assigned to a group of residents did not leave the facility before the scheduled oncoming nurse arrived at the facility to assume the responsibility of a group of residents (08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024). This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate. S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to all 110 residents that were reported to reside in the facility on 08/30/2024. 1. Cross Reference F658 In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so. In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders. In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders. 2. Cross Reference F658 In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time. S2DON further indicated that S3LPN should not have documented she checked the placement of Resident #1's wander guard when she had never visualized Resident #1. 3. Cross Reference F689 In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders. In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders. 4. Cross Reference F725 In an interview on 09/04/2024 at 11:52 a.m., S20Assistant Director of Nursing (ADON) indicated that when she arrived to the facility on the morning shifts, she did not accept the responsibility of residents' direct care. S20ADON further indicated that more than 1 direct care nurse was needed for 109 to 110 residents. S20ADON confirmed she assigned 3 direct care nurses for a night shift with 109 to 110 residents. 5. Cross Reference F725 In an interview on 09/05/2024 at 9:55 a.m. S2Director of Nursing (DON) indicated if a nurse had to leave during their assigned shift or if the oncoming nurse was running late to their assigned shift, the nurse should notify administrative staff so a nurse could be assigned to the group of affected residents. S2DON further indicated residents should not be without an assigned nurse at any time. S2DON indicated on 08/21/2024 she had identified that nurses were leaving their assigned shift prior to the oncoming nurse arriving at the facility, leaving residents without an assigned nurse. S2DON confirmed administrative staff was not made aware of the above mentioned time periods where residents were left without an assigned nurse to care for them. S2DON indicated she was unaware of how frequently nurses were leaving residents without an assigned nurse.

Based on interview and record review, the facility failed to administer pain medication when a nonverbal resident showed signs and symptoms of pain for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in actual harm for Resident #2 beginning on 04/09/2024 when S4Occupational Therapist (OT) reported to S3Licensed Practical Nurse (LPN) Resident #2 had facial grimacing with movement of the right lower extremity with no intervention to manage Resident #2's pain. Findings: Review of the facility's policy titled, Pain Management dated January 2024 revealed, in part, identifying pain in a non-verbal resident was observing for facial grimacing and being resistive to movement and care. Further review revealed pain can be managed by pharmacological interventions such as prescribed medication. Further review revealed interventions for pain would need to be reassessed and if it has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Review of Resident #2's record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, in part, of aphasia (a condition in which a person is unable to express themselves verbally) and a history of Polio (a virus that may cause muscle pain, joint pain, loss of bone density, and osteoporosis related fractures). Review of Resident #2's Polio care plan initiated on 12/06/2023 revealed, in part, an intervention for staff to observe Resident #2 for muscle, bone or joint pain and medicate as ordered. Review of Resident #2's April 2024 Physician's orders revealed, in part, an order with a start date of 11/18/2019 for Acetaminophen (a medication given for pain) 325 milligrams (mg) tablet give 2 tablets every 6 hours as needed for pain. Review of Resident #2's Occupational Therapist note dated 04/09/2024 revealed Resident #2 had appeared uncomfortable and was grimacing with right lower extremity movement. Review or Resident #2's nurse's notes dated 04/10/2024 at 3:23 p.m., revealed S3Licensed Practical Nurse (LPN) documented Resident #2 was complaining of pain to the right lower leg. Review of Resident #2's April 2024 Electronic Medication Administration Record (EMAR) revealed no documented evidence and the facility was unable to provide any documented evidence Resident #2 received pain medication. Review of Resident #2's x-ray results dated 04/11/2024 revealed, in part, a subacute fracture of the left distal femur (bone in upper leg) which required surgery. In an interview on 04/16/2024 at 2:16 p.m., S4OT indicated she worked with Resident #2 on 04/09/2024. S4OT further indicated when she went to take Resident #2's legs off of the leg rest and Resident #2 grimaced in pain. S4OT stated she notified S3LPN of Resident #2's pain. In an interview on 04/16/2024 at 2:54 p.m., S5Certfiied Nursing Assistant (CNA) indicated on 04/10/2024, Resident #2 pushed her a way when S5CNA would touch or try to reposition Resident #2. S5CNA further indicated Resident #2 displayed facial grimacing. In an interview on 04/17/2024 at 1:00 p.m., S5CNA indicated on 04/11/2024, Resident #2 did not want to be touched, and she reported Resident #2's pain to S7CNA Supervisor. S5CNA further indicated S7CNA Supervisor instructed her to report Resident #2's pain to the Director of Nursing (DON). In an interview on 04/17/2024 at 1:10 p.m., S2DON indicated she went to assess Resident #2 after S5CNA reported Resident #2 did not want to be touched, and S2DON noticed bruising and swelling to Resident #2's left lower leg. S2DON further indicated she notified Resident #2's doctor after her assessment, and the doctor ordered an x-ray, which revealed a fracture. In an interview on 04/17/2024 at 3:20 p.m., S3LPN indicated a nonverbal sign of pain was facial grimacing. S3LPN confirmed she did not give Resident #2 any pain medication on 04/09/2024 or 04/10/2024 following staff's reports of Resident #2's pain. S3LPN further indicated she should have given Resident #2 pain medication. In an interview on 04/17/2024 at 4:27 p.m., S2Director of Nursing indicated the nurse should have administered pain medication to Resident #2.

Based on record review, observations, and interview, the facility failed to: 1. assess the resident for risk of entrapment from bedrails prior to installation; 2. review the risks and benefits with the resident's representative and obtain informed consent prior to installation; 3. assess the resident's mattress for compatibility with the bedrails and bed frame; and 4. ensure scheduled maintenance of bedrails in use according to the manufacturers' recommendations and specifications for installing and maintaining bedrails. The deficient practice was identified for 1 (#1) of 5 (#1-#5) residents reviewed for bedrail use. The deficient practice resulted in an Immediate Jeopardy for Resident #1 on [DATE] at 3:06am when a CNA found the resident lying in bed on her right side, with her feet hanging on the floor, and her jaw and part of her neck lodged in the bedrail. Resident #1 was found unresponsive, pale, with a faint pulse of 45 beats per minute. EMS (Emergency Medical Services) was contacted. CPR (cardiopulmonary resuscitation) was initiated and was in progress by 3 staff members until first responders arrived at 3:05am and took over CPR. The resident expired on [DATE] at 3:39 am. The deficient practice ended for the other 25 residents with side rail usage (Resident #2-#26) on [DATE] when all resident side rail assessments, resident risk for entrapment assessments, and in-services/trainings had been completed. On [DATE] the facility had decreased the side rail usage to only 11 residents (Resident #2-#12). The facility fully implemented a corrective action plan which was completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #1's record revealed the resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. Review of Resident #1's record revealed [DIAGNOSES REDACTED]. Further review revealed an unstaged wound to the sacrum. Review of Resident #1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed in part: the resident had a BIMS (Brief interview for mental status) score of 5 (score of ,[DATE] indicated severely impaired cognition for daily decision making). Resident #1 had no signs or symptoms of [MEDICAL CONDITION] noted and no behaviors noted. Resident #1 required extensive assistance of one person for bed mobility and extensive assistance of two persons for transfers. Review of Resident #1's record revealed no documented evidence of an assessment of Resident #1's bed rails for risk for entrapment, no documented evidence of an assessment for Resident #1's need for bed rail use, and no documented evidence of informed consent by Resident #1's Representative for side rail usage. Review of Resident #1's Care Plan revealed the resident required extensive to total assistance with ADLS due to a [DIAGNOSES REDACTED]. Resident #1 was at risk for alteration in skin integrity related to existing pressure ulcer, with goal date of [DATE], with an approach of place resident on air mattress for wounds. Resident #1 had a potential for falls related to weakness, unsteady gait and decreased cognition with goal date of [DATE]. Further review revealed the following approaches: reminder not to ambulate or transfer without assistance; assist resident in timely manner; grab bars for self-positioning; monitor position while in bed to ensure resident is in the middle of the mattress; and monitor every 2 hours and as needed. Review of Resident #1's Nurses Notes dated [DATE] at 4:13am (late entry) revealed a staff aide called the nurse to the resident's room. The staff aide stated the resident did not look right, upon entering the room the resident noted lying in bed on her right side in the fetal position, with her head against bed rail. Resident #1 was nonresponsive, and pale in color. The nurse attempted to obtain blood pressure with a faint pulse of 45 beats per minute obtained. The facility staff contacted emergency medical services. The resident was positioned on the board and CPR (cardiopulmonary resuscitation) was initiated and was in progress by 3 staff members until two first responders arrived at 3:05am and continued CPR. Resident #1's physician was notified via phone. Police officers and emergency medical technicians arrived and continued with CPR. Further review revealed the police officer stated the resident had expired. Review of Resident #1's Nurses Notes dated [DATE] at 7:13am revealed the resident's time of death was called at 3:39am. In an interview on [DATE] at 1:02pm, S2Regional Administrator stated Resident #1 was placed in the bed with side rails and the alternating pressure and low air loss mattress. S2Regional Administrator stated that Resident #1 was on the same bed with side rails and the alternating mattress that was placed on when admitted to the facility. Review of S5CNA Supervisor's statement dated [DATE] revealed on [DATE] at 12:45am while getting her supplies, she noticed Resident #1 with her legs hanging out of bed and her upper body against the grab bar. S5CNA Supervisor asked the resident to let her (S5CNA Supervisor) help her reposition. Resident #1 stated, I'm trying to go home. S5CNA Supervisor stated she repositioned the resident laying her in the bed properly on her left side, with a pillow behind the resident's back. Further review revealed around 3:00am S3CNA called for help to Resident #1's room. S5CNA Supervisor documented the resident's legs were out of the bed and the resident's head was between the grab bar and the mattress and the resident appeared unresponsive. S5CNA Supervisor stated we lifted the resident and placed her properly in the bed. S5CNA Supervisor documented they then obtained the crash cart and began CPR until the emergency medical staff arrived and took over. Review of S3CNA's statement dated [DATE] revealed on [DATE] at approximately 3:06am she (S3CNA) was walking on the resident's hallway. S3CNA documented she happened to glance into the resident's room and saw the resident was on her right side with her feet hanging on the floor. S3CNA documented she ran to look for help, and found S4LPN and S5CNA supervisor. S3CNA, S4LPN, and S5CNA Supervisor all ran to the resident's room and found Resident #1's jaw and part of her neck was in the bed rail. The staff rolled the resident over in the bed and the nurse started her assessment. S3CNA, S4LPN, and S5CNA Supervisor performed CPR until emergency medical services arrived. Review of S6CNA's statement dated [DATE] revealed on [DATE] at approximately 12:51pm the CNA went into Resident #1's room and called for another staff to assist in repositioning her in bed. S6CNA documented at approximately 1:37am or 2:30am S6CNA had glanced in the room and the resident was on her back watching television. S6CNA documented she went on her lunch break at 3:05am. S6CNA documented approximately around 3:10am, she was told to go check on Resident #1 and upon arrival, she walked upon the officers. Review of S4LPN's statement dated [DATE] revealed on [DATE] upon making nursing rounds up and down hallway between 1:30am and 2:30am she had checked on the resident by looking into room. Resident #1 appeared to be sleeping with eyes closed lying supine position. At around 2:50am a staff member came to the nurse and requested she check on the resident. The staff member stated the resident did not look right, and upon entering resident's room, the resident was lying in the fetal position on her right side with her left leg handing out of bed, and the resident's head was lodged in the side rail. Resident #1 was nonresponsive. S4LPN with two other staff members repositioned the resident and dislodged the resident's head, and positioned the resident supine on bed. Resident #1's vital signs were attempted with a faint pulse of 45 beats per minute. CPR initiated while another staff member contacted emergency medical services. S4LPN documented she continued CPR until the first responders took over. Emergency medical technicians and police officers arrived. Emergency medical technicians announced the resident had expired. In an interview on [DATE] at 3:18pm, S5CNA Supervisor stated on [DATE] she was up and down the halls helping but was assigned a