Every finding on record at West Point Community Living Center

Based on record review, staff interviews, and facility policy review, the facility failed to ensure that a resident was free of significant medication errors as evidence by failure to remove a Fentanyl 12 microgram per hour (MCG/HR) patch prior to applying the next dose for one (1) of three (3) residents reviewed. Resident #1 Findings include:Record review of facility policy titled Medication Administration-General Guidelines, Policy and Procedures revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices .Record review of facility policy titled Controlled Substances Destruction Policy and Procedure revealed Policy: Controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Procedure .2. It must be witnessed by another nurse and placed in Sharp's container for disposal. 3. Disposal is to be documented on the narcotic record on the line representing that dose and signed by administering nurse and witness nurse .In a telephone interview on 8/3/26 at 12:09 PM, with Licensed Practical Nurse (LPN) #1 she reported that on 7/09/26, when she went to apply the residents scheduled Fentanyl patch, Resident #1 had two (2) patches on. One was dated 7/03/26 and the other was dated 7/06/26. Both patches were initialed by Registered Nurse (RN) #1. Record review of July 2026 Medication Administration Record (MAR) for Resident #1 revealed an active physician's order dated 12/5/2025, for Fentanyl Transdermal 72-hour patch 12 MCG/HR, apply one (1) patch transdermally at bedtime every three (3) days for pain related to chest pain. Further record review of Resident #1's MAR revealed that on 7/03/26 and 7/06/26, the Fentanyl 12 MCG/HR patch was signed as applied by RN #1.Record review of the Controlled Drug Receipt/Record/Disposition Form for Resident #1 revealed that on 7/03/26 and 7/06/26, a Fentanyl 12 MCG/HR patch was signed as wasted by RN #1 and LPN #2.During an interview on 8/3/26 at 12:43 PM, LPN #2 acknowledged she signed as the witness for disposal on 7/6/26 of the 7/3/26 Fentanyl patch without actually observing removal of the patch from the resident or witnessing its disposal. She stated facility practice required the witnessing nurse to observe disposal to ensure the patch was not diverted. She acknowledged this process was not followed and failure to do so could cause the resident to have too much medication or diversion of the medication.Interview with the Director of Nursing (DON) on 8/3/26 at 1:00 PM, she confirmed that LPN #1 reported to her on 7/9/26 that Resident #1 had two (2) fentanyl patches on. She stated that she instructed LPN #1 to remove the patches and notify the physician. She further stated that she also notified the physician herself the next day. She verified that it was her expectation that the previous Fentanyl patch would be removed prior to the application of the new dose and that having on two patches was a significant error.Record review of the admission Record revealed the facility admitted Resident #1 on 10/7/25 with diagnoses that included Acute on Chronic Right Heart Failure and Chronic Atrial Fibrillation.

Based on record review, staff interviews, and facility policy review the facility failed to ensure the physician was notified of resident lab results which caused a delay of treatment for one (1) of three (3) sampled residents reviewed. Resident #1 Findings include: Review of facility policy titled Change In Condition Policy and Procedure, revealed Purpose: To provide guidance to licensed nurses on follow-up documentation post-acute episode, antibiotic therapy, incident and accident, change in condition, hospital return, etc.Procedure.a. Acute episodes/Change in Condition/hospital return: i. Notify physician and document results of physician contact . Record review of molecular urinalysis results for Resident #1 revealed a urine specimen was collected on 6/10/26 and laboratory results were received on 6/11/26, indicating that the resident had a urinary tract infection (UTI).Record review of a Progress Note dated 6/16/26, for Resident #1 revealed new order per PA (Physician Assistant): cipro 500 mg (milligrams) po (by mouth) bid (two times a day) x (times) 10 days r/t (related to) UTI. Record review of the June 2026 Medication Administration Record (MAR) for Resident #1 revealed that the antibiotic Cipro 500 mg for UTI was not administered until 6/17/26.Interview with Assistant Director of Nursing (ADON) on 08/03/26 at 2:30 PM, she explained that it was the facility practice that laboratory results were forwarded to her and it was her responsibility to notify the physician. She verified that the molecular urinalysis results for Resident #1 were received on 6/11/26, but she did not notify the physician of the lab results until 6/16/26. The ADON was unsure what caused the delay in notification but agreed that treatment was delayed and that could lead to worsening of the infection.On 08/03/26 at 2:40 PM, interview with Director of Nursing (DON) she agreed it was her expectation that the laboratory results would be reported timely.A record review of admission Record revealed that the facility admitted Resident #1 on 10/07/25 with diagnoses of acute on chronic right heart failure and chronic atrial fibrillation.

Based on record review, staff interviews, and facility policy review the facility failed to ensure the clinical record was complete and accurately documented when a licensed nurse signed the Controlled Drug Receipt/Record/Disposition Form indicating she witnessed the removal and disposal of a Fentanyl 12 microgram per hour (MCG/HR) patch when she did not observe the removal or disposal of the medication for one (1) of three (3) residents reviewed. Resident #1.Findings included:Record review of facility policy titled Controlled Substances Destruction Policy and Procedure revealed Policy: Controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Procedure: 2. It must be witnessed by another nurse and placed in Sharp's container for disposal. 3. Disposal is to be documented on the narcotic record on the line representing that dose and signed by administering nurse and witness nurse .Record review of Resident #1's July 2026 Medication Administration Record (MAR) revealed that on 7/03/26 and 7/06/26, the Fentanyl 12 MCG/HR patch was signed as applied by RN #1.Record review of the Controlled Drug Receipt/Record/Disposition Form for Resident #1 revealed that on 7/03/26 and 7/06/26, a Fentanyl 12 MCG/HR patch was signed as wasted by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2.On 8/3/26 at 12:09 PM, in a telephone interview with LPN #1 she reported that on 7/09/26, when she went to apply the resident's scheduled Fentanyl patch, Resident #1 had two (2) patches on. One was dated 7/03/26 and the other was dated 7/06/26. Both patches were initialed by RN #1.During an interview on 8/3/26 at 12:43 PM, LPN #2 she stated facility practice required the witnessing nurse to observe disposal to ensure the patch was not diverted. She verified she signed as the witness for disposal on 7/6/26 of the 7/3/26 Fentanyl patch without actually observing removal of the patch from the resident or witnessing its disposal and acknowledged this process was not followed.Interview with the Director of Nursing on 8/3/26 at 1:05 PM she confirmed that the Controlled Drug Receipt/Record/Disposition Form for Resident #1 was not accurate.Record review of the admission Record revealed the facility admitted Resident #1 on 10/7/25 with diagnoses that included acute on chronic right heart failure and chronic atrial fibrillation.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure residents right to be free from abuse for six (6) of 6 residents reviewed for abuse and neglect. Resident #20, #21, #5, #41, #34 and #50. On 06/30/25 the facility reported that a resident with a history of behaviors and aggression towards others, (Resident #65) stood up from his chair while sitting in the dining room, and had gotten behind Resident #20 while he sat in his wheelchair and choked him. Staff heard other residents yelling for help and the staff separated Resident #65 from choking Resident #20. Resident #20 immediately began to have seizures that lasted for three or more minutes and continued to have multiple seizures a day until he was sent out to the hospital on [DATE]. Additionally, the SA determined that Resident #45, Resident #46 and Resident #65 had aggressive behaviors towards other residents in the facility and were not monitored, nor were protective measures taken to prevent the abuse of Resident #5, Resident #20, Resident #21, Resident #34, Resident #41 and Resident #50. These residents sustained verbal, physical and mental abuse.During the annual survey of the investigations of the complaints and the FRI, the SA identified Immediate Jeopardy (IJ) and SQC which began on 06/30/25, when Resident #65 choked Resident #20 who began to have seizures.The IJ and SQC existed at:CFR 483.12(a)(1) Freedom from Abuse and Neglect (F600) Scope/Severity (S/S) =KThe facility's failure to ensure the right to be free from abuse and neglect placed Resident #5, Resident #20, Resident #21, Resident #34, Resident #41 and Resident #50 and other residents at risk and placed them in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death.The SA notified the facility's Administrator of the IJ and SQC on 08/06/25 at 12:20 PM and provided the Administrator with the IJ Template.The facility provided an acceptable Removal Plan on 08/06/25, in which the facility alleged all corrective actions were completed to remove the IJ on 08/06/25 and the IJ removed on 08/07/25.The SA validated the Removal Plan on 8/7/25 and determined the IJ was removed on 8/7/25, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Freedom from abuse and neglect F600 was lowered to a E, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 10/22, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including but not necessarily limited to: a. facility staff; b. other residents. Resident #65 and Resident #20 Record review of the Facility Reported Incident revealed on June 30, 2025, it was reported to Administrator that a physical altercation transpired between Residents #20 and #65. According to a resident who witnessed the incident, the residents were all hanging out in their typical hangout spot prior to dinner-the dining area. During their fellowship time, there was a verbal exchange between Residents #20 and #65. Resident stated Resident #65 first acted playfully with his hands, pretending he was going to hit Resident 20. Their verbal exchange then got serious and led to Resident #65 wrapping his arms around the other resident's neck in a choking manner. Resident #65 is ambulatory, but Resident #20 is wheelchair bound. Resident #65 let Resident #20’s neck go before the staff approached them. Resident #20 has a history of having seizures. Because of that, the incident triggered Resident #20 to have a seizure. Administrator attempted to interview Resident #65 who quickly answered, I ain't done s***! Immediately afterwards, Resident #65 approached Social Services and admitted to her that he had choked the other resident due to him always talking s**t. Social Services followed Resident #65 to his room to redo his BlMs (Brief Interview for Mental Status). Prior to beginning her BIMS interview, the resident asked, ls doing this going to help me get the h*** out of here? Resident #65 began answering the questions better than he ever has since being admitted to the facility. The resident had never scored a 15 on his BIMS since being admitted . Resident #65 was placed on 1 :1 per shift from 06/30/2025-07/02/2025 for safety and well-being of all residents' safety. The facility attempted to find an alternate placement for Resident #65. However, the resident was booked into the County Jail due to charges being pressed against him from Resident #20 and his resident representative. The facility does substantiate abuse. During interviews with Resident #20 on 8/4/25 at 3:10 PM and 8/5/25 at 2:45 PM, Resident #20 revealed he was in his wheelchair in the dining room on 06/30/25 when Resident #65 approached him from behind and wrapped his arm around his neck and tightened the grip with his other arm squeezing his neck and choking him. He expressed how this frightened him and said, “He could have killed me”. He stated he had five (5) seizures after the event and was sent to the hospital for evaluation and his last seizure prior to this incident was months ago. He was glad that Resident #65 had to leave the facility but stated he did not feel as safe now as he did before the incident occurred. An interview with the Social Worker on 8/5/25 at 1:35 PM, revealed the facility was aware of Resident #65’s aggressive behaviors towards staff and other residents and had tried several times to get him admitted into a psychiatric facility, but due to his insurance type and his diagnosis of dementia, they could not find placement. She acknowledged the staff held meetings to discuss his behaviors and monitoring needs. They monitored him one-on-one when he showed signs of aggression, they placed him in a private room, and offered tasks and activities for him to participate in. She stated, “I think we did everything possible to monitor him” but acknowledged that if Resident #65 had been on one-on-one supervision, he would have been unable to harm Resident #20. She confirmed that one-on-one monitoring would have kept Resident #65’s aggressive behavior from causing harm to others but the facility failed to consistently have him under this supervision. An interview with the Administrator on 8/5/25 at 1:45 PM revealed Resident #65 was difficult to redirect and had aggressive behaviors with staff and other residents. There were multiple incidents documented of Resident #65’s aggression and physical and verbal altercations. She acknowledged that Resident #65’s aggressive behavior was an ongoing concern, and they had been unsuccessful in finding a behavioral health facility placement for him. She stated they implemented interventions such as one-on-one observations when he had aggressive behaviors, but once behaviors improved, the interventions were discontinued. She acknowledged that one-on-one supervision was “sporadic” during his stay depending on his behaviors and if he had remained on this constant supervision, Resident #20 and other residents would have been protected, but this did not occur. When the incident occurred, Resident 65 was not on one-on-one supervision. He was unsupervised in the dining room with other residents. Resident #65 was ambulatory, and Resident #20 was in his wheelchair and Resident #65 went behind the wheelchair and choked Resident #20. She stated Resident #20 had a history of seizures with his last documented seizure dated 4/11/25 and with the choking incident, the resident was “traumatized” and this incident “triggered” his seizures. At that time, Resident #65 was placed on one-on-one supervision, which continued until he left the facility. The Medical Director was notified of the incident, and Resident #20 was treated in-house until the third day, and he was then sent to the hospital with a physician’s order for evaluation. Resident #20’s family chose to press charges. Resident #65 remained in facility until he was arrested. She acknowledged that each resident had the right to be free from abuse and should feel safe in their home. She confirmed residents with known aggressive behaviors, such as Resident #65, required more supervision to ensure safety of all residents. She confirmed the facility failed to protect residents by not providing adequate supervision to ensure each resident was free from abuse from other residents. During an interview with Registered Nurse (RN) #2 on 8/5/25 at 3:00 PM, she revealed she did not witness the incident of Resident #65 choking Resident #20, but after it occurred, Resident #20 was upset and embarrassed” about what happened to him. She stated she asked Resident #65 why he did that, and he told her, “So I could shut him up” An interview with the Interim Director of Nursing on 8/5/25 at 3:15, revealed Resident #65 had aggressive behaviors towards staff and residents and had previously hit other residents. He could not be redirected and was not compliant with following requests by the staff. She was not in the dining room when the incident between Resident #65 and Resident #20 occurred, but she came in quickly when she heard other residents calling out for assistance. Resident #20 appeared upset and embarrassed and was crying. He complained of a sore throat and neck pain and soon had a seizure. She acknowledged that Resident #65 had been on one-on-one monitoring at times due to his aggression, but he was not on this supervision when this incident occurred and if he was under this supervision, the incident would not have occurred. She confirmed the facility failed to adequately supervise Resident #65 with known aggressive and physical behaviors, therefore allowing Resident #20 to be choked. An interview on 8/5/25 at 3:25 PM with Certified Nursing Assistant (CNA) #4 revealed she came into the dining room when incident occurred. Resident #65 had released his hold from Resident #20’s neck but was attempting to get back to him and Resident #65 told Resident #20 that he was “going to choke him again”. She stated she asked Resident #65 why he did that and was told to get him to shut up and that he didn't care, and he would choke him again. Resident #20 was crying after the incident. She stated Resident #65 had a history of being difficult to redirect and had behaviors which included physical and verbal aggression towards staff and other residents. He had been in one-on-one supervision at times but was not when this incident occurred. During a phone interview on 8/6/25 at 11:40 AM, the facility’s Medical Director stated he was notified of the incident when Resident #20 was choked by Resident #65 but was uncertain if it was immediately when the incident occurred or shortly after that. He stated he did not remember specifically that the resident had multiple seizures after the incident and if he had been notified that the resident was having recurrent seizures, he would have given the order to send to the emergency room for evaluation. If the seizure was a one-time event he would attempt to treat it in house, with medication, monitoring, lab work, and observation of how the resident responded. He acknowledged that stress could be a contributing factor and an altercation like what Resident #20 went through would be stressful and could stimulate a seizure. He acknowledged his expectation was if a resident had behaviors that escalated to the point that they were abusive to residents that could not protect