different hall, not Resident #1's hall. S5CNA Supervisor stated the first time she passed her room she looked okay, then around 1:05am she had checked on the resident and the resident's feet were hanging out of the bed, and she was holding on to the rail. Resident #1 stated she was going home. S5CNA Supervisor stated she had put the resident back in bed, facing the left side with a pillow supporting her back to keep her from getting back up. Resident #1 did not try to move again once I repositioned her again. S5CNA Supervisor stated she had placed Resident #1's bed in the lowest position, and the resident was calm and peaceful when I left the room. Upon leaving the resident's room, the nurse was passing medications on the hall. S5CNA Supervisor stated she notified S6CNA, the CNA assigned to Resident #1, to keep a close eye on the resident. S5CNA Supervisor further stated S3CNA was making rounds on the hall and saw the resident's legs hanging out of the bed again and called for assistance. S5CNA Supervisor stated we (S5CNA Supervisor and S3CNA) assisted S4LPN with repositioning the resident and started CPR. In an interview on [DATE] at 10:32am, S4LPN stated prior to the incident she had observed Resident #1 lying supine with her eyes closed facing the television. S4LPN stated around 3:00am she was by the nurses' station and S3CNA stated she needed a nurse and the resident did not look right. S4LPN stated Resident #1 was laying on the bed in the fetal position, with her feet hanging down out of the bed with the resident's chin was leaning in side rail and the resident's head was stuck in the bedrail. S4LPN stated they could not get an accurate palpable pulse, but on pulse oximeter, the heart rate registered 45 beats per minute. S4LPN stated they obtained the crash cart, positioned the resident and started CPR, and notified emergency support services. S4LPN stated the police and first responders came first and took over CPR. S4LPN confirmed Resident #1 was using a low air loss mattress when she was found in the side rails. In an interview on [DATE] at 11:29am, S3CNA stated Resident #1 was not assigned to her on [DATE], however she was walking down Resident #1's hallway the night of the incident. S3CNA stated upon passing Resident #1's room she had noticed the resident's legs hanging off bed. S3CNA stated Resident #1's head and neck was stuck in the side rail. S3CNA stated she knew she could not move the resident and she ran to get help. S3CNA stated she found S4LPN and S5CNA Supervisor, and it took the three of them to get the resident back on the bed properly. S3CNA stated someone got the CPR board and the crash cart. S3CNA stated they started CPR and they placed the pulse oximeter and some numbers popped up, S3CNA stated she thought someone stated they obtained a 45 beats per minute heartrate. S3CNA stated the first responders took over CPR when they arrived. In an interview on [DATE] at 3:01pm, S7LPN stated Resident #1 was in a good mood but extremely confused, which was normal for her. S7LPN stated the night before the incident, she was moving around and repositioning herself in the bed and we would have to reposition her due to her sacral wound. Resident #1 favored her right side and would squirm in bed to get close to the rail. S7LPN stated the staff were trying to keep her off that side due to the wound. Review of Drive P503 Owner's Manual (brand of bed frame and bedrail used for Resident #1) revealed the mattress thickness range should be between 5.5 inches and 7 inches. Further review revealed possible entrapment hazard may occur if you do not use the recommended specification mattress. Resident entrapment may occur leading to injury or death. Mattress height must be a minimum of 5.5 inches and a maximum of 7 inches. Review of Drive Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress Replacement System Operator's Manual, (brand of mattress used for Resident #1) revealed the air cells were 8 inches in height with a static 4 inch air call base. In an interview on [DATE] at 11:10am, S2Regional Administrator stated the facility had a system called BIONIX Bed System Measurement Device, which was used to assess the beds and bed rails for entrapment risk. S2Regional Administrator stated the last time the beds and rails were assessed prior to [DATE] was on [DATE]. S2Regional Administrator stated he could not guarantee Resident #1's mattress, bed, and side rails were tested on [DATE], and the facility did not have a system in place to assess the bed rails on an ongoing basis until [DATE]. S2Regional Administrator further presented training and in-services for maintenance to perform monthly side rails assessments on all beds with side rails in use. S2Regional Administrator further stated the facility since [DATE] had assessed all residents for side rail usage, and removed side rails which were not needed, assessed all side rails for risk for entrapment, updated care plans, updated consents for side rail usage, and obtained physician orders [REDACTED]. S2Regional Administrator stated the facility did not have any documentation to present of Resident #1 having been assessed for side rail usage and risk for entrapment. In an interview on [DATE] at 1:02pm, S2Regional Administrator stated the bed came with the side rails and both the bed and the mattress was from the same manufacturer. S2Regional Administrator stated the air mattress with the side rails was the cause of Resident #1's entrapment. S2Regional Administrator stated Resident #1 was placed in the bed with side rails and air mattress upon admit on [DATE]. In an interview on [DATE] at 12:44pm, S1Administrator stated the facility chose to make it a policy to no longer use side rails with low air loss beds in the facility. S1Administrator stated upon investigating the incident on [DATE] Resident #1's mattress was set to alternating pressure and they theorized the alternating of pressure in the mattress allowed her head to become entrapped. In an interview on [DATE] at 12:52pm, S2Regional Administrator stated the facility could not say that the facility had in-serviced the staff prior to this event regarding monitoring for gaps in the bed. Review of In-service Environmental Rounds dated [DATE] revealed housekeeping to make environmental observations while cleaning be sure to report any maintenance concerns to maintenance director or add to repair binder at nurse's station. Further review revealed housekeeping staff present during inservice. Review of In-service Side Rails dated [DATE] revealed maintenance to check side rails on a monthly basis to ensure there are no gaps between the mattress and the side rail, and side rails and in working order without disrepair. Maintenance Director to use bed rail check sheet and bed rail test results worksheet attached. Review of In-service Hospital Bed Safety and Entrapment dated [DATE] revealed an in-service on entrapment, assessing bed for grab/side rails bars, ensuring residents are safe, reporting any/all rails are considered a restraint. Review revealed report any/all concerns or issues to the supervisor on duty. Further review revealed entrapment zones- the head, neck, and chest as key body parts at risk for entrapment. In-service identified these 7 potential zones of entrapment in hospital beds: within the rail, under the rail, between the rail supports or next to a single rail support, between the rail and the mattress, between the rail at the ends of the rail, between the split bed rails, between the end of the rail and side edge of the head or foot board; between the head or foot board and the mattress end; access if rails are necessary in each instance; other potential hazards associated with bed rail use; including serious injuries from falls when patients climb over rails; and patients feel isolated or unnecessarily restricted. Further review revealed safety tips of: ensure that each component the bed frame, mattress and rails and any added accessories properly fits together make sure the mattress is the correct size for the bed frame so unsafe gaps are not present; if you see an opening let a health care professional know or call the manufacturer. When in doubt consult the bed frame manufacturer to determine if a component or accessory is compatible with your bed frame; use rails cautiously patients should not try to climb around or over the rails to get out of bed. Review of the facility's QAPI (Quality Assurance and Performance Improvement) Binder revealed all residents residing in the facility were screened for possible use/need for bed rails by end of day on [DATE]. Review revealed all 11 residents with bed rails had consents signed for side rail usage completed [DATE]. Further review revealed all 11 residents in the facility with side rail usage had weekly bed rail assessments completed with the BIONIX Bed System Measurement Device and initialed or completed by S2Regional Administrator. Observation on [DATE] at 12:30am revealed the facility had 11 residents residing in the facility with a bed rail in use. Further observation revealed none of the residents requiring the need of bed rails had a low air loss/alternating pressure mattress, and all of the residents with bed rails had properly fitting mattresses with the bed rails. In [DATE] at 2:30pm, S1Administrator and S2Regional Administrator stated the administrator and QAPI would review all resident assessments, consents, and bed rail assessments weekly for one month, then monthly for three months, and then quarterly during QAPI meetings. On [DATE] at 2:30pm, S1Administrator and S2Regional Administrator was informed of the Past Noncompliance at the Immediate Jeopardy level that began on [DATE] when Resident #1 was admitted and placed on an alternating pressure/low air loss mattress and ended on [DATE] when all assessments and staff in-services/trainings were completed. The facility has implemented the following actions to correct the deficient practice: 1. On [DATE], the facility assessed every resident with low air loss mattresses and implemented protective interventions as needed. Any mattress and bed frame for any resident, which did not meet standards, was changed to ensure proper fitting between mattress and frame. 2. On [DATE], the facility assessed every resident with a side rail on their bed and implemented protective interventions as needed. All beds with side rails were assessed to assure side rails were securely mounted to the bed and no gaps exists between mattress and bed rail such that could entrap resident head or body. Any mattress and bed frame for any resident, which did not meet standards, was changed to ensure proper fitting between mattress and frame. 3. The facility utilized the BIONIX entrapment Measurement Tool to assist staff in assessing risk for entrapment. Using the Entrapment Measurement Tool, the staff ensured each resident was appropriately assessed for entrapment risk, prior to distributing an air-filled mattress and/or prior to changing out a mattress, i.e. pressure relieving mattress or some other type. Ongoing assessment will be completed on a monthly basis. 4. Residents with air-filled mattresses will be reviewed weekly for one month, then monthly x3 months and then quarterly. 5. Findings will be reported to the facility's QAPI committee, on a quarterly basis and as needed. 6. Direct care staff were in-serviced on [DATE]. Each staff will be in serviced upon hire, annually, and as needed regarding immediate reporting of concerns/issues related to air-filled mattresses or any mattress, by the staff development coordinator/designee. Learning effectiveness will be evaluated by discussions, return demonstrations, performance observations, and/or a written post-test. 7. On [DATE], the facility put into effect a policy to no longer use side rails with a low air loss mattress. Staff have been trained in proper handling of emergency situations. 1. On [DATE] the staff development coordinator in-serviced staff on proper handling of emergency situations. 2. If not already done, the facility will ensure that all staff are in-serviced in advance of their oncoming shift. Topics to be covered include [MEDICAL CONDITION], Choking, and Care of the Fallen be at shift change, to ensure all staff are in-serviced prior to providing care. 3. The NFA/DON will ensure all staff are in-serviced. Emergency Situation Response will be incorporated into the facility's staff development program upon hire, annually, or as needed. 4. Staff development coordinator will provide written documentation, to the NFA/DON, to ensure all current employees have been in-serviced. A written summary will be presented, discussed, and reviewed during the facility's quarterly QAPI committee meeting. Issues/concerns requiring immediate attention may be addressed by a QAPI call meeting. Findings of existing side rails in facility: 1. On [DATE], 35 of the facility's 122 total beds were identified to have bed rails. Of these only 25 of 35 are currently in use. All are appropriately attached. 2. When side rails are necessary, the facility will ensure all beds, with bed rails attached, are without disrepair. 3. The nursing staff will review the side rail assessments for all current residents for completion and accuracy. The nursing staff will also physically observe all residents to ensure assessment interventions have been implemented, by [DATE]. 4. The facility's maintenance staff will audit all beds to identify maintenance needs, monthly. Findings will be reported to the nursing facility administration, upon completion. A side rail assessment will be completed: prior to placing side rails, and if placed, at least quarterly and with significant change. The Nurse Management Team will in-service licensed nursing staff on the correct completion of side rail assessments, prior to implementing the use of side rails for a resident currently without side rails. The facility's administrative staff will implement the use of Safety rounds to ensure routine identification of safety concerns. The nursing staff will re-evaluate each resident's need for bed rails, utilizing an objective set of criteria-not to supersede clinical judgement, nor ignore the facility's commitment to resident-centered care. 5. On [DATE], of the 25 currently in use, the facility determined that only 20 of these are appropriate. 6. On [DATE], of the 20 currently in use, the facility determined that only 11 of these are appropriate. Facility had completed all corrective actions on [DATE].