themselves, the psychiatric Nurse Practitioner (NP) should evaluate them, and the resident should remain on one-on-one supervision until evaluated by the NP for safety. The Medical Director stated that this was not occurring in the facility. Record review of a Progress Note dated 6/30/25 for Resident #20 revealed “After residents were separated, he began sobbing and shaking. Resident went into full clonic seizure activity that lasted 3 (three) minutes. RP (responsible party) made aware, and PRN (as needed) given…” Record review of a Progress Note dated 7/2/25 at 8:19 AM revealed Resident sitting among peers talking and began having a seizure. Seizure lasted two minutes PRN Nayzilam Nasal Solution given. Resident assisted to bed via two staff with mechanical lift. RP notified MD notified orders to send to ER for evaluation. Record review of Resident #20’s Order Summary Report revealed an order dated 3/20/25 for Nayzilam Nasal Solution 5 (five) milligrams (mg)/0.1 milliliter (ml) 5 gram in both nostrils every six (6) hours as needed for seizures related to conversion disorder with seizures or convulsions. Record review revealed an order dated 2/24/24 for Acetaminophen 650 mg by mouth every 4 (four) hours as needed for general discomfort. Record review of Resident #20’s electronic “Medication Administration Record” revealed the resident received Acetaminophen 650 mg for neck pain on 7/1/25 at 3:25 AM. Resident received no Acetaminophen during the month of June 2025. Record review revealed the resident received Nayzilam Nasal Solution as needed for seizures on 6/30/25 at 5:10 PM and on 7/2/25 at 8:05 AM. He did not receive this any other time during the months of June or July 2025. Record review of Resident #20’s “admission Record” revealed the facility admitted the resident on 11/09/24, with diagnoses that included conversion disorder with seizures or convulsions. Record review of Resident #20’s Minimum Data Set (MDS) Section C dated 6/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated a moderate cognitive impairment. Record review of Resident #65’s “admission Record” revealed resident was admitted to the facility on [DATE], with diagnoses that included dementia and psychosis. Record review of Resident #65’s Minimum Data Set (MDS) Section C dated 6/11/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated a moderate cognitive impairment. The latest MDS dated [DATE] indicated a BIMS score of 15. Resident #65 and Resident #21 Record review of Facility Investigation revealed that around lunch time on 05/24/25, a physical altercation occurred between Resident #21 and Resident #65. According to CNA #3 (Proper Name) Resident #65 slapped Resident #21 on the side of the head. CNA #3 heard (Proper Name) Resident #65 say to (Proper Name) Resident 21, “Stop stealing my stuff! Do not come in my room anymore.” CNA #2 (Proper Name) helped CNA #3 (Proper Name) separate the two residents to de-escalate the situation. Resident (Proper Name) #65 was immediately moved to another room on a different hall. Residents were assessed with no injury to either resident. Upon notification of the incident, Administrator questioned Resident (Proper Name) #65 and he stated, “I did not slap him. I pushed him against the side of his head for taking my snacks….” Resident (Proper Name) #65 received counsel and education that physical contact was not allowed and to report further issues to personnel. Record review of Witness Statement completed by CNA #3 (Proper Name), revealed that On Saturday, May 24, 2025, during lunch. (Proper Name) Resident #65 turned and slapped (Proper Name) Resident #21 on the side of his head. Then yelled at him ‘stop stealing my stuff, don't come in my room anymore.’ I told (Proper Name) CNA #2 what happened, and she stood between the two men to deescalate the situation. Then nurse, (Proper Name), was notified of the incident. An interview with Certified Nursing Assistant (CNA) #2 on 08/05/2025 at 11:05 AM, revealed that there was an altercation between Resident #21 and Resident #65 back in May. She revealed that she did not witness the incident, but she was called by CNA #3, and she assisted with the two residents. CNA #2 revealed that the incident occurred in the hallway near the opening of the small dining area at the end of the 400 hall. She revealed that CNA #3 witnessed Resident #65 slap Resident #21 in the head with an open hand. She revealed that Resident #21 went into Resident #65’s room and took some snacks, Resident #65 followed Resident #21 down the hall and slapped him. CNA #2 revealed that they separated the residents to de-escalate the situation and Resident #65 was moved to another room on a different hall. CNA #2 revealed that Resident #21 and Resident #65 had adjoining rooms and shared a bathroom. She revealed that Resident #21 often wandered and took snacks from wherever he could find them. She revealed that he had taken Resident #65's snacks more than once and on that particular day, it made Resident #65 mad. CNA #2 revealed that Resident #65 was a “handful” and always kept other residents “worked up.” She revealed that it was the best thing to get him out of there. She revealed that Resident #65 was always grabbing at the staff and residents, cursing loudly, and it was chaos while he was there. CNA #2 revealed that they had to redirect Resident #65 frequently, he knew he was messing up, but he wouldn’t listen to them. CNA #2 stated, “I hope he’s at a place to get some help; we never knew what he would do or say here.” An interview with Administrator on 08/05/25 at 3:10 PM revealed that on 05/24/25 Resident #21 went into Resident #65’s room and took his snacks. She revealed that this made Resident #65 mad and he (Resident #65) hit him (Resident #21). She revealed that she investigated the incident, they moved Resident #65 to another room and educated him that he could not hit other people and told him to report further issues to staff. An interview with Interim Director of Nursing (DON) on 08/06/25 at 8:50 AM, revealed that Resident #21 and Resident #65 stayed in adjoining rooms and shared a bathroom at the time of the incident. She revealed that Resident #21 often went into Resident #65 and other residents’ rooms and took their snacks. DON revealed that on 05/24/25, staff reported to her that Resident #21 went into Resident #65’s room and took some of his snacks. Interim DON revealed that Resident #65 got mad, came up the hall behind Resident #21, he yelled at and slapped him on the head. Interim DON revealed that CNA #3 witnessed the incident, separated the two residents and the nurse checked them out and there were no injuries identified. Interim DON revealed that they should have monitored Resident #65 more closely and that he should have had 1:1 supervision from the day he slapped the other three residents. Interim DON revealed that had the staff been closely monitoring Resident #65, they could have redirected him and prevented the incident. She revealed that they implemented 1:1 monitoring after this altercation, but it did not continue when his behavior improved. She stated, “The close monitoring should have continued.” Record review of Resident #21's Progress Note dated 05/24/25 revealed: Nurse was notified by CNA (Certified Nursing Assistant) that resident was hit in head by another resident with open hand. Nurse immediately assessed resident, neuros complete…., no c/o pain or discomfort, no bruises or wounds noted. Nurse separated from peer. Nurse noted that resident took resident snacks from room…” Record review of Resident #65’s “Progress Note” dated 05/24/25 revealed: “Nurse was notified by CNA that resident hit peer in head with open hand. Nurse immediately separated resident from peer and completed an assessment, neuros completed…… .no c/o (complain of) pain or discomfort, no bruises or wounds noted. Resident (#65) stated, ‘that mother f****r (explicit language) stealing my stuff out my room.’ .” Record review of Resident #21 admission Record revealed an admission date of 02/20/25 and that he had diagnoses that included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Basilar Artery Aphasia, Schizoaffective Disorder and Aphasia. Record review of Resident #21’s Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/10/25 under Section C revealed that Brief Interview for Mental Status (BIMS) should not be completed due to resident is rarely/never understood. Resident #65 and Resident #5 Record review of the facility “Resident-to-Resident Abuse Investigation” revealed, “On August 14, 2024, Unsampled Resident #1, Unsampled Resident #2, and Resident #5 all came to Nursing Home Administrator (NHA) between 4:30 and 5:00 PM to report that they were all hit by Resident #65. Unsampled Resident #2 stated she was sitting in her chair earlier that day in her bedroom when Resident #65 entered her room and hit her on the top of the head. Unsampled Resident #1 stated Resident #65 forcefully slapped her on the right cheek in the dining area. Resident #5 stated Resident #65 also slapped him on the right cheek in the dining area. Resident #15 and Resident #1 said they both witnessed Resident #5 and Unsampled Resident #1 being slapped by Resident #65 in the dining room. Resident #65 was immediately separated from the other residents.” Further review revealed, “Due to Resident #65 being Medicaid only and having a primary diagnosis of dementia, psych facilities