Based on record review and interview the facility failed to provide adequate supervision and monitoring to prevent a confused, wandering resident (#4) from eloping 75 to 100 yards away from the facility. The facility identified 9 residents (#4 - #12) as having wandering behaviors. The facility failed to: 1) Have a system in place to monitor the correct operation of the " coded alert bracelet " door alarm system, Wanderguard system. 2) Have a system in place to verify and monitor the coded alert bracelet secured to the extremities of residents identified as wanderers were activated by the 90 day activation date on the device; so that once the devices were activated the facility would know when the 90 day time period was up. 3) Immediately conduct a thorough investigation to determine how a confused, wandering Resident #4 got out of the facility on 10/09/13 without the facility staff being aware of her exit from the building. 4) The facility failed to have a post elopement policy and procedure to have the facility's quality assurances/improvement team review facility systems to evaluate if all systems are working properly after a confused, wandering Resident # 4 wearing a coded alert bracelet device eloped from the facility without staff knowledge on 10/9/13. 5) Failed to document when a new wanderguard was replaced per policy. The Immediate Jeopardy (IJ) began on 10/9/13 at 5:45pm for Resident # 4, a confused resident with wandering behaviors, after the resident was discovered missing from the facility. During the time of the elopement, Resident #4 was wearing a " coded alert bracelet " device designed to lock the facility exit doors when the resident came in close proximity to any closed exit door equipped with the " Coded Alert Bracelet " alarm system. The resident's coded alert bracelet also was designed to sound an audible alarm if the exit door was open and the resident wearing the coded alert bracelet neared the door in order to alert staff of possible resident elopement or wandering out of the facility. The immediate jeopardy continued on 10/9/13 for the other 8 residents (#5, #6, #7, #8, #9, #10, #11, & #12) identified by the facility as having wandering behaviors when Resident # 4 was returned to the facility and the facility failed to immediately identify and implement interventions to prevent the other identified residents ' elopement from the facility. The Immediate Jeopardy was lifted on 10/28/13 at 11:50pm, when an acceptable plan of removal was presented. The facility's plan revealed the elopement policy and procedure and the Wanderguard policy and procedure were established and available at the nurse ' s station, Wanderguards would be dated in permanent marker with the date it is placed on the resident, door monitor daily log would be implemented and kept in the administrator ' s office, Wanderguard devices would be checked every shift by the nurses and, all nurses have been inserviced starting on 10/25/13 of the new procedure, 90 day tracking log for signaling devices began and kept at each nurse ' s station, a list of current Wanderguard residents would be kept at the two nurse ' s station and updated weekly by social services, beginning in October 2013, facility is conducting monthly elopement drills for 6 months and then yearly thereafter, all Wanderguards were replaced 10/25/13 and checked for proper functioning, 4 additional signaling devise testers were ordered 10/25/13 and to be kept at each nurses cart, facility wide inservices to disseminate all new policies and procedures are to happen on November 7th, 2013. There were 9 of 9 residents (#4- #12) identified as confused residents with wandering behaviors with a total sample of 12 residents. The facility's Resident Census and Conditions of Residents was listed as having 109 residents residing at the facility on 10/24/13. The deficient practice remains at a Scope/Severity of level 2 (E), potential for more than minimum harm, pattern for all residents with wanderguard devices(#4-#12). Findings: In an interview on 10/24/13 at 9:30am, S1/Administrator stated that Resident #4 had eloped from the facility and she had walked over to another facility. S1/Administrator was asked to present everything the facility had done related to the resident ' s elopement and prevention. Review of Resident #3 ' s Minimum Data assessment dated [DATE], an assessment done before her elopement, revealed her cognitive impairment was severely impaired. Observation on 10/24/13 at 11:10am revealed Resident #4 was in the day room with other residents and had her eyes closed with a Wanderguard applied to her left wrist. In an interview on 10/24/13 at 11:10am, S7/Activity Director stated that Resident #4 was confused and hard of hearing and the resident had to read lips to try and understand what one was saying to her. In an interview on 10/24/13 at 11:25am, Resident #4 was in the day room and was asked slowly three times about how she was doing, and she kept on answering yes; therefore, she could not be interviewed. Review of the information presented was a facility ' s investigative form , though not requested, revealed, in part, it was dated 10/9/13 at 8:25pm and had been written per S3/LPN, was the nurse at the time of Resident #3 ' s elopement.. Review of this report revealed incident type was elopement and location was off the facility grounds. Review of the narrative of incident and description of injuries revealed, in part, Resident #4 was on unit around supper in the dining room and left dining room and the search for her started immediately. Review of the report revealed Resident #4 was found around 8:25pm and was returned to facility per staff. Review of the form revealed maintenance was at the facility to check for any malfunction of the equipment or cracks in the wanderguard alarm system. Review of the next section titled immediate action taken revealed, in part, the alarm and door was checked for failure and proper functioning, the Wanderguard was checked for malfunction and camera to see if door malfunctioned, checked all alarms to see if any malfunction. Review of this form revealed medical risk factors possibly related to incident was fall history and inability of Resident #4 to understand others with confusion and disorientation. Review of S3/LPN Departmental notes dated 10/9/13 at 10:44pm revealed Resident #4 was on unit around supper in dining room and left dining room. Review of these notes revealed search was started immediately and the resident was found around 8:25pm and returned to the facility per staff. Review of the facility ' s form titled In-Service Report revealed it was dated 10/10/13 at 11:00am and a brief outline of content covered was Elopement policy and elopement drill. Review of another form with Elopement 2013 hand written on top and dated 10/9/13, revealed, in part; who was responsible and what action would be taken in certain instances. Review of this form revealed all staff (Responsibility) will notify the highest ranking personnel of missing resident (action). Review revealed the highest ranking nursing personnel will direct unit staff to begin search of unit immediately and would announce " Dr Wander " if a resident was in a room. Further review of this form revealed, in part, was a lists of what action to take in the event of an elopement. In an interview on 10/24/13 at 12:00pm, S1/Administrator stated that S3/LPN whom was taking care of resident #4 when she had eloped was off today and tomorrow (10/24/13 & 10/25/13), but he could give the surveyor her number. He was also asked again to give anything else he had related to Resident #4 ' s elopement such as an investigation or anything else the facility had done since the incident. He stated that he would get with nursing services. In an interview on 10/24/13 at 1:04pm, S2/DON was asked if she had anything else to present and she stated that there was a drill preformed which was listed on the Facility Form In-service Report dated 10/10/13 at 11:00am and under the section Evaluation, Comments, suggestions revealed all staff were able to demonstrate policy and respond correctly to drill. S2/DON was asked again if she had anything else to present related to Resident #4 ' s elopement and she stated that that she did not. In an interview on 10/24/13 at 1:10pm S1/Administrator stated that he had nothing else to present for the elopement for Resident #4. He stated that not all of his staff were recently inserviced about the elopement, and he had left an inservice for the night shift to read at the nurse ' s station. He further stated that all the staff were to be inserviced, but not everybody was inserviced. Review of the facility ' s Elopement Risk Assessment for Resident #4 dated 6/5/13 revealed, in part,(;) Resident #4 wanders aimlessly and wanders throughout the facility halls and to exits. Review of Resident #4 ' s Care Plan with a goal date of 11/12/13 revealed at risk for elopement due to cognitive lost. Review of this care plan revealed interventions to monitor the resident every 2 hours and as needed, apply Wanderguard, alert staff of high risk for elopement, and photographic documentation. Review of another problem in Resident #4 ' s Care Plan revealed a goal date of 12/12/13 and was a wander with the same interventions as above along with give a " baby dole " to walk with. In an interview on 10/25/13 at 1:05pm, S2/DON stated that Resident #4 was assessed as high risk for elopement. Review of the facility ' s Wander Guard Policy revealed that Wanderguard bracelets are checked by the floor nurses and noted in the medication administration record weekly. Wanderguard door units are monitored weekly by maintenance director. If the wander guard bracelet does not work a new functioning bracelet will be replaced immediately and documented. Review of the Wanderguard D Series Signaling Device Tester Operating Instructions Model revealed, in part, test Wanderguard signaling devices daily and record the results in the resident ' s records. Review of Wanderguard Departure Alert System User Instructions revealed, in part, Warning: Test each signaling device before using. Thereafter, test the device daily and record the results in the resident ' s records. Further review revealed Device Model is a 90-day device and date stamped shows the activate by date- the date stamped indicates the last date the device can be activated to permit approximately 90 days of use. Review further revealed a Shelf Life of 4-6 months - the device can be kept on hand 4-6 months before it must be used- check the activate by date stamped on the back. Review revealed Warning: Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash bars, push-bars, etc. Metal could interfere with the signal sent to the door modules. -Staff are to respond to every alarm and do a head count after every alarm. -Wanderguard equipment must be operated by trained personnel who are thoroughly familiar with the procedures outlined in this user manual, train and test new staff members before they begin their duties. -Test the Wandergaurd ID system regularly test each monitoring system weekly with all surrounding devices turned on, record the results, test bracelets daily as detailed in the bracelet instructions and Wanderguard ID Universal Tester Manual, record the results in each resident ' s records. -alternate monitoring protocols must be in place to help prevent unauthorized departures during the system self-test; the alarm will not sound if a resident with a bracelet exits a monitored door during the self-test; the system performs a self-test every 8 hours. -do not rely exclusively on system self-tests to indicate that the system is working properly, test all monitors at least weekly and bracelets daily using a universal tester according to the instructions -Use only Wanderguard universal tester model to test the Wanderguard ID system this is the only device to be used with the Wanderguard system. -the 90 day bracelet (models and ) is designed for 90 days of useful life if activated properly the date stamped on the bracelet indicated the last date on which the bracelet can be activated to permit approximately 90 days of use. Review of the Wanderguard Departure Alert System Wanderguard ID System User and Installation Manual revealed the following warnings: -Wanderguard ID system monitors are designed to assist staff, not replace them, the responsibility for maintaining the security of " wanderers " remains with a conscientious, alert, respond to every alarm and do a head count after every alarm. Review of the facility ' s Door Alarm Checklist revealed, in part, the only documented checks of different facility exits were done on 10/10/13, 10/11/13, and 10/15/13 per maintenance. The next day revealed the facility documented 10/24/13 on the checklist which was 9 days after 10/15/13. Review revealed there was no documentation of the door alarm checklist before Resident #4 eloped and immediately after her elopement on 10/9/13. In an interview on 10/24/13 at 2:10pm, S12/Maintenance stated that he checks the Wanderguard system weekly but had no documentation to support it. He stated that after the incident of elopement he took one Wanderguard transmitter and went to each door in the facility and made sure it worked. S12/Maintenance stated that he was not sure if the Wanderguard system was working from the resident ' s Wanderguard transmitter. In an interview on 10/24/13 at 1:20pm, with S1/Administrator, S2/DON, and S10/ADON present outside the facility when informed that per the information given and documented it was not clear as to what happened and/or what was done about Resident #4 ' s elopement. S10/ADON stated that Resident #4 was at the other facility and another unidentified lady was with her. In an interview on 10/24/13 at 1:21pm, S1/Administrator stated that the alarm quit working sometime after noon and her Wanderguard did not work when she came back to the facility. In an interview on 10/24/13 at 1:22pm, S10/ADON stated that the Wanderguard bracelets are checked weekly and documented on the Resident ' s Medication Administration Record weekly. In an interview on 10/24/13 at 1:35pm, S11/LPN, who had Resident #4 ' s Electronic Medication Administration Record (EMAR) on the computer screen, stated that the facility used to check the Wanderguard once a week but now they don ' t check it, and she looked on the EMAR for Resident #4 and stated that she did not see the Wanderguard check listed. She further stated that a month or two months ago a facility staff member used to check the Wanderguard with a scanner and it was the same system used for everybody. Review of Resident #4 ' s August, September, and October 2013 EMAR revealed, in part, Wanderguard for Safety due to Wandering, Check Workability every week on Mondays. Review of the EMAR revealed there was weekly documentation of this per S11/LPN every week prior to Resident #4 ' s elopement. Further review of the EMAR revealed there was Nurse ' s initials for Monitor the residents whereabouts every 2 hours and times to document this was 5:00am, 1:00pm, and 9:00pm. Review of the EMAR revealed on 10/9/13 there was a check for documentation of every 2 hours on the three above noted times. In interview on 10/25/13 at 9:28am S12/LPN was asked how often the nurses check the Wanderguard bracelets on the residents, and she answered she had never had to perform any checks but has heard whenever the computer prompts you to. S12/LPN further indicated I don ' t think I have any residents with Wanderguards at all. S12/LPN was asked if she took care of Resident #5 and Resident #7 and she responded yes and proceeded to the residents in their wheelchairs, in the hallway near the doorway by the nurses ' station. She was able to locate Resident #5 ' s Wanderguard on her body, but not able to locate Resident #7 ' s Wanderguard on any of her extremities. In interview on 10/25/13 at 9:44am, S1/Administrator stated that the nurses were checking the Wanderguard bracelets weekly but new policy went into effect today (10/25/13) to check the Wanderguard bracelets twice a day. He stated that the staff will either use the tester to check the bracelets or will bring them by the door to see if alarm goes off. S1/Administrator further stated that he was not aware of the Wanderguard bracelets having an activate by date on the bracelet or the bracelet only being a 90-day bracelet. Observation on 10/25/13 at 9:33am, Resident #7 was observed with no Wanderguard present and this was also observed by S13/LPN. Observation on 10/25/13 starting at 9:44am, revealed with S1/Administrator present for confirmation of the following resident ' s Wanderguards revealed the following: -at 9:44am revealed Resident #5 with a Wanderguard to left wrist with activate by date of 06/19/13, -at 9:50am revealed Resident #6 with a Wanderguard to left handle of back of wheelchair with activate by date of 03/20/13, -at 9:50am revealed Resident #8 with a Wander guard to left arm with activate by date of 12/10/13, -at 9:52am revealed Resident #9 with a Wanderguard to left wrist with activate by date of 6/19/13, -at 9:52am revealed Resident #12 with a Wanderguard to right wrist with activate by date of 12/10/13, -at 9:53am revealed Resident # 10 had no Wanderguard applied to her body, -at 9:55am revealed Resident #11 with a Wanderguard to her right wrist with activate by date of 03/20/13. There were no noted activation dates of when these Wanderguards were placed on these above residents and there was no other system presented to show document of the activation dates so the facility would know when the 90 day time frame was up for replacement per manufacturer recommendations. In interview on 10/25/13 at 10:35am, S1/Administrator, S14/Admissions, and S10/ADON present with surveyor to show the surveyors how to check the alarm with the tester they (Administrator, Admissions, and ADON) were unaware if the tester was compatible with the bracelet or if the bracelet was compatible with two types of wander guard systems Model # and Part Number 0900-272 In an interview on 10/25/13 at 2:20pm, S3/LPN stated that the last time she had seen Resident #4 was on 10/9/13 at 5:45pm. She stated that the Resident #4 was at the building which was 4 or 5 stories high across the street and police had been called and had notified the staff when she was found and the police returned the resident to the facility. S3/LPN further stated that we don ' t check the Wanderguard and the former DON used to check the Wanderguard and we are supposed to check the Wanderguard on the day shift but have a lot to do. In an interview on 10/25/13 at 3:11pm S4/CNA stated that he last saw Resident #4 on 10/9/13 at 4:45pm. He stated that Resident #4 had a Wanderguard but the staff did not hear the alarm go off. S4/CNA stated that when Resident #4 came back we cut off her Wanderguard, and he put a new Wanderguard on her from the charge nurse who gave it to him. S4/CNA stated that he checked the old alarm that was cut off by the door and it wasn ' t working. S4/C.N.A stated that other than seeing the Wanderguard on the resident they do not know which resident has them on. S4/CNA stated that the day she was missing S5/CNA and him started checking rooms and no announcements were made of the elopement until all rooms were checked by them. S4/CNA stated that when they couldn' t find Resident #4 then the Charge Nurse was notified and announcements were made to start searching for Resident #4. In interview on 10/25/13 at 3:36pm S14/Admissions was asked when the elopement policy was created she indicated the policy presented was revised on 10/10/13. S14/Admission was then asked for policy and procedure in effect the day of the elopement and she indicated she was unsure if there was one and she would pull the policy and procedure binder to see if the facility even has one. In interview on 10/25/13 at 3:38pm S14/Admissions stated that the facility did not have any elopement policy and procedure before the elopement on 10/09/13. In interview on 10/25/13 at 3:52pm, S1/Administrator stated that the facility did not have an elopement policy prior to 10/09/13.

Based on record review and interview the facility failed to be administered in manner to use its resources effectively and efficiently to attain the highest practical wellbeing by not providing adequate supervision and monitoring to prevent a confused, wandering resident (#4) from eloping from the facility crossing the street to another building approximately 75 to 100 yards away from the facility. The facility identified 9 residents (#4, - #12) as having wandering behaviors. The facility failed to: 1) Have a system in place to monitor the correct operation of the " coded alert bracelet " door alarm system, Wanderguard system. 2) Have a system in place to verify and monitor the coded alert bracelet secured to the extremities of residents identified as wanderers were activated by the 90 day activation date on the device so that once the devices were activated the facility would know when the 90 day time period was up. 3) Immediately conduct a thorough investigation to determine how a confused, wandering Resident #4 got out of the facility on 10/09/13 without the facility staff being aware of her exit from the building. 4) The facility failed to have a post elopement policy and procedure to have the facility's quality assurances/improvement team review facility systems to evaluate if all systems are working properly after a confused, wandering Resident # 4 wearing a coded alert bracelet device eloped from the facility without staff knowledge on 10/9/13. 5) Failed to document when a new wanderguard was replaced per policy. The Immediate Jeopardy (IJ) began on 10/9/13 at or around 5:45pm for Resident # 4, a confused resident with wandering behaviors, after the resident was discovered missing from the facility. During the time of the elopement, Resident #4 was wearing a " coded alert bracelet " device designed to lock the facility exit doors when the resident came in close proximity to any closed exit door equipped with the " Coded Alert Bracelet " alarm system. The resident's coded alert bracelet also was designed to sound an audible alarm if the exit door was open and the resident wearing the coded alert bracelet neared the door in order to alert staff of possible resident elopement or wandering out of the facility. The immediate jeopardy continued on 10/9/13 for the other 8 residents (#5, #6, #7, #8, #9, #10, #11, & #12) identified by the facility as having wandering behaviors when Resident # 4 was returned to the facility and the facility failed to immediately identify and implement interventions to prevent the other identified residents ' elopement from the facility. The Immediate Jeopardy was lifted on 10/28/13 at 11:50pm, when an acceptable plan of removal was presented to the surveyor. The facility's plan revealed the elopement policy and procedure and the Wanderguard policy and procedure were established and available at the nurse ' s station, Wanderguards would be dated in permanent marker with the date it is placed on the resident, door monitor daily log would be implemented and kept in the administrator ' s office, Wanderguard devices would be checked every shift by the nurses and all nurses, all nurses have been inserviced starting on 10/25/13 of the new procedure, 90 day tracking log for signaling devices began and kept at each nurse ' s station, a list of current Wanderguard residents would be kept at the two nurse ' s station and updated weekly by social services, beginning in October 2013, facility is conducting monthly elopement drills for 6 months and then yearly thereafter, all Wanderguards were replaced 10/25/13 and checked for proper functioning, 4 additional signaling devise testers were ordered 10/25/13 and to be kept at each nurses cart, facility wide inservices to disseminate all new policies and procedures are to happen on November 7th, 2013. There were 9 of 9 residents (#4-#12) identified as confused residents with wandering behaviors with a total sample of 12 residents. The facility's Resident Census and Conditions of Residents was listed as having 109 residents residing at the facility on 10/24/13. The deficient practice remains at Scope/Severity of level 2 (E), potential for more than minimum harm, pattern. Findings: In an interview on 10/24/13 at 9:30am, S1/Administrator stated that Resident #4 had eloped from the facility and she had walked over to another facility. S1/Administrator was asked to present everything the facility had done related to the resident's elopement and prevention. Review of Resident #3 ' s Minimum Data assessment dated [DATE], an assessment done before her elopement revealed her cognitive impairment was severely impaired. Observation on 10/24/13 at 11:10am revealed Resident #4 was in the day room with other residents and had her eyes closed with a Wanderguard applied to her left wrist. In an interview on 10/24/13 at 11:10am, S7/Activity Director stated that Resident #4 was confused and hard of hearing and the resident had to read lips to try and understand what one was saying to her. In an interview on 10/24/13 at 11:25am, Resident #4 was in the day room and was asked slowly three times about how she was doing, and she kept on answering yes; therefore, she could not be interviewed. Review of the information presented was a facility ' s investigative form, though not requested, revealed, in part, it was dated 10/9/13 at 8:25pm and had been written per S3/LPN, who was the nurse at the time of Resident #3 ' s elopement.. Review of this report revealed incident type was elopement and location was off the facility grounds. Review of the narrative of incident and description of injuries revealed, in part, Resident #4 was on unit around supper in the dining room and left dining room and the search for her started immediately. Review of the report revealed Resident #4 was found around 8:25pm and was returned to facility per staff. Review of the form revealed maintenance was at the facility for the alarms and to check for any malfunction of the equipment or cracks in the system. Review of the next section titled immediate action taken revealed, in part, the alarm and door was checked for failure and proper functioning, the Wanderguard was checked for malfunction and camera to see if door malfunctioned, checked all alarms to see if any malfunction. Review of this form revealed medical risk factors possibly related to incident was fall history and inability of Resident #4 to understand others with confusion and disorientation. Review of S3/LPN Departmental notes dated 10/9/13 at 10:44pm revealed Resident #4 was on unit around supper in dining room and left dining room. Review of these notes revealed search was started immediately and the resident was found around 8:25pm and returned to the facility per staff. Review of the facility ' s form titled In-Service Report revealed it was dated 10/10/13 at 11:00am and a brief outline of content covered was Elopement policy and elopement drill. Review of another form with Elopement 2013 hand written on top and dated 10/9/13, revealed, in part,(;) of who was responsible and what action would be taken in certain instances. Review of this form revealed all staff (Responsibility) will notify the highest ranking personnel of missing resident (action). Review revealed the highest ranking nursing personnel will direct unit staff to begin search of unit immediately and would announce " Dr Wander " if a resident was in a room. Further review of this form revealed, in part, was a lists of what action to take in the event of an elopement. In an interview on 10/24/13 at 12:00pm, S1/Administrator stated that S3/LPN whom was taking care of resident #4 when she had eloped was off today and tomorrow (10/24/13 & 10/25/13), but he could give the surveyor her number. He was also asked again to give anything else he had related to Resident #4 ' s elopement such as an investigation or anything else the facility had done since the incident. He stated that he would get with nursing services. In an interview on 10/24/13 at 1:04pm, S2/DON was asked if she had anything else to present and she stated that there was a drill preformed which was listed on the Facility Form In-service Report dated 10/10/13 at 11:00am and under the section Evaluation, Comments, suggestions revealed all staff were able to demonstrate policy and respond correctly to drill. S2/DON was asked again if she had anything else to present related to Resident #4 ' s elopement and she stated that that she did not. In an interview on 10/24/13 at 1:10pm S1/Administrator stated that he had nothing else to present for the elopement for Resident #4. He stated that not all of his staff were recently inserviced about the elopement, and he had left an inservice for the night shift to read at the nurse ' s station. He further stated that all the staff were to be inserviced but not everybody was inserviced. Review of the facility ' s Elopement Risk Assessment for Resident #4 dated 6/5/13 revealed, in part, Resident #4 wanders aimlessly and wanders throughout the facility halls and to exits. Review of Resident #4 ' s Care Plan with a goal date of 11/12/13 revealed at risk for elopement due to cognitive lost. Review of this care plan revealed interventions to monitor the resident every 2 hours and as needed, apply Wanderguard, alert staff of high risk for elopement, and photographic documentation. Review of another problem in Resident #4 ' s Care Plan revealed a goal date of 12/12/13 and was a wander with the same interventions as above along with give a " baby dole " to walk with. In an interview on 10/25/13 at 1:05pm, S2/DON stated that Resident #4 was assessed as high risk for elopement. Review of the facility's Wander Guard Policy revealed that Wanderguard bracelets are checked by the floor nurses and noted in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If the wander guard bracelet does not work a new functioning bracelet will be replaced immediately and documented. Review of the Wanderguard D Series Signaling Device Tester Operating Instructions Model revealed, in part, test Wanderguard signaling devices daily and record the results in the resident ' s records. Review of Wanderguard Departure Alert System User Instructions revealed, in part,(;) Warning: Test each signaling device before using. Thereafter, test the device daily and record the results in the resident ' s records. Further review revealed Device Model is a 90-day device and date stamped shows the activate by date- the date stamped indicates the last date the device can be activated to permit approximately 90 days of use. Review further revealed a Shelf Life of 4-6 months - the device can be kept on hand 4-6 months before it must be used- check the activate by date stamped on the back. Review revealed Warning: Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash bars, push-bars, etc. Metal could interfere with the signal sent to the door modules. -Staff are to respond to every alarm and do a head count after every alarm. -Wanderguard equipment must be operated by trained personnel who are thoroughly familiar with the procedures outlined in this user manual, train and test new staff members before they begin their duties. -Test the Wandergaurd ID system regularly test each monitoring system weekly with all surrounding devices turned on, record the results, test bracelets daily as detailed in the bracelet instructions and Wanderguard ID Universal Tester Manual, record the results in each resident ' s records. -alternate monitoring protocols must be in place to help prevent unauthorized departures during the system self-test; the alarm will not sound if a resident with a bracelet exits a monitored door during the self-test; the system performs a self-test every 8 hours. -do not rely exclusively on system self-tests to indicate that the system is working properly, test all monitors at least weekly and bracelets daily using a universal tester according to the instructions -Use only Wanderguard universal tester model to test the Wanderguard ID system this is the only device to be used with the Wanderguard system. -the 90 day bracelet (models and ) is designed for 90 days of useful life if activated properly the date stamped on the bracelet indicated the last date on which the bracelet can be activated to permit approximately 90 days of use. Review of the Wanderguard Departure Alert System Wanderguard ID System User and Installation Manual revealed the following warnings: -Wanderguard ID system monitors are designed to assist staff, not replace them, the responsibility for maintaining the security of " wanderers " remains with a conscientious, alert, respond to every alarm and do a head count after every alarm. Review of the facility ' s Door Alarm Checklist revealed, in part, the only documented checks of different facility exits were done on 10/10/13, 10/11/13, and 10/15/13 per maintenance. The next day revealed the facility documented 10/24/13 on the checklist which was 9 days after 10/15/13. Review revealed there was no documentation of the door alarm checklist before Resident #4 eloped and immediately after her elopement on 10/9/13. In an interview on 10/24/13 at 2:10pm, S12/Maintenance stated that he checks the Wanderguard system weekly but had no documentation to support it. He stated that after the incident of elopement he took one Wanderguard transmitter and went to each door in the facility and made sure it worked. S12/Maintenance stated that he was not sure if the Wanderguard system was working from the resident ' s Wanderguard transmitter. In an interview on 10/24/13 at 1:20pm, with S1/Administrator, S2/DON, and S10/ADON present outside the facility when informed that per the information given and documented it was not clear as to what happened and/or what was done about Resident #4 ' s elopement. S10/ADON stated that Resident #4 was at the other facility and another unidentified lady was with her. In an interview on 10/24/13 at 1:21pm, S1/Administrator stated that the alarm quit working sometime after noon and her Wanderguard did not work when she came back to the facility. In an interview on 10/24/13 at 1:22pm, S10/ADON stated that the Wanderguard bracelets are checked weekly and documented on the Resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview on 10/24/13 at 1:35pm, S11/LPN, who had Resident #4 ' s Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' t check it, and she looked on the EMAR for Resident #4 and stated that she did not see the Wanderguard check listed. She further stated that a month or two months ago a facility staff member used to check the Wanderguard with a scanner and it was the same system used for everybody. Review of Resident #4 ' s August, September, and October 2013 EMAR revealed, in part, Wanderguard for Safety due to Wandering, Check Workability every week on Mondays. Review of the EMAR revealed there was weekly documentation of this per S11/LPN every week prior to Resident #4 ' s elopement. Further review of the EMAR revealed there was Nurse ' s initials for Monitor the residents whereabouts every 2 hours and times to document this was 5:00am, 1:00pm, and 9:00pm. Review of the EMAR revealed on 10/9/13 there was a check for documentation of every 2 hours on the three above noted times. In interview on 10/25/13 at 9:28am S12/LPN was asked how often the nurses check the Wanderguard bracelets on the residents, and she answered she had never had to perform any checks but has heard whenever the computer prompts you to. S12/LPN further indicated I don ' t think I have any residents with Wanderguards at all. S12/LPN was asked if she took care of Resident #5 and Resident #7 and she responded yes and proceeded to the residents in their wheelchairs, in the hallway near the doorway by the nurses ' station. She was able to locate Resident #5 ' s Wanderguard on her body, but not able to locate Resident #7 ' s Wanderguard on any of her extremities. In interview on 10/25/13 at 9:44am S1/Administrator stated that the nurses were checking the Wanderguard bracelets weekly but new policy went into effect today (10/25/13) to check the Wanderguard bracelets twice a day. He stated that the staff will either use the tester to check the bracelets or will bring them by the door to see if alarm goes off. S1/Administrator further stated that he was not aware of the Wanderguard bracelets having an activate by date on the bracelet or the bracelet only being a 90-day bracelet. Observation on 10/25/13 at 9:33am, Resident #7 was observed with no Wanderguard present and this was also observed by S13/LPN. Observation on 10/25/13 starting at 9:44am, revealed with S1/Administrator present for confirmation of the following resident ' s Wanderguards revealed the following: -at 9:44am revealed Resident #5 with a Wanderguard to left wrist with activate by date of 06/19/13, -at 9:50am revealed Resident #6 with a Wanderguard to left handle of back of wheelchair with activate by date of 03/20/13, -at 9:50am revealed Resident #8 with a Wander guard to left arm with activate by date of 12/10/13, -at 9:52am revealed Resident #9 with a Wanderguard to left wrist with activate by date of 6/19/13, -at 9:52am revealed Resident #12 with a Wanderguard to right wrist with activate by date of 12/10/13, -at 9:53am revealed Resident # 10 had no Wanderguard applied to her body, -at 9:55am revealed Resident #11 with a Wanderguard to her right wrist with activate by date of 03/20/13. There were no noted activation dates of when these Wanderguards were placed on these above residents and there was no other system presented to show document of the activation dates so the facility would know when the 90 day time frame was up for replacement per manufacturer recommendations. In interview on 10/25/13 at 10:35am, S1/Administrator, S14/Admissions, and S10/ADON present with surveyor to show the surveyors how to check the alarm with the tester they (Administrator, Admissions, and ADON) were unaware if the tester was compatible with the bracelet or if the bracelet was compatible with two types of wander guard systems Model # and Part Number 0900-272 In an interview on 10/25/13 at 2:20pm, S3/LPN stated that the last time she had seen Resident #4 was on 10/9/13 at 5:45pm. She stated that the Resident #4 was at the building which was 4 or 5 stories high across the street and police had been called and had notified the staff when she was found and the police returned the resident to the facility. S3/LPN further stated that we don ' t check the Wanderguard and former DON used to check the Wanderguard and we are supposed to check the Wanderguard on the day shift but have a lot to do. In interview on 10/25/13 at 3:11pm S4/CNA stated that he last saw Resident #4 on 10/9/13 at 4:45pm. He stated that Resident #4 had a Wanderguard but the staff did not hear the alarm go off. S4/CNA stated that when Resident #4 came back we cut off her Wanderguard, and he put a new Wanderguard on her from the charge nurse who gave it to him. S4/CNA stated that he checked the old alarm that was cut off by the door and it wasn ' t working. S4/C.N.A stated that other than seeing the Wanderguard on the resident they do not know which resident has them on. S4/CNA stated that the day she was missing S5/CNA and him started checking rooms and no announcements were made of the elopement until all rooms were checked by them. S4/CNA stated that when they couldn ' t find Resident #4 then the Charge Nurse was notified and announcements were made to start searching for Resident #4. In interview on 10/25/13 at 3:36pm S14/Admissions was asked when the elopement policy was created she indicated the policy presented was revised on 10/10/13. S14/Admission was then asked for policy and procedure in effect the day of the elopement and she indicated she was unsure if there was one and she would pull the policy and procedure binder to see if the facility even has one. In interview on 10/25/13 at 3:38pm S14/Admissions stated that the facility did not have any elopement policy and procedure before the elopement on 10/09/13. In interview on 10/25/13 at 3:52pm, S1/Administrator stated that the facility did not have an elopement policy prior to 10/09/13.