have denied him entry. The facility will continue one-on-one supervision and proper monitoring until alternate placement is found.” According to the facility investigation, Resident #65 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment and had a diagnosis of Dementia with Behavior Disturbance. Resident #65 received counsel and was instructed not to hit others, although he denied hitting either of the residents. An interview with Resident #5 on 8/04/2025 at 10:52 AM revealed he had an altercation with another male resident a while back ago (unsure of the exact date). He explained that he was in the dining room, and he saw Resident #65 cursing and hit a female resident in the face. He stated he went over to Resident #65 and told him, “You don't hit on women” and stated the resident slapped him in the face. The resident stated the facility took no effective action and allowed Resident #65’s violent behavior toward others to continue in the facility. He revealed Resident #65 was frequently touching the nurses, physically assaulting residents, verbally abusing staff and residents before the incident, and it continued afterward. He stated Resident #65 was arrested recently and in jail due to an altercation with another resident in the facility. When asked how the incident made him feel and if he felt safe now since the resident was arrested, he replied, No, I don't feel safe. That’s why I don't go out of my room. The resident explained that Resident #65 was his roommate at the time of their altercation. He revealed the staff did move Resident #65 out of the room that day and stated, They moved him because I told them if they left him in the room, he was going to have a pillow over his face in the morning. Record review of Resident #5’s “Progress Note” dated 8/14/25 revealed, “Resident stated that he was slapped by Resident #65 on his right cheek. Resident does appear to have some swelling under his right eye.” Record review of the “Proper name of police department Incident Report” dated 8/15/25 revealed an officer responded to the facility in reference to the altercation that occurred on 8/14/24 with no indication charges were filed. An interview with the Administrator on 8/4/25 at 3:10 PM revealed Resident #65 was admitted to the facility with a diagnosis of dementia on 9/14/23. She explained that he had a lot of behaviors on admit such as inappropriately touching the nurses, cursing, hitting other residents and was aggressive toward the staff and residents. She stated he was unable to be redirected by staff, and they had tried to get him into psych facilities, but no one would accept him because he had Medicaid and a primary diagnosis of dementia. She revealed at the time of the altercation on 8/14/24, the staff separated the residents involved and they did one-on-one monitoring for Resident #65. However, she could not account for any one-on-one monitoring and could not verify how long the facility did these actions to keep the other residents safe since Resident #65 remained in the facility. She revealed they did move Resident #65 from the room with Resident #5 and acknowledged Resident #65 continued to pose a threat to the safety of all residents residing in the facility. An interview on 8/4/25 at 3:30 PM with Resident #15, who witnessed the event on 8/14/24 confirmed he did see Resident #65 slap Resident #5 across the face in the dining room. He stated, “It was a while ago, but I remember it was in the dining room while the residents were just sitting around.” Record review of the “admission Record” revealed the facility admitted Resident #5 on 9/6/19 with medical diagnosis of Sarcoidosis. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #5 was cognitively intact. Resident #46 and Resident #41 Record review of the “Facility Investigation” of the altercation between Resident #41 and Resident #46 on 07/21/25, revealed that CNA #1 witnessed the aftermath of a physical altercation between the residents. They were tussling over Resident #41’s walker. CNA #1 called CNA #2 for assistance to help separate the two residents. Both CNAs saw bleeding on Resident #46’s hand and bleeding and swelling on Resident #41’s eye. Administrator interviewed both residents. Resident #46 stated Resident #41 kicked his foot out to trip him up, which led to the physical altercation. Resident #41 stated he was sitting on the side of the room watching television and was suddenly hit in the eye with a closed fist by Resident #46. Resident #41 stated that he was not in any pain but was confused as to why he was hit by his roommate. Assessments were completed by the Interim DON and injury was noted to both residents. Resident #41 had a cut above the left eyebrow open 2 inches by 1 inch. Resident #46 had a skin tear to the knuckle on the right hand. They both received counsel that physical contact was not allowed and to report any issues to staff for proper handling. First aid was provided to both residents. On 07/21/25, Resident #46 was transported to (Proper Name) behavioral health facility for psych treatment and behavior management. Resident #41 was transported to hospital on [DATE] due to his swollen eye worsening with no orbital fracture or major concerns noted. Behavioral Health facility called and notified the facility staff that Resident #46’s right hand began to swell which led to x-ray conducted on 07/23/25. The x-ray findings revealed that Resident #46 had a right-hand fracture because of the recent physical altercation. There were no signs of pain and showed good hand mobility prior to leaving the facility following the physical altercation. Record review of “Statement” written by CNA #1 revealed, “I had got up to go get more linen before the next shift started. Passing by resident room I noticed (Proper Name) Resident #46 and Resident #41 both tussling over the walker. I called for my partner we immediately separated them. (Proper Name) Resident #46 hand was bleeding. (Proper Name) Resident #41 had a gash on left eye, bleeding.” This written statement was dated 07/21/25 and signed by CNA #1. Record review of “Statement” written by CNA #2 revealed, “The other CNA was down the hall. She yelled up the hall for me. I came running got to the room (Proper Names) Resident #46 and Resident #41 was tussling over the walker and we took it from them. Both of them was bleeding. (Proper Name) Resident #46 was bleeding on the hand, and (Proper Name) Resident #41 was bleeding on the head and his eye was swollen.” This statement was signed by CNA #2 and dated 07/21/25. An observation and interview on 08/04/25 at 11:40 AM with Resident #46, revealed him sitting up on the side of bed eating lunch with his two sisters present at his side. He had a brace intact on his right arm and had bruising to the top of his right hand down to his knuckles of his thumb, index, middle, and fourth fingers. Resident #46 revealed that he had been out of the facility and had just returned today. An observation and interview on 08/06/25 at 8:05 AM with Resident #46 revealed him in his bed in his room and a brace was intact to his right arm. Resident #46 revealed that while he was out, his hand started hurting, they x-rayed it and found that his hand was broken. He revealed that another resident smarted off to him and he popped him in the eye. Resident #46 stated, “He (Resident #41) sure backed up when he found out I was the boss. An interview with Certified Nursing Assistant #1 on 08/06/25 at 8:20 AM, revealed that she worked on the day that Resident #46 hit Resident #41. She revealed that these two residents were roommates at the time, and they had not had any prior issues. CNA #1 described Resident #41 as a quiet resident who kept to himself and enjoyed watching westerns on television. CNA #1 revealed that on 07/21/25, she walked down the hall and saw that Residents #41 and #46 were in their room and were tussling with a walker. She revealed that she called another staff member to help, and they separated the two residents. CNA #1 revealed that she observed that Resident #41’s eye was bloody and that there was blood on Resident #46’s knuckles. CNA #1 revealed that she removed Resident #46 from the room, and they watched him until he went out to behavioral health. CNA #1 revealed that there was no yelling going on, they were just fighting over a walker. She revea

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to investigate a resident's allegation of sexual abuse by another resident for one (1) of six (6) residents reviewed for abuse. The facilities failure to investigate and implement protective interventions made the resident feel angry, violated, and unsafe, and lead him to avoid leaving his room for fear of being watched by the alleged perpetrator. This failure placed Resident #34 at risk for further abuse, emotional distress, and significant harm to his sense of safety and well-being. Resident #34Findings Include:Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 10/22 revealed under, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.An observation and interview with Resident #34 on 8/04/2025 at 10:30 AM revealed he was sitting in his wheelchair in his room. He explained that he was admitted to the facility in February 2025 and his only concern was another male resident residing in the facility had been making sexually inappropriate statements to him asking him to Suck his d*** and telling him he wanted to have sex with him. He stated the encounter happened in July near 100 hall but he could not remember the exact date. He explained that he told the staff after the incident and the resident named the Administrator (ADM) and Registered Nurse (RN) # 1 as the staff members he told. The resident stated, I'm not gay and I'm not down for that s***. The resident explained that after the incident he came back to his room and could not get it off his mind. He stated it made him angry, and he felt violated. The resident explained that the incident occurred with other residents and staff around. He stated he wanted to handle things by stabbing him because if he did not do anything to the perpetrator, he felt as though it made him look like a punk (in the eyes of people who may have witnessed the event).He stated after he reported the incident to the ADM, he came away with the feeling nothing would be done. He revealed he called the Long-Term Care Ombudsman, and she came out to talk to him on July 29th. He stated, I still don't know what was done about it. He revealed the perpetrator's name was (Resident #45). He revealed Resident #45 had not said anything else to him since the incident, but stated, He always watches me, and I don't like that s***. The resident stated, I went up to him and stuck my finger in his eye and told him, I am not like that and to stop staring at me. The resident explained that he did not want to be the one that might go to jail because he retaliated against another resident. He stated Resident #45 made him uncomfortable and he did not want to come out of his room. He stated they have a lot of resident-to-resident interactions in the facility and stated that administration did not do anything about the resident's behaviors of cursing, threats, and aggression when they first start and wait until things are out of control before they react. When asked whether he felt safe in the facility and felt as though the staff would protect him, he stated, I will protect myself.A telephone interview with the Long-Term Care Ombudsman on 8/4/25 at 1:36 PM revealed Resident #34 called her to come out and speak with him and she did so on 7/29/25. She explained it was regarding another male resident that was making obscene sexual comments to him. She stated the resident reported he had notified the Administrator (ADM) previously about the incident, but he felt that nothing was going to be done, so he called me. She revealed she spoke with the ADM on 7/29/25 and was told they had other complaints about the perpetrator, and she would be sending the resident out to Geri psych. She revealed Resident #34 never told her the name of the alleged perpetrator.An interview with the Administrator (ADM) on 8/05/25 at 1:42 PM confirmed Resident #34 came and reported an incident to her regarding Resident #45. She explained that Resident #34 stated that Resident #45 threatened to interact with him sexually and Resident #34 had inquired whether Resident #45 was gay. She confirmed the Ombudsman did come by and speak with her, but she thought it was just a misunderstanding. She explained that she did not investigate or do anything about Resident #34's concerns and stated, He keeps changing his story. The ADM revealed Resident #34 had told the Interim Director of Nursing, ‘He did not know these types of things (male to male sexual interactions) happened in a nursing home.' She revealed they tried to send Resident #45 out to Geri psych, but they could not find anyone to accept him. An interview with Registered Nurse (RN) #1 on 8/06/25 at 8:15 AM revealed Resident #34 did report to her the incident with Resident #45. She explained that she did not overhear anything, but Resident #34 had told her that Resident #45 made sexually inappropriate statements to him. She also stated that she saw Resident #34 telling a housekeeper about it, but she could not recall who the housekeeper was or the details of the incident and stated, I have a lot to do. RN #1 confirmed she did not document or report it to anybody and acknowledged what Resident #34 reported was resident to resident abuse.Record review of the Abuse and Neglect sign in sheet dated 6/30/25 revealed Registered Nurse #1 was in attendance for the in-service.Record review of the admission Record revealed the facility admitted Resident #34 on 2/26/25 with a medical diagnosis of Multiple Sclerosis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #34 was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection during medication administration as evidenced by failing to ensure Enhanced Barrier Precautions (EBP) were utilized and ensuring a multi-use glucometer was properly cleaned and disinfected for two (2) of four (4) medication observations. Resident #21, Resident #40Findings include:Record review of the facility policy titled, Enhanced Barrier Precautions with no revision date revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (.feeding tube) . Record review of the facility policy titled, Blood Sampling-Capillary (Finger Sticks) undated, revealed Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employee. Equipment and Supplies: 6. Approved EPA registered disinfectant for cleaning of sampling device. General Guidelines 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Resident #21 An observation on 8/6/2025 at 8:20 AM revealed Personal Protective Equipment (PPE) hanging on Resident #21's room door. Licensed Practical Nurse (LPN) #1 entered Resident #21's room to provide medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 administered the medications through the PEG tube without donning a gown. During an interview on 8/06/2025 at 8:35 AM, LPN #1 revealed that any residents with wounds or PEG tubes are under enhanced barrier precautions. She confirmed that Resident #21 is under EBP due to having a PEG tube and acknowledged that she failed to wear a gown, and she should have protected herself and the resident from potential exposure to bodily fluids and infections. During an interview on 08/07/2025 at 10:45 AM, the interim Director of Nurses (DON) revealed that she had conducted in-services on infection control January 2025, which included EBP requirements. She revealed that LPN #1 and all nursing staff were trained to wear the proper PPE while providing care to any resident under enhanced barrier precautions. She confirmed Resident #21 is under enhanced barrier precautions, and a gown should have been worn by LPN #1 while administering his PEG medications. Record review of Resident #21's admission Record revealed an admission date of 02/20/2025 with medical diagnoses that included Dysphagia following Cerebral Infarction. Record review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of July 10, 2025, revealed, under Section C' that the resident is rarely/never understood. Resident #40 An observation and interview on 8/06/2025 at 8:45 AM, revealed Registered Nurse (RN) #1 performed an Accu-Check on Resident #40 using a multi-use glucometer. After using it, she placed the glucometer on the medication cart, then put it into a blue basket in the top drawer without disinfecting it. The State Agent (SA) inquired if she needed to clean the glucometer. The nurse stated, Oh yeah. RN #1 opened the bottom right drawer on the medication cart, and a white container with a blue top was observed. The nurse looked down and then shut the drawer. She picked up an alcohol swab from the top of the medication cart, briskly cleaned the glucometer, and placed the glucometer back into the top-drawer basket. RN #1 revealed she may not have cleaned the glucometer correctly, but they were out of disinfectant wipes, and she just cleaned with what she had, which was an alcohol swab. The SA prompted RN #1 to look in her bottom drawer again. RN #1 opened the right bottom drawer of her medication cart, and the same white container with a blue top, labeled Micro-kill bleach Germicidal Bleach Wipes, was noted. RN #1 stated, Oh yeah, there are some disinfectant wipes here. She removed the glucometer from the top-drawer basket, wiped it briskly with the disinfectant wipe, and then laid the glucometer back on top of the medication cart, not utilizing a clean barrier. During an interview on 8/7/2025 at 11:00 AM, the interim Director of Nurses revealed that usually each diabetic resident has their own personal glucometer that is kept in their room; however, Resident #40 is relatively new and doesn't have her personal glucometer yet. She revealed that regardless of whether she did not have her own glucometer, the glucometer on the cart was available for her use, and it should have been cleaned and disinfected appropriately. She confirmed it is never an acceptable nursing practice to clean with only alcohol swabs, and the nursing staff knows that is not acceptable. She revealed it is our expectation and practice to clean and disinfect the multi-use glucometer with the Germicidal bleach wipes, and leave it wet for two to three minutes on a clean barrier to ensure it is thoroughly disinfected. Record review of Resident #40's admission Record revealed an admission date of 06/12/2025 with medical diagnoses that included Type 2 Diabetes Mellitus. Record review of Resident #40's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of June 18, 2025, revealed, under Section C' a Brief Interview Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired.