Based on record review and interview the facility failed to ensure that a comprehensive assessment was performed for 1 of a sampled 13 residents (resident#2). Resident #2 was admitted with a medical history of [REDACTED]. Check every 30 min. Release every 2 hours and prn for toileting/positioning. The resident was placed in immediate jeopardy after the facility became aware that the resident could remove the lap buddy and the facility failed to reassess the resident and implement approaches to ensure the safety of the resident from fall and accident hazards. Resident #2 was found unconscious, face down on the floor in her room next to her wheelchair. The lap buddy was found partly in place on the wheelchair with one side of the lap buddy not in place. The immediate jeopardy was removed for this resident when she was transferred to the hospital on [DATE]. The deficient practice continues at an actual harm for resident #2 and at a potential for more than minimal harm for any resident in the facility who uses a lap buddy. The facility has not put quality assurance systems in place to ensure the deficient practice does not reoccur. Findings: Resident #2 Record review revealed resident #2's medical history included fall injury. Record review of the physician's orders [REDACTED]. Check every 30 min. Release every 2 hours and prn for toileting/positioning. Review of the medical record revealed that an informed consent was obtained for the use of the lap buddy. Review of the medical record also revealed that lap buddy was care planned for use as a restraint and positioning. Review of resident#2's medical records revealed no documentation to support that other measures were taken to ensure that the resident was safe from fall injury while using the lap buddy. Review of the medical record revealed that the order for lap buddy was discontinued on 2/23/11 and the resident is totally bedbound. During an interview on 3/4/11 at 9:50 a.m. conducted with S2, LPN, she stated that she was the nurse assigned to care for resident #2 on 2/10/11, the date of the fall. S2, LPN stated she was called to the room by resident#2 ' s roommate at 6:40 a.m.. S2, LPN stated that when she reached the resident's room, she observed that resident#2 had fallen from the wheelchair. S2, LPN stated that when she assessed resident#2, the resident was unconscious and lying face down on the floor. S2, LPN added that the lap buddy was partly in place on the wheelchair with one side of the lap buddy not in place. S2, LPN also stated that she observed a gash on the left side of the resident' s forehead and approximately one half cup of pooled blood on the floor, from the injury to the resident ' s left forehead. Resident#2 sustained a subdural hematoma and was hospitalized in a local hospital ' s Intensive Care Unit where she remained until being discharged back to the facility on [DATE]. S2, LPN also stated that she did not witness the incident. S2, LPN added resident#2 could and had in the past been able to maneuver the lap buddy. S2, LPN added that removal of one side of the lap buddy enabled resident #2 to be released from the lap buddy. S2, LPN further stated that resident#2 had managed to displace the positioning of the lap buddy in the past. This resulted in an Immediate Jeopardy situation which was lowered to actual harm when the resident was removed from the facility. The surveyor asked S2, LPN had she in the past reported to anyone or documented that resident#2 was able to remove the lap buddy. S2, LPN stated that she had not. An interview was conducted with S1, ADON on 3/4/11 at 1:30 p.m. During the interview S1, ADON stated that she was also aware of resident #2's ability to remove the lap buddy in the past. S1, ADON stated that she did not believe that the doctor had been made aware of the fall potential. S1, ADON further stated that no revisions were made to the care plan or care measures to prevent resident #2 from sustaining any fall injury.

Based on record review and interview the facility failed to ensure that a comprehensive assessment was performed for 1 of a sampled 13 residents (resident#2). Resident #2 was admitted with a medical history of [REDACTED]. Check every 30 min. Release every 2 hours and prn for toileting/positioning. The resident was placed in immediate jeopardy after the facility became aware that the resident could remove the lap buddy and the facility failed to reassess the resident and implement approaches to ensure the safety of the resident from fall and accident hazards. Resident #2 was found unconscious, face down on the floor in her room next to her wheelchair. The lap buddy was found partly in place on the wheelchair with one side of the lap buddy not in place. The immediate jeopardy was removed for this resident when she was transferred to the hospital on [DATE]. The deficient practice continues at an actual harm for resident #2 and at a potential for more than minimal harm for any resident in the facility who uses a lap buddy. The facility has not put quality assurance systems in place to ensure the deficient practice does not reoccur. Findings: Resident #2 Record review revealed resident #2's medical history included fall injury. Record review of the physician's orders [REDACTED]. Check every 30 min. Release every 2 hours and prn for toileting/positioning. Review of the medical record revealed that an informed consent was obtained for the use of the lap buddy. Review of the medical record also revealed that lap buddy was care planned for use as a restraint and positioning. Review of resident#2's medical records revealed no documentation to support that other measures were taken to ensure that the resident was safe from fall injury while using the lap buddy. Review of the medical record revealed that the order for lap buddy was discontinued on 2/23/11 and the resident is totally bedbound. During an interview on 3/4/11 at 9:50 a.m. conducted with S2, LPN, she stated that she was the nurse assigned to care for resident #2 on 2/10/11, the date of the fall. S2, LPN stated she was called to the room by resident#2 ' s roommate at 6:40 a.m.. S2, LPN stated that when she reached the resident's room, she observed that resident#2 had fallen from the wheelchair. S2, LPN stated that when she assessed resident#2, the resident was unconscious and lying face down on the floor. S2, LPN added that the lap buddy was partly in place on the wheelchair with one side of the lap buddy not in place. S2, LPN also stated that she observed a gash on the left side of the resident' s forehead and approximately one half cup of pooled blood on the floor, from the injury to the resident ' s left forehead. Resident#2 sustained a subdural hematoma and was hospitalized in a local hospital ' s Intensive Care Unit where she remained until being discharged back to the facility on [DATE]. S2, LPN also stated that she did not witness the incident. S2, LPN added resident#2 could and had in the past been able to maneuver the lap buddy. S2, LPN added that removal of one side of the lap buddy enabled resident #2 to be released from the lap buddy. S2, LPN further stated that resident#2 had managed to displace the positioning of the lap buddy in the past. This resulted in an Immediate Jeopardy situation which was lowered to actual harm when the resident was removed from the facility. The surveyor asked S2, LPN had she in the past reported to anyone or documented that resident#2 was able to remove the lap buddy. S2, LPN stated that she had not. An interview was conducted with S1, ADON on 3/4/11 at 1:30 p.m. During the interview S1, ADON stated that she was also aware of resident #2's ability to remove the lap buddy in the past. S1, ADON stated that she did not believe that the doctor had been made aware of the fall potential. S1, ADON further stated that no revisions were made to the care plan or care measures to prevent resident #2 from sustaining any fall injury.

Based on observation, record review, and interview the facility failed to ensure the resident's environment remains free of accident hazards and each resident receives adequate supervision to prevent accidents for 1 of 13 residents who use restraint devices (#2). The facility failed to: 1. realize the lap buddy had become an accident hazard after becoming aware the resident could remove the lap buddy. 2. correct discrepancies between physician orders [REDACTED]. 3. assess the resident and update the plan of care after realizing the resident could remove the lap buddy; 4. increase supervision of the resident while up in wheelchair after realizing the resident could remove the lap buddy; 5. consult with the physician regarding the order for lap buddy and to release every 2 hours and prn after the facility recognized the resident could remove the lap buddy; Resident#2 ' s medical history included fall injury. physician's order [REDACTED]. Check every 30min. Release every 2 hours and prn for toileting/positioning. The resident was placed in immediate jeopardy after the facility became aware that the resident could remove the lap buddy. The facility failed to realize the lap buddy was an accident hazard and failed to stop using the lap buddy. The facility failed to reassess and update the care plan with approaches to increase supervision to ensure the resident did not injure herself from a fall. Resident #2 was found unconscious, face down on the floor in her room next to her wheelchair. The lap buddy was found partly in place on the wheelchair with one side of the lap buddy not in place. The immediate jeopardy was removed for this resident when she was transferred to the hospital on [DATE]. The deficient practice continues at an actual harm for resident #2 and at a potential for more than minimal harm for any resident in the facility who uses a lap buddy. The facility has not put quality assurance systems in place to ensure the deficient practice does not reoccur. Findings: Resident #2 Review of Resident #2's Nurse's Notes dated 02/10/11 at 6:40am revealed that on 2/10/11 resident #2 partially removed the lap buddy, fell from the wheelchair and sustained a subdural hematoma. Review of Resident #2's current plan of care with a goal date of 4/19/11 revealed there was no documented evidence the plan of care had been updated after it was known by staff that resident #2 could malposition/remove the lap buddy making it an accident hazard. Revisions were not made to care plan until Resident#2 returned to the facility on [DATE]. Prior to fall injury, Resident#2 was wheelchair bound with some ability to ambulate. Resident is now totally bed bound. Record review of the physician's orders [REDACTED]. Check every 30min. Release every 2 hours and prn for toileting/positioning. Review of resident#2's medical record revealed no documentation to support that other measures were in place to prevent fall injury while using lap buddy. Fall Risk Assessment for Resident #2 dated 7/20/10 revealed that resident#2 had a total risk assessment score of 21, which detailed a history of 3 or more falls within the past three month period . The Fall Risk Assessment score for 1/11/2011, which was the last date documented prior to resident#2's fall, was 13. A total score of 10 or above represents high risk. Care Plan for Resident #2 dated 8/8/10 revealed a Potential for Injury nursing [DIAGNOSES REDACTED]. Resident#2's medical history included fall injury. During an interview on 3/4/11 at 9:50 a.m. conducted with S2, LPN, she stated that she was the nurse assigned to care for resident #2 on 2/10/11, the date of the fall. S2, LPN stated she was called to the room by resident#2's roommate at 6:40 a.m.. S2, LPN stated that when she reached the resident's room, she observed that resident#2 had fallen from the wheelchair. S2, LPN stated that when she assessed resident#2, the resident was unconscious and lying face down on the floor. S2, LPN added that the lap buddy was partly in place on the wheelchair with one side of the lap buddy not in place. S2, LPN also stated that she observed a gash on the left side of the resident' s forehead and approximately one half cup of pooled blood on the floor, from the injury to the resident ' s left forehead. Resident#2 sustained a subdural hematoma and was hospitalized in a local hospital ' s Intensive Care Unit where she remained until being discharged back to the facility on [DATE]. S2, LPN also stated that she did not witness the incident. S2, LPN added resident#2 could and had in the past been able to maneuver the lap buddy. S2, LPN added that removal of one side of the lap buddy enabled resident #2 to be released from the lap buddy. S2, LPN further stated that resident#2 had managed to displace the positioning of the lap buddy in the past. This resulted in an Immediate Jeopardy situation which was lowered to actual harm when the resident was removed from the facility. The surveyor asked S2, LPN had she in the past reported to anyone or documented that Resident#2 was able to remove the lap buddy. S2, LPN stated that she had not. An interview was conducted with S1, ADON on 3/4/11 at 1:30pm. During the interview S1, ADON stated that she was also aware of Resident#2's ability to remove the lap buddy in the past. S1, ADON stated that she did not believe that the doctor had been made aware of the fall potential. S1, ADON further stated that no revisions were made to the care plan or care measures implemented to prevent Resident#2 from sustaining any fall injury once it was known by facility staff that resident #2 could mal-position the lap buddy.