Based on staff interview, record review, and facility policy review, the facility failed to follow the requirements for obtaining a Preadmission Screen (PAS) for a resident in the facility for greater than 30 days for one (1) of five (5) residents reviewed. Resident #10Findings include: Record review of facility policy titled, admission Criteria, dated 4/10/23, revealed, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process . During an interview on 8/6/25 at 8:20 AM, the Social Worker stated Resident #10 was admitted to the facility for therapy with plans to be discharged home within 30 days, but her therapy was extended. She acknowledged the resident had diagnoses of bipolar disorder and anxiety disorder. She confirmed the Pre-admission Screening (PAS) process evaluated residents for proper placement in nursing facilities and she confirmed the facility failed to submit a PAS for a resident that was admitted in the facility for greater than 30 days. An interview with the Administrator on 8/6/25 at 9:00 AM, revealed a PAS was part of the process to help ensure residents were appropriate for nursing home care. She acknowledged that Resident #10 had diagnoses of bipolar disorder and anxiety disorder. She confirmed the facility failed to complete the required PAS for a resident in the facility for greater than 30 days. Record review of Resident #10's admission Record revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder and anxiety disorder.Record review of Minimum Data Set (MDS) Section C dated 6/24/25, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD) (Resident #5), Bipolar and anxiety disorder (Resident #10), and failed to implement a care plan for a resident receiving nectar thickened liquids (Resident #27) for three (3) of 22 care plans reviewed. Resident #5, #10, #27Findings Include: Resident #5 Review of the facility policy titled “Care Plans, Comprehensive Person-Centered” reviewed 10/2022, revealed under, “Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident . Record review of Resident #5’s Care Plans revealed a care plan was not developed for past traumatic events or potential triggers. On 8/4/25 at 10:52 AM, an observation and interview with Resident #5 revealed he was lying in bed with the curtains closed and the room dark. The resident stated he suffered from depression and took an antidepressant. He explained that he served in the [NAME] Corps for 17 years and was diagnosed with post-traumatic stress disorder (PTSD). He stated that having to kill people during his service deeply affected him. He reported trouble sleeping due to nightmares and said almost everything bothers him, including crowded areas, noise, and loud environments. An interview with Social Services (SS) #1 on 8/6/25 at 8:45 AM confirmed Resident #5 did not have a care plan for post-traumatic stress disorder. She revealed the care plan should be developed because staff need to know the residents' triggers and the things that cause the resident distress such as loud noises so they can better care for him. On 8/7/25 at 9:10 AM, an interview with the Interim Director of Nursing revealed Resident #5 was a veteran and confirmed he should have a care plan to address his triggers so that staff were aware of the things to avoid. Record review of the “admission Record” revealed the facility re-admitted Resident #5 on 4/7/24 with medical diagnoses of post-traumatic stress disorder dated 1/9/25 and schizophrenia affective disorder, bipolar type. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #5 was cognitively intact. Resident #27 Record review of Resident #27’s “Care Plans” revealed under, “Focus: I have a nutritional problem or potential nutritional problem r/t (related to) my dysphagia mechanical soft diet restrictions.” Also revealed under, “Interventions: Provide, serve diet as ordered.” A record review of the “Order Summary Report” revealed the following diet order dated 5/19/25: “Dysphagia mechanical soft texture, nectar consistency, add ground meats.” On 8/4/25 at 11:20 AM, during an observation of Resident #27’s lunch meal, she was provided a carton of 2% milk (non-thickened) with a straw inserted. A record review of Resident #27’s meal ticket dated 8/7/25 revealed the following note: “Nectar liquids, nectar milk, nectar water.” On 8/4/25 at 11:28 AM, an observation and interview with Dietary Staff #1 confirmed Resident #27 was served the wrong consistency milk. An interview with the MDS Nurse on 8/7/25 at 8:38 AM revealed the purpose of the care plan was to alert staff of what care to provide for the residents. She confirmed the care plan was not followed for Resident #27 in relation to the nectar thickened liquids. Record review of the admission Record revealed the facility re-admitted Resident #27 on 6/16/25 with medical diagnoses that included Dementia with Anxiety, Dysphagia, and Conversion Disorder with Seizures or Convulsions. A record review of the MDS with an ARD of 6/30/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #10 During the record review of Resident #10's care plan, it was revealed that the resident did not have a care plan for her diagnoses of anxiety disorder and bipolar disorder. During an interview with the Licensed Practical Nurse (LPN) MDS Coordinator on 8/6/25 at 10:05 AM, it was revealed that care plans guide the residents' care and preferences for the staff to follow. She acknowledged Resident #10 had diagnoses of bipolar disorder and anxiety disorder and the care plan failed to include the individualized care plan for these mental health diagnoses. She confirmed she was responsible for developing the care plan and due to an oversight, she failed to develop the care plan for her mental health diagnoses. An interview with the Administrator on 8/6/25 at 10:15 AM, revealed the care plan offers a guide for each resident's care and Resident #10 did not have a care plan developed for her diagnoses of bipolar disorder and anxiety disorder. She confirmed the facility failed to develop care plan for a resident's mental health diagnoses. Record review of Resident #10's admission Record revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder and anxiety disorder. Record review of MDS Section C dated 6/24/25, revealed resident had a BIMS score of 15 which indicated the resident was cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to assess and identify potential triggers for a trauma survivor for one (1) of three (3) residents reviewed for post-traumatic stress disorder (PTSD). Resident #5Findings Include:Review of the facility policy titled Trauma-Informed and Culturally Competent Care, revised 8/22, revealed under Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice, and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization.An observation and interview with Resident #5 on 8/4/25 at 10:52 AM revealed he was lying in bed with the curtains closed and the room dark. The resident stated he suffered from depression and took an antidepressant. He explained that he served in the [NAME] Corps for 17 years and was diagnosed with post-traumatic stress disorder (PTSD). He stated that having to kill people during his service deeply affected him. He reported trouble sleeping due to nightmares and said almost everything bothers him, including crowded areas, noise, and loud environments.Record review of Resident #5's Psychiatry Note dated 1/9/25 revealed: In [NAME] Corps for 17 years; when I first got out of the military, I stuck a gun in my mouth, then had to go to a mobile mental health center; nightmares every now and then-last one about a week ago (revisiting the past). The resident was diagnosed with PTSD.Record review revealed the facility did not complete a trauma assessment for Resident #5.An interview with Social Services (SS) #1 on 8/5/25 at 4:01 PM revealed she was responsible for conducting trauma-informed care assessments. She learned in January 2025 that Resident #5 had post-traumatic stress disorder (PTSD) after the nurse practitioner saw the resident. She confirmed no assessment had been completed and stated it should have been done to inform staff about his PTSD and potential triggers that could cause re-traumatization.An interview with the Interim Director of Nursing on 8/7/25 at 9:10 AM revealed Resident #5 was a veteran. She stated that trauma assessments should be conducted quarterly to ensure his psychosocial needs and mental well-being were met.Record review of the admission Record revealed the facility re-admitted Resident #5 on 4/7/24 with medical diagnoses of post-traumatic stress disorder dated 1/9/25 and schizophrenia affective disorder, bipolar type.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #5 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to maintain a medication error rate of less than 5% by ensuring that residents received all physician-ordered medications for three (3) of 28 medication administration opportunities observed during medication pass. The medication error rate was 10.71%.Review of the facility policy titled, Medication Administration dated November 1, 2008 revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . B. Administration . 2) Medications are administered in accordance with written orders of the attending physician . On 8/06/2025 at 9:35 AM, a medication administration observation with Registered Nurse (RN) #1 revealed a medication administration to Resident # 5. The medications administered were Diazepam tablet 5 mg (milligrams), Linzess oral capsule 145 mcg (micrograms) Prednisone tablet 5 mg (3 tablets) Pantoprazole Sodium tablet delayed release 40 mg, Keppra tablet 500 mg, Gabapentin capsule 100 mg, Imuran tablet 150 mg, Eliquis tablet 5 mg, and Glycolax powder (polyethylene Glycol 3350) 17 grams. The total number of medications administered to Resident #5 was nine (9). During medication reconciliation, a record review of the Order Summary Report and Medication Admin Audit Report revealed that Resident #5 did not receive three (3) medications that were prescribed by the Physician to be given during that medication administration time. Medications omitted were Metformin HCI Tablet 500 mg, Oxybutynin Chloride ER (extended release) tablet 24-hour 10mg, and Risperdal tablet 0.5 mg. Review of the Medication Admin Audit Report revealed that the three omitted medications were documented as given under the administration time as 09:38 and the documented time as 09:40 during the medication observation with RN #1. During an interview on 8/6/25 at 11:10 AM the interim Director of Nurses (DON) revealed it is our expectation that our nurses administer to the residents all of the medications that the physician has ordered. She revealed that not giving a resident their medications is not acceptable, and if a medication is unavailable, the nurse must call the physician and notify the DON. In an interview on 8/6/2025 at 1:30 PM, RN #1 revealed she returned after the Medication administration pass and later gave Resident #5 the other medications. SA inquired why the medications were not given simultaneously with the other morning medications listed on Resident #5's physician orders. RN #1 revealed she needed some time and exited the room where the interview was being held. A record review of the facility admission Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Post-Traumatic Stress Disorder, Schizoaffective disorder, Bipolar type, and Overactive bladder.A record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of July 24, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #5 is cognitively intact.

Based on observation, staff interview, and record review, the facility failed to serve a therapeutic diet as ordered for one (1) of six (6) residents reviewed for the dining task. Resident #27Findings Include:An interview with the Administrator on 8/7/25 at 10:06 AM revealed the facility did not have a policy regarding serving diets as ordered.An observation of Resident #27's lunch meal on 8/4/25 at 11:20 AM revealed she received a meal in the dining room consisting of cornbread dressing with cranberry sauce, rice with gravy, diced carrots, a roll, milk, and apple cobbler. The resident was provided with a carton of 2% milk (non-thickened) with a straw inserted. She was observed feeding herself.A record review of Resident #27's meal ticket revealed the following note: Nectar liquids, nectar milk.An observation of Dietary Staff #1 on 8/4/25 at 11:28 AM revealed she brought a carton of nectar-thickened milk to Resident #27's meal tray and removed the regular consistency milk. In an interview, Dietary Staff #1 confirmed that the resident had been served regular milk. She explained she came out of the kitchen to get another resident a sausage and noticed the error at that time. She stated the resident was supposed to be on nectar liquids and said, I caught it; I don't think she drank any of it. She acknowledged that aspiration was a possible risk. She also explained she had a new tray line server who was still in training but emphasized that the server should be reading the tray cards before sending trays to the dining room.A record review of the Order Summary Report revealed the following diet order dated 5/19/25: Dysphagia mechanical soft texture, nectar consistency, add ground meats.An interview with the interim Director of Nursing (DON) on 8/7/25 at 9:10 AM revealed her expectation was for certified nurse aides to check the meal ticket against the food provided at mealtime to ensure the correct diet was served. She confirmed Resident #27 was on nectar liquids and acknowledged that the resident could have choked, aspirated, and developed an infection.An interview with the Speech Therapist (ST) on 8/7/25 at 9:49 AM revealed Resident #27 was on the speech therapy caseload due to poor dentition and a history of aspiration pneumonia. She stated she had trialed thin liquids with the resident but decided to maintain thickened liquids because the resident's condition fluctuated and she experiences seizure episodes.Record review of the admission Record revealed the facility re-admitted Resident #27 on 6/16/25 with medical diagnoses that included Dementia with Anxiety, Dysphagia, and Conversion Disorder with Seizures or Convulsions. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from misappropriation of a resident's medication for one (1) of five (5) residents reviewed for misappropriation. Resident #1 Cross Reference F610 Findings include: Record review of facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education dated [DATE], revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. Misappropriation of resident property - Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Record review of facility policy titled, Resident Rights dated [DATE], revealed, The facility must protect and promote the rights of the resident. Record review of facility policy titled, Controlled Substances, undated, revealed, . 5. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 6. All keys to controlled substance containers are on a single key ring that is different from any other keys. 7. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers . During an interview on [DATE] at 9:45 AM, the Administrator stated she had reported the incident of missing narcotic medication to the required entities and acknowledged that Licensed Practical Nurse (LPN) #1 had left the medication keys unattended at the nurses station while she went outside for a break and also left the keys on the medication cart unattended while the corporate nurse checked the medication cart. When LPN #1 returned from her break she went to the medication cart to obtain a PRN (as needed) medication for Resident #1 and realized that a medication card for a 30 count Norco Oral Tablet ,d+[DATE] milligram was missing, and she reported it and an investigation was initiated immediately. During an interview on [DATE] at 4:00 PM, the Registered Nurse (RN) Supervisor revealed that around 2:30 PM - 3:00 PM on [DATE], LPN #1 informed her that one of Resident #1's pain medication cards was missing. They immediately searched for this card but were unable to locate it. An investigation began, and drug screens and statements were obtained on each staff member that worked that day. The RN Supervisor determined that LPN #1 had gone outside for a break earlier that day and left the narcotic keys unattended on the desk in the nurses' station. She had also left these keys on the medication cart while the corporate nurse checked her cart for expired and unlabeled medications. She acknowledged the medication keys were to remain with the nurse on their person at all times to prevent an unauthorized person having access to the residents' medications and confirmed that LPN #1 had failed to prevent the misappropriation of a resident's medication by leaving her narcotic keys unattended. A phone interview with LPN #1 on [DATE] at 5:30 PM, revealed she had worked in the facility from around 7:00 AM until 11:00 PM on [DATE], the day the medications went missing. She stated on that morning she made a careless mistake and when she went outside to take a break that she left the medication cart and narcotic box keys on the nurses' desk. When she returned, the keys were where she left them, and she was unaware of any concern. She stated around 2:00 PM - 2:20 PM, she opened the medication cart for the corporate nurse to check her cart and left her keys on top of the cart and she was nearby, but the corporate nurse did not go into the controlled medication locked box on the cart. Then around 2:30 PM - 3:00 PM, she unlocked the medication cart to get Resident #1's medication and noticed that one of the narcotic medication cards was missing for that resident. She reported this to the nurse supervisor, and they began searching for the medication which they did not locate. LPN #1 confirmed that she was tested for drugs, which was negative, and wrote a statement about what occurred. She confirmed she left the keys unsecured at the desk and on the medication cart and a resident's narcotic medication was missing. She confirmed she had been in-serviced on this and knew not to leave the keys unattended and it was a careless mistake that I won't do again. She stated this occurred around 3:00 PM and she was told to finish her shift which was a shift from 7:00 AM - 11:00 PM and then she was off for two days after that. She completed her assignment for that evening which included the medication pass for the evening shift. She stated she was not told to turn in her keys or leave the facility immediately and she returned to work after her two days off. She acknowledged that she had been in-serviced on abuse/neglect/misappropriation, resident rights, and medication administration which included keeping keys in her possession and locking the medication cart. During an interview on [DATE] at 2:15 PM, the Administrator confirmed that Resident #1 had narcotic medication that was missing and had not been located, and LPN #1 was the nurse responsible for that medication cart. She acknowledged LPN #1 left her keys on the desk while she went outside and on the medication cart while the corporate nurse was checking the cart for expired medication. She acknowledged the medication keys were to remain with the nurse on their person at all times to prevent an unauthorized person having access to the residents' medications. She confirmed the facility failed to prevent the misappropriation of a resident's medication by not ensuring that the keys remained in a nurse's possession and not left unattended. Record review of Order Summary Report revealed an order dated [DATE] for Norco (Hydrocodone) Oral Tablet ,d+[DATE] milligram; give one tablet by mouth every six (6) hours as needed for severe pain. Record review of Controlled Drug Receipt/Record/Disposition Form revealed two cards of 30 count Hydrocodone/APAP tablets each were delivered to the facility on [DATE] and two more cards with 30 tablets each was delivered to the facility on [DATE]. One of these cards was the one that was missing, and the other of these medication cards was completed being used by the resident. Record review of Controlled Drugs Count Record for February 2025 revealed on [DATE], LPN #1 signed that the narcotic medication count was correct when she came in at 7:00 AM and signed again when she was leaving at 11:00 PM that the narcotic medication count was correct. Record review of LPN #1's Employee Time Cards revealed on [DATE], she clocked in at 6:37 AM and clocked out at 11:36 PM, and she did not return to work until [DATE]. Record review of in-service signature sheets revealed that LPN #1 had been trained on Medication Administration, Compliance Requirements (Abuse/Neglect), Resident Rights, Code of Conduct, Medication Administration, Five Rights, and Documentation. Record review of Resident #1's Admission Record revealed she was originally admitted to the facility on [DATE] with the most recent admission being [DATE], with diagnoses that included displaced midcervical fracture of left femur, aftercare following joint replacement surgery, and dementia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 which indicated this resident had a moderate cognitive impairment.