Based on observation, record review and interview, the facility failed to ensure that the environment is free from accidental hazards by having unlocked/unattended cleaning chemicals in the dining room cabinet and by having an entire stock of unlocked/unattended housekeeping department cleaning chemicals and cleaning machine. Facility has 14 wanderers. Findings: Observation during initial kitchen tour/dining room tour on 01/25/2011 at 9:00am revealed a staff member taking out a can from the cabinet in the dining room. Observation revealed that the cabinet contained cleaning products, which consisted of: 1 plastic Spray bottle of disinfectant, 3 cans of germicide/deodorant, and 1 can of powder germicide/deodorant along with a torn pack of napkins and plastic flowers. A dirty tray was also on the top of the cabinet. In an interview on 01/25/2011 at 9:00am, S4, Dietary Supervisor, indicated that the cabinet in the dining room does not belong to the dietary department. 01/25/2011 at 9:00 am, S5, Director of Environment, stated that those napkins are not for residents. He also removed the cleaning products from the cabinet. Review of the facility ' s list of wandering residents revealed that 14 wandering residents reside at the facility. Facility's Policy for Storage Area Safety revealed that the storage area is required to be locked in order to maintain proper safety and security. In an interview on 01/28/2011 at 8:45 am, S5, Director of Environment, stated that those chemicals were used by the housekeeping staff for cleaning the dining room and should not be left in the unsecured cabinet. 01/28/2011 at 10:25 am surveyor asked the housekeeping staff, S6, where all the cleaning products were stored. He brought the surveyor to the storage room. There were cleaning chemicals (liquid floor cleaning, carpet deodorant power, furniture cleaning, disinfectant, Clorox bleach, etc.) for housekeeping use stocked on the shelves. There was also a floor cleaning machine in the room. The door was not locked, and no one was in the room. The storage room is located next to residents ' rooms. 01/28/2011 at 11:05 am surveyor again visited the chemical storage room with S1, the administrator and observed that the room was again unlocked/unattended. In an interview on 01/28/2011 at 11:05am the administrator acknowledged the above findings.

Based on clinical record review and interviews with the staff, the facility failed to notify a resident's physician of a change in a resident's condition for 1 of 5 sampled residents, #3. There was no documented evidence provided that indicated the resident's physician was notified until greater than 18 hours after the resident was identified with the initial complaints of bladder spasms. The resident was catheterized on admission to the emergency room with purulent urine and diagnosed with [REDACTED]. The deficency resulted in actual harm. Based on the facility Resident's Census & Condition, there were 110 resident's residing in the facility at the time of the investigation. There were 3 of 9 residents residing in the facility at the time of the survey with catheters. There were 3 residents with catheters identified with UTIs at the time of the survey. All residents residing in the facility at the time of the survey had the potential to be affected by this deficient practice. Findings: Record review of resident #3 ' s clinical record on 11/01/2010 to 12/03/2010 indicated the followings: 1. Resident #3 was admitted to the nursing home from the hospital on [DATE], following an authorized hospitalization (10/29/2010 to 11/02/2010) due to the husband ' s inability to care for the resident related to his required hospitalization for shoulder surgery. 2. The Resident was admitted in part, with Diagnoses: [REDACTED]. 3. The resident was also admitted to the nursing home with an indwelling catheter to [MEDICAL CONDITION] bag, with clear straw colored urine. The clinical record indicated the resident's Foley catheter was to be changed on 12/01/2010. 4. The resident ' s admission vital signs found on the Vital Signs & Weight Flow Sheet dated 11/02/2010, 1:30pm: b/p (blood pressure) 132/78, T (temperature) 98.2 (? Fahrenheit), P (pulse) 76, r (respiration) 17, wt (weight) blank. Lungs clear; can hold phone, needs staff to help. There were no other vital signs found on the resident ' s Vital Sign & Weight Flow Sheet. The only other vital signs found in the resident ' Interdisciplinary Progress Notes were the V/Ss dated 11/05/2010, 2:40am (b/p 122/87, p 96, r 20 & t 98.2) and 11/09/2010, 7:40pm (prior to the resident ' s hospital transfer) b/p 144/90, t 102.8, r 32 & p 94 (greater than 18 hours after the resident ' s initial complaint on 11/09/2010 at 12:30am). 5. The resident ' s Interdisciplinary Progress Notes read in part, a. 11/09/2010, 12:30am, Found awake, holding foley catheter GU ([MEDICAL CONDITION]) bag in hand, c/o (complain of) pain, bladder area, squeezing type pain-possible bladder spasm. Foley-dark amber urine. b. 11/09/2010, 4:30am, (4 hours later) found by CNA (Certified Nursing Assistant) holding Foley cath (catheter) & GU tubing again. 6. Clinical Laboratory: draw date, 11/04/2010 WBC (White Blood Count) 10.3 (reference range: 4.5-11.0). Draw date 11/09/2010, 4:14am, WBC 13.7H (High). There was no documented evidence found in the resident ' s clinical record that indicated the physician was notified by the staff of the 4:14am, 11/09/2010 abnormal WBC laboratory results. There was no documented evidence that indicated the resident ' s physician had been notified of the resident ' s initial complaint of 11/09/2010, 12:30am, documented in the resident ' s Interdisciplinary Progress Notes which indicated the resident was found awake and complaining of a squeezing type pain-possible bladder spasm in the bladder area and having dark amber urine; there also was no documented evidence that indicated the resident ' s physician was notified of the resident ' s condition on the same day, when documentation in the Interdisciplinary Progress Notes indicated on 11/09/2010, at 4:30am (4hours later), a CNA found the resident holding the foley catheter & tubing. There continued to be no documented evidence that indicated the status and/or complaints of the resident were reported to the physician, until after 7:40pm on 11/09/2010, (greater than 18 hours later), when the resident ' s Interdisciplinary Progress Notes dated 11/09/2010, 7:40pm read in part, NSG (nursing): Resident ' s husband and family members arrived to facility prior to getting to resident ' s room. Husband was yelling at the top of his lungs about no one has checked on his wife all day even when he called approximately 4:20pm. Resident ' s husband states he spoke with someone who informed him she was hard to arouse this am. Resident ' s husband states she should have been sent to the ER (emergency room ) then went to resident ' s room, shortly after finishing up with another resident. Attempted to reassure resident ' s husband, he interrupted to say " I want my wife out of here and I ' ll (will) take her home before she comes back here. 911 called by charge nurse/former DON/S5. Continued to monitor resident prior to the arrival of A-Med, v/s (vital signs) B/P (blood pressure) 144/90, temp (temperature) 102.8, r (respiration) 32, p (pulse) 94. 11/09/2010. 11/09/2010, 7:45pm to 8:10pm, Instructed by floor nurse needed in room by family same time, informed of T 102.8, P 94, R 32. Family wants her to go to ER. Call placed to physician. Informed of above. No send to ER. 11/09/2010, 7:48pm, to room to inform of ambulance called. Husband is elderly man back to desk, she needs to be packed in ice. Recalled physician, what to do, they want for us to treat and manage her or go to ER. 11/09/2010, 7:55pm, to room with paramedics. Physical attempts to arousal, non effective. Leaned in and whispered (name) in ear x (times) 1, eyes popped open. Still without verbal response. Drawing hand away during IV (intravenous) initiation. To ER via stretcher at 8:10pm. The resident ' s hospital emergency room Documentation notes dated: 11/09/2010 indicated the resident was treated in the emergency room and admitted to the hospital ' s CCU (Critical Care Unit). The resident ' s emergency room Documentation sheet dated 11/09/2010 read in part, General: Has slight tachypnea. Appears weak. Abdomen: The patient has a distended abdomen; findings consistent with a distended bladder. GU: The patient has an indwelling Foley catheter with no urine output. emergency room Course and medical decision-making: The patient ' s Foley catheter was changed. The patient immediately had purulent urine output noted. The patient was also impacted and passed a large hard bowel movement in the emergency room . Laboratory Data: White blood count was 23,000. Urinalysis was consistent with significant urinary tract. Impression: Altered Mental Status, Urosepsis and [MEDICAL CONDITION] versus Dehydration. The facility failed to assure that the resident ' s MD was notified of a change in the resident ' s medical condition, even though there was documented evidence found in the resident ' s clinical record that indicated the resident complained twice on 11/09/2010 at 12:30am and again when the resident was found by the CNA at 4:30am (greater than 4 hours later) complaining of pain & having bladder spasms; and, the resident had a history of [REDACTED]. arrived and requested that the resident be transferred to the hospital. The resident was admitted to the hospital ' s CCU and remained in CCU for greater than 2 days. During an interview with S14/LPN on 12/02/2010 at 09:45am, she stated if a resident has a problem or a noted change in condition, the physician was to be notified immediately. During an interview with S8/LPN, on 12/02/2010 at 1:53pm, she stated at times, resident #3 ' s urine was icky looking.

Based on observations, clinical record reviews and interviews with the staff, the facility failed to assure and provide a resident with ongoing care and services to assist the resident in achieving the highest state of medical and physical wellbeing. A resident was admitted with the following Diagnosis: [REDACTED]. The resident was also admitted to the facility with an indwelling foley catheter. For 1 of 5 sampled residents, #3, out of total of 9 residents with foley catheters, resident #3 had developed a UTI within 7 days of admission to the facility and hospitalized in a CCU (Critical Care Unit). The resident was admitted to the facility on [DATE] and admitted to the hospital on [DATE]. Residents with indwelling foley catheters had the potential to be affected by this deficient practice. The facility's Resident Census & Conditions indicated that the facility had a total of 110 residents and 9 residents with indwelling catheters. The facility failed to assess vital signs, assess for UTI and address the need for catheter care and assessment of UTI in the Interim Plan of Care for resident #3 which resulted in the resident being transfered and admitted to a hospital's CCU. Findings: Record review of resident #3 ' s clinical record revealed the followings: 1. Resident #3 was admitted to the nursing home from the hospital on [DATE], with Diagnoses: [REDACTED]. 2. The resident ' s admission vital signs on the Vital Signs & Weight Flow Sheet dated 11/02/2010, 1:30pm, were: B/P (blood pressure) 132/78, T (temperature) 98.2 (Fahrenheit), P (pulse) 76 and r (respiration) 17. 3. The resident ' s Medicare Skilled Nurses Notes directions sheet indicated charting must include vital signs; s (signs)/sx (symptoms) of infection; UTI (Urinary Tract Infection)/Pneumonia/Other Infections: urinary output-color, consistency, odor. 4. During an interview with the Acting DON (Director of Nursing)/S3, she stated if a resident was skilled, the resident ' s Interdisciplinary Progress Notes guidelines were to be followed daily on each shift. 5. Record review revealed that the vital signs had been documented on admit. No other vital signs were found on the resident ' s Vital Sign & Weight Flow Sheet except her admission vital signs. 6. Record review revealed documented vital signs in the Interdisciplinary Progress Notes dated 11/05/2010, 2:40am (b/p 122/87, p 96, r 20 & t 98.2) and 11/09/2010, 7:40pm (prior to the resident ' s hospital transfer) b/p 144/90, t 102.8, r 32 & p 94. 7. Record review revealed that the resident ' s Intake and Output sheet dated 11/2010 revealed inconsistent daily intake documentation of fluids with medications, bedside and Meals fluid; and, no intake documentation under the Hydration column. 8. Record review revealed inconsistent documentation of the resident ' s Foley catheter urinary output. Documentation of output on the following days & shifts: 11/06/2010, 11(11:00) P (PM)-7(7:00) A (AM) & 7 A(AM)-3(3:00)P; 11/07/2010, 7A-3P and 11/08/2010, 3-11P. 9. Record review revealed that there wasn't any documented fluid intake or output from 11/2/2010 on admit until 11/06/2010 on the 3P-11P shift (greater than 3 days after her admission). There also was inconsistent ongoing documentation of the consistency and color of the resident ' s urine. 10. The resident ' s Interdisciplinary Progress Notes read in part, a. 11/02/2010, 1:30pm, (date of admission) Foley with clear straw colored urine. However, there was no documented evidence of the consistency of the resident ' s urine found on any other shift (3p-11p and/or 11p-7a) on 11/02/2010. There also was no documented evidence that indicated vital signs were done on the 3p-11p and/or 11p-7a shift on 11/02/2010. b. 11/03/2010, NSG (nursing) 7a-3pm, Foley cath (catheter) patent. There was no ongoing assessment of the resident ' s urinary status with documented evidence of the consistency and/or color of the resident ' s urine on the 7a-3p or 3p-11p shift on 11/03/2010. There also was no documented evidence that indicated vital signs were done on the 3p-11p and/or 11p-7a shift on 11/03/2010. c. 11/04/2010, 2:00am, Foley cath intact with yellow urine to GU bag, no s/s of pain or distress noted. There was no documentation of the consistency of the resident ' s urine on the 11p-7p and/or 3p-11p shift on 11/04/2010. d. 11/04/2010, 9:10am, Foley cath patent. There was no documented evidence of the color and/or consistency of the resident ' s urine found on the 7a-3p and/or 3p-11p shift on 11/04/2010. There also was no documented evidence that indicated vital signs were done on the 7a-3p, 3p-11p and/or 11p-7a shift on 11/04/2010. e. 11/05/2010, 2:40am, NSG, B/P 122/87, P 96, R 20 & T 98.2, Resting quiet with eyes closed. No complaints of pain or discomfort voiced. Foley catheter intact & patent with yellow colored urine draining to GU ([MEDICAL CONDITION]) bag. There was no ongoing assessment and documented evidence of the consistency of the resident ' s urine at that time and also was no documented evidence of the consistency of the resident ' s urine and/or color found on the 3p-11p shift on 11/05/2010. f. 11/05/2010 11-7 shift NSG. Resident resting quietly with eyes close. No signs of distress noted. No c/o (complaint of) pain. Foley catheter flowing with yellow urine noted. No sediment noted nor discomfort. g. 11/06/2010, 7-3 NSG, there was no documented evidence of the consistency and/or color of the resident ' s urine found on the 7a-3p shift. There also were no other assessments found on the resident ' s Interdisciplinary Progress Notes for the 3p-11p and/or 11p-7a shift on 11/06/2010. There was no documented evidence that indicated vital signs were done. h. 11/07/2010, 7a-3p NSG, there was no documented evidence of the consistency and/or color of the resident ' s urine found on the 7a-3p shift. There also were no other assessments found on the resident ' s Interdisciplinary Progress Notes for the 3p-11p and/or 11p-7a shift on 11/07/2010. There was no documented evidence that indicated vital signs were done. i. 11/08/2010, 8:00am, found on floor. There was no documented evidence that indicated an ongoing assessment was conducted of the resident status following the fall. j. 11/08/2010, 2 (2:00) pm, Foley cath (catheter) patent. There was no documented evidence of the consistency and/or color of the resident ' s urine. There were no documented evidence of the color and consistency of the resident ' s urine on the 3p-11p and/or 11p-7a shift on 11/08/2010. There was no documented evidence that indicated vital signs were done. k. 11/09/2010, 12:30am, Found awake, holding Foley catheter GU ([MEDICAL CONDITION]) bag in hand, c/o (complain of) pain, bladder area, squeezing type pain-possible bladder spasm. Foley-dark amber urine. There was no documented evidence that the nurse assessed for signs and symptoms of UTI. There was no evidence that the physician or family were notified. l. Record review revealed that on 11/09/2010 at 4:30am, (4 hours later) found by CNA (Certified Nursing Assistant) holding Foley cath (catheter) & GU tubing again. The Interdisciplinary Progress Note indicated it was written by S/ 11-7pm nurse. There was no documented evidence of the consistency of the resident ' s urine.There was no documented evidence that indicated the resident ' s vital signs were taken at that time. There also was no documented evidence that indicated the physician or family were notified of the resident's condition at that time. m. 11/09/2010, (no time indicated) Foley Cath (catheter) patent. There was no documented evidence of the consistency, color or whether the resident ' s urine had an odor. n. 11/09/2010, 7:40pm (NSG/nursing) Resident ' s husband and family members arrived to facility prior to getting to resident ' s room (greater than 18 hours after the initial incident of 11/09/2010, 12:30 & 4:30am). Husband was yelling at the top of his lungs about no one has checked on his wife all day even when he called approximately 4:20pm. Resident ' s husband states he spoke with someone who informed him she was hard to arouse this am. Resident ' s husband states she should have been sent to the ER (emergency room ) then went to resident ' s room shortly after finishing up with another resident. Attempted to reassure resident ' s husband, he interrupted to say " I want my wife out of here and I ' ll (will) take her home before she comes back here. 911 called by charge nurse/former DON/S5. B/P (blood pressure) 144/90, temp (temperature) 102.8, r (respiration) 32, p (pulse) 94. o. 11/09/2010, 7:45pm to 8:10pm, Instructed by floor nurse needed in room by family same time, informed of T 102.8, P 94, and R 32. Family wants her to go to ER. Call placed to physician. Informed of above (Documentation in the resident's Interdisciplinary Progress Notes indicated the physician was not initially notified of the resident's condition until greater than 18 hours after the 11/09/2010,12:30am observation was made). p. 11/09/2010, 7:48pm, to room to inform of ambulance called. Husband is elderly man back to desk; she needs to be packed in ice. Recalled physician, what to do, they want for us to treat and manage her or go to ER. q. 11/09/2010, 7:55pm, to room with paramedics. Physical attempts to arousal, non effective. Leaned in and whispered (name) in ear x (times) 1, eyes popped open. Still without verbal response. Drawing hand away during IV (intravenous) initiation. To ER via stretcher at 8:10pm. 11. V/O (verbal order) dated 11/09/2010 at 7:45pm, indicated a verbal was received from the physician to send the resident to the ER to temp, 102.8F for evaluation and treatment. 12. Between 11/02/2010 (admission) to 11/09/2010 (day of transfer), there was no documented evidence of whether the resident ' s urine had an odor or not. 13. Clinical Laboratory: draw date, 11/04/2010 WBC (white blood count) 10.3 (reference range: 4.5-11.0). 14. Clinical Laboratory: draw date 11/09/2010, 4:14am, WBC 13.7H (High). There was no documented evidence found in the resident ' s clinical record that indicated the staff notified the physician of the resident ' s high 11/09/2010 4:14am WBC result. There was no documented evidence that indicated the physician was notified by the staff of the resident ' s abnormal WBC report. 15. The Interim Plan of Care (undated) revealed no documented evidence that indicated the resident was admitted with an indwelling Foley catheter, was admitted on antibiotics, had [MEDICAL CONDITION] and a history of UTIs with bladder spasms. The resident ' s Interim Plan of Care did not identify and include the necessary approaches to address the initial needs of the resident. 16. The resident ' s MAR (Medication Administration Record) indicated the resident was to receive Foley care on the 11p-7a shift. However, there was no documented evidence that indicated the resident received Foley care on the 11p-7a shift on 11/02/2010 and/or 11/05/2010. A review of the facility's Indwelling Catheter Care Policy & Procedure was conducted on 12/02/2010. The Indwelling Catheter Care Policy & Procedure read in part, Effective date 3/00. Monitoring: Assess for incontinence, urgency, dysuria or bladder spasms, fever, chills, or bladder distention. Howerver, there was no documented evidence in the resident's clinical record that indicated the resident recieved ongoing monitoring and assessment for bladder spasms, fever and bladder distention. The facility's 24 hour Report sheets, Remarks (Evening) & Remarks through 11/09/2010 morning shift revealed no documented evidence that indicated the resident had experienced a change in condition on 1/09/2010 at 12:30am , 1/09/2010 at 4:30am until 3(3:00)pm to 11(11:00)pm shift on 11/09/2010, when the resident was indicated on the 24hour Report/Change of Condition Report sheet as being sent to the emergency room per (by) family request, T102.8, with decrease responsiveness, Resp (respiratory) distress. The resident ' s hospital emergency room Documentation notes dated: 11/09/2010 indicated the resident was treated in the emergency room and admitted to the hospital ' s CCU. The resident ' s emergency room Documentation sheet dated 11/09/2010 read in part, General: Has slight tachypnea. Appears weak. Abdomen: The patient has a distended abdomen; findings consistent with a distended bladder. GU: The patient has an indwelling Foley catheter with no urine output. emergency room Course and medical decision-making: The patient ' s Foley catheter was changed. The patient immediately had purulent urine output noted. The patient was also impacted and passed a large hard bowel movement in the emergency room . Laboratory Data: White blood count was 23,000. Urinalysis was consistent with significant urinary tract. Impression: Altered Mental Status, Urosepsis and [MEDICAL CONDITION] versus Dehydration. A review of the facility QM (Quality Management), Infection Type per Month 2010, conducted on 12/03/2010, revealed documented evidence that indicated UTIs (Urinary Tract Infections) were an identified area of concern. The Infection Type per Month 2010 report sheet read in part, 7/2010 200 unit- 6, 400 unit-3; 8/2010 200 unit-4, 400 unit-9; & 9/2010 200 unit-3, 400 unit-3. However, there was no documented evidence found and/or provided by the DON, Administrator and/or by anyone else that indicated the facility had a system in place to address and to provide directions to address the facility ' s identified concern with UTIs. During an interview with S7/CNA on 12/01/2010 at 11:45am, she stated resident #4 was on restricted fluids and only received fluids with her meals. S7 concluded by stating that she recorded the resident ' s output & Bowel Movements on a sheet of paper that she gave the nurses; the nurses were responsible for documenting the resident ' s output on the I & O sheets. During an interview with S14/LPN on 12/02/2010 at 09:45am, she stated if a resident has a problem or a noted change in condition, the physician was to be notified immediately. During an interview with S9/LPN (Licensed Practical Nurse) on 12/02/2010 at 1:30pm, she stated all residents classified as skilled, are required to have vital signs done and charted every shift. The nurse/S9 continued by stating even if a resident was on an antibiotic, that resident ' s vital signs are to be done and charted in the nurses notes (Interdisciplinary Progress Notes) every shift. S9 /LPNconcluded by stating if a resident had an indwelling Foley catheter, that resident was to have I (Intake) & Os (Output) documented on the I & O sheet found in the chart. During an interview with S8/LPN, on 12/02/2010 at 1:53pm, she stated at times, resident #3 ' s urine was icky looking. S8 continued by stating she encouraged the resident to drink more fluids. S8 concluded by stating she did not remember if the resident was on fluid restrictions. According to an interview with S9/LPN on 12/03/2010 at 2:00pm, she stated the normal draw time for the laboratory drawers are Tuesdays & Thursdays around 4:00am. (There was no documented evidence found on the laboratory report that indicated the physician was notified of the result by the staff or that the order to draw the lab was ordered on that day, 11/09/2010, by the physician). According to an interview with the Administrator/S2 on 12/03/2010 at 11:00am, he acknowledged that he had spoken with the Acting DON/S concerning the identified issues on the facility Q/M (Quality Management) report dated 2/01/2010 for run period, 8/26/2010 and the monthly Infection Type Per Month 2010 report. But, she made no response. The Administrator/S2 concluded by stating that he was just hired by the facility, his first day at the facility was 11/29/2010; and, he had no follow-up information regarding the facility 's indicators or QM report. There was no documented evidence found or provided by the DON/S3 and/or the Administrator/S4 that indicated the facility had a system in place to monitor and evaluate identified quality indicator such as UTIs. The facility failed to assure that the resident ' s MD was notified of a change in the resident ' s medical condition, even though there was documented evidence found in the resident ' s clinical record that indicated the resident complained twice on 11/09/2010 at 12:30am and again when the resident was found by the CNA at 4:30am (greater than 4 hours later) complaining of pain & having bladder spasms; and, the resident had a history of [REDACTED]. arrived and requested that the resident be transferred to the hospital. The resident was admitted to the hospital ' s CCU on 11/9/2010 for UTI, altered mental status and fever. The resident remained in CCU for greater than 2 days.

Based on clinical record review and interviews with the staff, the facility failed to ensure that a resident who was incontinent of urine that had and indwelling catheter was provided with the necessary treatment and services to prevent urinary tract infections by failing to: 1. Notify the resident's physician of a change in a resident's condition at the time of its occurence and the resident's abnormal laboratory results; 2. Provide complete ongoing daily assessments & monitoring of a resident's urinary status; and, 3. Failed to provide the necessary approaches on the resident's Interim Care Plan begining at admission, to address a resident's individualized needs for 1 of 3 sampled residents with an indwelling catheter, #3; out of a total sample of 5 residents. This deficient practice resulted in actual harm. The resident's physician was not notified until greater than 18 hours after the initial change of condition observation, 1/09/2010, 12:30am, was made. Upon admission to the hospital emergency room , the resident was catheterized and found to have purulent urine. The resident was diagnosed with [REDACTED]. Based on the facility Resident's Census & Condition, there were 110 resident's residing in the facility at the time of the investigation. There were 3 of 9 residents residing in the facility at the time of the survey with catheters. There also were 3 residents with catheters identified with UTIs at the time of the survey. All residents residing in the facility at the time of the survey with an indwelling Foley Catheter had the potential to be affected by this deficient practice. Findings: Review of resident #3 ' s clinical record on 11/30/2010 through 12/03/2010 revealed the followings: 1. Resident #3 was admitted to the nursing home from the hospital on [DATE], following an authorized hospitalization (10/29/2010 to 11/02/2010) due to the husband ' s inability to care for the resident related to his required hospitalization for shoulder surgery with Diagnoses: [REDACTED]. The resident was also admitted to the nursing home with an indwelling catheter to [MEDICAL CONDITION] bag with clear straw colored urine on [MEDICATION NAME] 100mg 1 PO (by mouth) daily, UTI (Urinary Tract Infection). 2. The resident ' s admission vital signs found on the Vital Signs & Weight Flow Sheet dated 11/02/2010, 1:30pm: b/p (blood pressure) 132/78, T (temperature) 98.2 (? Fahrenheit), P (pulse) 76, r (respiration) 17, wt (weight) blank. Lungs clear; can hold phone, needs staff to help. 3. The resident ' s Medicare Skilled Nurses Notes directions sheet indicated charting must include vital signs; s (signs)/sx (symptoms) of infection; UTI (Urinary Tract Infection)/Pneumonia/Other Infections: urinary output-color, consistency, odor. At that time, according to an interview with the Acting DON (Director of Nursing)/S3, she stated if a resident was skilled the resident ' s clinical Interdisciplinary Progress guidelines were to be followed daily on each shift. However, there were no other vital signs found on the resident ' s Vital Sign & Weight Flow Sheet. The only other vital signs found, were in the resident ' s Interdisciplinary Progress Notes dated 11/05/2010, 2:40am (b/p 122/87, p 96, r 20 & t 98.2) and 11/09/2010, 7:40pm (prior to the resident ' s hospital transfer) b/p 144/90, t 102.8, r 32 & p 94. Also, the resident ' s Intake and Output sheet dated 11/2010 revealed inconsistent daily intake documentation of fluids with medications, bedside and Meals fluid; and, no intake documentation under the Hydration column. There also was inconsistent daily documentation of the Foley catheter urinary output on the following days & shifts: 11/06/2010, 11(11:00) P (PM)-7(7:00) A (AM) & 7 A(AM)-3(3:00)P; 11/07/2010, 7A-3P and 11/08/2010, 3-11P. There was no documented evidence found in the resident ' s clinical record and/or provided by the Acting DON/S3 and/or anyone else that indicated the resident had I (Intakes) & Os (Outputs) done from the beginning of her admission, 11/02/2010 until 11/06/2010 on the 3P-11P shift (greater than 3 days after her admission). There also was inconsistent documentation of the consistency and color of the resident ' s urine. The resident was on a 1500cc Fluid Restriction. 4. The resident ' s Interdisciplinary Progress Notes read in part, a. 11/02/2010, 1:30pm, (date of admission) Foley with clear straw colored urine. However, there was no documented evidence of the consistency of the resident ' s urine found on any other shift (3p-11p and/or 11p-7a) on 11/02/2010. There also was no documented evidence that indicated vital signs were done on the 3p-11p and/or 11p-7a shift on 11/02/2010. b. 11/03/2010, NSG (nursing) 7a-3pm, Foley cath (catheter) patent. There was no documented evidence of the consistency and/or color of the resident ' s urine on the 7a-3p or 3p-11p shift on 11/03/2010. There also was no documented evidence that indicated vital signs were done on the 3p-11p and/or 11p-7a shift on 11/03/2010. c. 11/04/2010, 2:00am, Foley cath intact with yellow urine to GU bag, no s/s of pain or distress noted. There was no documentation of the consistency of the resident ' s urine on the 11p-7p and/or 3p-11p shift on 11/04/2010. d. 11/04/2010, 9:10am, Foley cath patent. There was no documented evidence of the color and/or consistency of the resident ' s urine found on the 7a-3p and/or 3p-11p shift on 11/04/2010. There also was no documented evidence that indicated vital signs were done on the 7a-3p, 3p-11p and/or 11p-7a shift on 11/04/2010. e. 11/05/2010, 2:40am, NSG, B/P 122/87, P 96, R 20 & T 98.2, Resting quiet with eyes closed. No complaints of pain or discomfort voiced. Foley catheter intact & patent with yellow colored urine draining to gu ([MEDICAL CONDITION]) bag. There was no documented evidence of the consistency of the resident ' s urine at that time. There also was no documented evidence of the consistency of the resident ' s urine and/or color found on the 3p-11p shift on 11/05/2010. f. 11/05/2010 11-7 shift NSG. Resident resting quietly with eyes close. No signs of distress noted. No c/o (complaint of) pain. Foley catheter flowing with yellow urine noted. No sediment noted nor discomfort. g. 11/06/2010, 7-3 NSG, there was no documented evidence of the consistency and/or color of the resident ' s urine found on the 7a-3p shift. There also were no other assessments found on the resident ' s Interdisciplinary Progress Notes for the 3p-11p and/or 11p-7a shift on 11/06/2010. There were no documented evidence that indicated vital signs were done. h. 11/07/2010, 7a-3p NSG, there was no documented evidence of the consistency and/or color of the resident ' s urine found on the 7a-3p shift. There also were no other assessments found on the resident ' s Interdisciplinary Progress Notes for the 3p-11p and/or 11p-7a shift on 11/07/2010. There was no documented evidence that indicated vital signs were done. i. 11/08/2010, 2 (2:00) pm, Foley cath (catheter) patent. There was no documented evidence of the consistency and/or color of the resident ' s urine. There were no documented evidence of the color and consistency of the resident ' s urine on the 3p-11p and/or 11p-7a shift on 11/08/2010. There was no documented evidence that indicated vital signs were done. j. 11/09/2010, 12:30am, Found awake, holding foley catheter GU ([MEDICAL CONDITION]) bag in hand, c/o (complain of) pain, bladder area, squeezing type pain-possible bladder spasm. Foley-dark amber urine. There was no documented evidence of the consistency of the resident ' s urine, whether the physician and/or family was notified. Even though the resident had a pain medication, [MEDICATION NAME] 7.5/750 mg (milligram) ordered every 4 hours prn (whenever necessary) for pain, there was no documented evidence found on the MAR (Medication Administration Record) that indicated the resident was offered the pain medication; and if not, the reason why the pain medication was not offered. There was no documented evidence that indicated the resident ' s vital signs were taken at that time. k. 11/09/2010 4:30am, (4 hours later) found by CNA (Certified Nursing Assistant) holding Foley cath (catheter) & GU tubing again. The Interdisciplinary Progress Note indicated it was written by S/ 11-7pm nurse. There was no documented evidence of the consistency of the resident ' s urine. Also again, there was no documented evidence of an ordered prn pain medication, [MEDICATION NAME] 7.5/750, being offered to the resident and if not, the reason why the pain medication was not offered and/or administered. There was no documented evidence that indicated the resident ' s vital signs were taken at that time. l. 11/09/2010, (no time indicated) Foley Cath (catheter) patent. There was no documented evidence of the consistency, color or whether the resident ' s urine had an odor. m. 11/09/2010, 7:40pm (NSG/nursing) Resident ' s husband and family members arrived to facility prior to getting to resident ' s room (greater than 4 hours into 3-11pm shift). Husband was yelling at the top of his lungs about no one has checked on his wife all day even when he called approximately 4:20pm. Resident ' s husband states he spoke with someone who informed him she was hard to arouse this am. Resident ' s husband states she should have been sent to the ER (emergency room ) then went to resident ' s room shortly after finishing up with another resident. Attempted to reassure resident ' s husband, he interrupted to say " I want my wife out of here and I ' ll (will) take her home before she comes back here. 911 called by charge nurse/former DON/S5. Continued to monitor resident prior to the arrival of A-Med, v/s (vital signs) B/P (blood pressure) 144/90, temp (temperature) 102.8, r (respiration) 32, p (pulse) 94. Indicated wrote by the assigned nurse/S (11-7pm nurse) n. 11/09/2010, 7:45pm to 8:10pm, Instructed by floor nurse needed in room by family same time, informed of T 102.8, P 94, R 32. Family wants her to go to ER. Call placed to physician. Informed of above. No send to ER. p. 11/09/2010, 7:48pm, to room to inform of ambulance called. Husband is elderly man back to desk, she needs to be packed in ice. Recalled physician, what to do, they want for us to treat and manage her or go to ER. q. 11/09/2010, 7:55pm, to room with paramedics. Physical attempts to arousal, non effective. Leaned in and whispered (name) in ear x (times) 1, eyes popped open. Still without verbal response. Drawing hand away during IV (intravenous) initiation. To ER via stretcher at 8:10pm. 5. V/O (verbal order) dated 11/09/2010, indicated a verbal was received from the physician to sent the resident to the ER with temp, 102.8F for evaluation and treatment. 6. Between 11/02/2010 (admission) to 11/09/2010 (day of transfer), there was no documented evidence of whether the resident ' s urine had an odor or not. 7. Clinical Laboratory: draw date, 11/04/2010 WBC (White Blood Count) 10.3 (reference range: 4.5-11.0). Draw date 11/09/2010, 4:14am) 13.7H (High). 8. The Interim Plan of Care (undated) revealed no documented evidence that indicated the resident was admitted with an indwelling Foley catheter, was admitted on antibiotics, had [MEDICAL CONDITION] and a history of UTIs with bladder spasms. The resident ' s Interim Plan of Care did not identify and include the necessary approaches to address the initial needs of the resident. 9. The resident ' s MAR (Medication Administration Record) indicated the resident was to receive Foley care on the 11p-7a shift. However, there was no documented evidence that indicated the resident received Foley care on the 11p-7a shift on 11/02/2010 and/or 11/05/2010. A review of the facility's Indwelling Catheter Care Policy & Procedure was conducted on 12/02/2010. The Indwelling Catheter Care Policy & Procedure read in part, Effective date 3/00. Monitoring: Assess for incontinence, urgency, dysuria or bladder spasms, fever, chills, or bladder distention. Howerver, there was no documented evidence in the resident's clinical record that indicated the resident recieved ongoing monitoring and assessment for bladder spasms, fever and bladder distention. There was no documented evidence in the resident's clinical record that indicated an ongoing assessment was done on the resident's urinary status. The facility's 24 hour Report sheets, Remarks (Evening) & Remarks through 11/09/2010 morning shift revealed no documented evidence that indicated the resident had experienced a change in condition on 1/09/2010 at 12:30am , 1/09/2010 at 4:30am until 3(3:00)pm to 11(11:00)pm shift on 11/09/2010, when the resident was indicated on the 24hour Report/Change of Condition Report sheet as being sent to the emergency room per (by) family request, T102.8, with decrease responsiveness, Resp (respiratory) distress. The resident ' s hospital emergency room Documentation notes dated: 11/09/2010 indicated the resident was treated in the emergency room and admitted to the hospital ' s CCU. The resident ' s emergency room Documentation sheet dated 11/09/2010 read in part, General: Has slight tachypnea. Appears weak. Abdomen: The patient has a distended abdomen; findings consistent with a distended bladder. GU: The patient has an indwelling Foley catheter with no urine output. emergency room Course and medical decision-making: The patient ' s Foley catheter was changed. The patient immediately had purulent urine output noted. The patient was also impacted and passed a large hard bowel movement in the emergency room . Laboratory Data: White blood count was 23,000. Urinalysis was consistent with significant urinary tract. Impression: Altered Mental Status, Urosepsis and [MEDICAL CONDITION] versus Dehydration. A review of the facility QM (Quality Management), Infection Type per Month 2010, conducted on 12/03/2010, revealed documented evidence that indicated UTIs (Urinary Tract Infections) were an identified area of concern. The Infection Type per Month 2010 report sheet read in part, 7/2010 200 unit- 6, 400 unit-3; 8/2010 200 unit-4, 400 unit-9; & 9/2010 200 unit-3, 400 unit-3. However, there was no documented evidence found and/or provided by the DON, Administrator and/or by anyone else that indicated the facility had a system in place to address and to provide directions to address the facility ' s identified concern with UTIs. During an interview with S9 /LPN (Licensed Practical Nurse) on 12/02/2010 at 1:30pm, she stated all residents classified as skilled, are required to have vital signs done and charted every shift. The nurse continued by stating even if a resident was on an antibiotic, that resident ' s vital signs were to be done and charted in the nurses notes (Interdisciplinary Progress Notes) every shift. S9 /LPNconcluded by stating if a resident had an indwelling Foley catheter, that resident was to have I (Intake) & Os (Output) documented on the I & O sheet found in the chart. A review of the facility Grievance Records for the past 3 months was conducted on 11/30/2010. The review revealed a grievance/complaint report for resident #3, dated received, 11/10/2010. The attached Interdisciplinary Notes dated: 11/09/2010, 7:45pm to 8:10pm indicated resident #3 ' s husband filed a complaint with the former DON/S4. The Grievance/Complaint Report read in part, Describe concern using factual terms: Resident #3's husband complained about 7:45pm, finding resident #3 in deplorable condition shaking and unresponsive. The complaint continued and read in part, He then sent his brother in law out to get the nurse. A review of the resident's Interim Care Plan, revealed no documented evidence that indicated the resident was initially assessed with [REDACTED].#3's) needs on admission and to provide the necessary nursing approaches to address those needs (Indwelling Foley Catheter, History of UTI with Bladder Spasms and other admission needs). During a telephone interview with S13/LPN on 12/01/2010 at 12:10pm, she stated that she did not remember the resident (#3) or incident of 11/09/2010, 12:30am or 4:30am. But, S13 acknowledged that she worked the night shift (11:00pm to 7:00am). S13 concluded by stating that they (the staff) made rounds at night, but if the resident was sleeping, they let the resident slept. (S8 acknowledged that the name written next to the 11/09/2010 12:30am & 4:30am entry was S13's). During an interview with S3/DON on 12/01/2010 at 12:05pm, she stated I & Os are not required to be done to monitor all residents with Foleys. S3/DON concluded by stating that it was a nursing judgment. S3 was then questioned whether resident #3 who had a known history of UTIs with Bladder Spasms & was on fluid Restrictions, should she (#3) have been monitored for I & Os. S3 responded by stating yes. During an interview with S9/LPN (Licensed Practical Nurse) on 12/02/2010 at 1:30pm, she stated all residents classified as skilled, are required to have vital signs done and charted every shift. The nurse continued by stating even if a resident was on an antibiotic, that resident ' s vital signs are to be done and charted in the nurses notes (Interdisciplinary Progress Notes) every shift. During an interview with S8/LPN, on 12/02/2010 at 1:53pm, she stated at times, resident #3 ' s urine was icky looking. S8 continued by stating she encouraged the resident to drink more fluids. S8 concluded by stating she did not remember if the resident was on fluid restrictions. According to an interview with the Administrator/S2 on 12/03/2010 at 11:00am, he acknowledged that he had spoken with the Acting DON/S concerning the identified issues on the facility Q/M (Quality Management) report dated 2/01/2010 for run period, 8/26/2010 and the monthly Infection Type Per Month 2010 report. But, she made no response. The Administrator/S2 concluded by stating that he was just hired by the facility, his first day at the facility was 11/29/2010; and, he had no follow-up information regarding the facility 's indicators or QM report. There was no documented evidence found or provided by the DON/S3 and/or the Administrator/S4 that indicated the facility had a system in place to monitor and evaluate identified quality indicator such as UTIs.