Based on staff interviews, record review, and facility policy review, the facility failed to prevent further potential medication misappropriation by allowing a nurse to continue to work during an investigation for one (1) of five (5) residents reviewed for misappropriation of property. Resident #1 Cross Reference F602 Findings include: Record review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 10/22, revealed, All reports of .theft/misappropriation of resident property are .thoroughly investigated by facility management. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Record review of facility policy titled, Controlled Substances, undated, revealed, . 5. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 6. All keys to controlled substance containers are on a single key ring that is different from any other keys. 7. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers . During an interview on 4/7/25 at 9:45 AM, the Administrator stated the facility had a 30-count card of Hydrocodone medication for Resident #1 that was reported missing on 02/18/25 by Licensed Practical Nurse (LPN) #1. On 4/7/25 at 5:30 PM, a phone interview with LPN #1 revealed she had worked in the facility from around 7:00 AM until 11:00 PM on 2/18/25, the day Resident #1's medications went missing. She admitted that she left the medication cart keys unattended on the desk while she went outside and left the keys on the medication cart while the corporate nurse checked the cart that day. She stated the missing medication was noticed around 2:30 PM - 3:00 PM and was reported to the nurse supervisor. She stated she continued to complete her assignment and give medications to the residents which included the medication pass for the evening shift until around 11:00 PM the night of 02/18/25. She revealed she was not told to turn in her keys or leave the facility during the investigation and she continued to work her remaining shift and the next shift that evening and clocked out after 11:00 PM that night. On 4/8/25 at 2:15 PM, during an interview the Administrator confirmed that Resident #1 had narcotic medication that was missing and had not been located, and LPN #1 was the nurse responsible for that medication cart. She acknowledged the facility allowed the nurse to continue to work on the medication cart and did not require her to turn in the keys and leave the facility during the investigation. She confirmed the facility failed to prevent the misappropriation of a resident's medication and she confirmed the facility failed to prevent further potential misappropriation of a resident's medication by not removing LPN #1 from the facility during the investigation. A record review of the Police Department Incident Report, dated 02/19/25, stated that on 02/18/25 they responded to the facility for a report of missing pack of Norco. The police report revealed that LPN #1 was then drug tested and went back to her duties at work. Record review of LPN #1's Employee Time Cards revealed on 2/18/25, she clocked in at 6:37 AM and clocked out at 11:36 PM. Record review of Controlled Drugs Count Record for February 2025 revealed on 2/18/25, LPN #1 signed for the total narcotic medication cards count as being correct when she came in at the beginning of her shift at 7:00 AM, the end of that shift at 3:00 PM, the beginning of the 3:00 PM shift, and at the end of that shift at 11:00 PM. She left for the day at 11:36 PM.

Based on interview, record review and facility policy review the facility failed to report an allegation of abuse timely for one (1) of three (3) residents reviewed. Resident #1. Based on the implementation of the facility's corrective actions taken on 11/08/2024, the deficient practice was determined to be Past Non-Compliance, and the facility had put measures in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]. Findings Include: Record review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education with revision date of 11/14/17 revealed Reports must be within 24 hours (if the allegation does not involve abuse or there is not serious bodily injury) after forming your reasonable suspicion. Within 2 (two) hours (if the allegation involves abuse or there is serious bodily injury) after forming your reasonable suspicion In an interview on 02/03/25 at 9:40 AM, with the Administrator (ADM) she revealed that she reported an allegation of abuse on 11/07/24 when she found out about it. She revealed that on 11/07/24, Certified Nursing Assistant (CNA) #3, came to her and reported that she overheard a conversation that morning about an allegation of abuse. ADM revealed that this was the first she heard about it and that she didn't know how long ago it happened until she investigated it. ADM revealed that she initiated an investigation, and during interviews, found that the incident occurred on 10/10/24. She revealed that she found out that Licensed Practical Nurse (LPN) #1 had sent a message to the Director of Nursing (DON) on 10/11/24 that a staff member had hit a resident the day before. ADM revealed that she suspended LPN #1 pending investigation for not immediately reporting the incident. ADM revealed that she questioned LPN #1 about not reporting and she told her that she went to DON's office to report the incident, and she was not at the facility at that time, and she had gotten busy and had forgotten about it. A phone interview on 02/03/25 at 11:35 AM, with Licensed Practical Nurse (LPN) #1 revealed that she witnessed the last part of the incident between CNA #1 and Resident #1. She stated that on 10/10/24, she was working on the medication cart on 400 hall during lunch time when she heard a commotion in the dining room. LPN #1 revealed that she walked to the dining room and saw CNA #1 standing over Resident #1. LPN #1 revealed that later, CNA #2 told her that CNA #1 had hit Resident #1. She revealed that she realized this was a serious allegation and that she should have reported it immediately. She revealed that she tried to report it to the DON, but she was gone for the day and confirmed that she did not report this to anyone else. LPN #1 revealed that she reported it to the DON the next day. LPN #1 revealed that she was suspended because she reported the incident too late and she had decided not to return to the facility after that and she quit. On 02/03/25 at 12:42 PM, an interview with CNA #2, revealed that on 10/10/24, she was in the dining room helping with the lunch meal. She stated that she asked Resident #1 if she was done eating and she told her, No but there wasn't anything left on her tray. CNA #2 revealed that she tried to take Resident #1's tray, and the resident slung the tray across the table and turned her cup over as well. CNA #2 revealed that CNA #1 was sitting across the room in a chair and she got up from her seat, walked over to Resident #1 and she punched Resident #1 in the face with her fist. CNA #2 revealed that Resident #1 stated, You hit me. You hit me. CNA #2 revealed that LPN #1 was in the hall on the medication cart and came into the dining room. She revealed that LPN #1 came over and got CNA #1 away from the resident and made sure she was okay. CNA #2 revealed that she and LPN #1 looked at Resident #1 and there was no redness, no type of bruise or injury to her face. An interview with ADM on 02/03/25 at 4:08 PM revealed that an allegation of abuse should be reported within 24 hours if there was no injury and within two hours if it was abuse with injury. She confirmed that they were still out of that window and that it should have been reported immediately. ADM revealed that she found out during the investigation that the alleged abuse occurred on 10/10/24 and she didn't find out until 11/07/24 and that's when she reported it. Record review of the Facility Investigation revealed that on November 07, 2024, CNA #3 reported to ADM that she overheard a conversation involving CNA #1 who allegedly abused Resident #1. CNA #3 did not know when it happened or know any further details. CNA #2 told ADM that she witnessed CNA #1 hit Resident #1 in the nose with a closed fist. CNA #2 revealed that she got LPN #1 involved and intervened by addressing CNA #1. CNA #2 revealed that she took over Resident #1's care while CNA #1 moved on to picking up trays. LPN #1 looked for the DON to report it and couldn't find her. LPN #1 revealed that she returned to her hall, addressed call lights and finished up the shift that was about to end. LPN #1 reported that she reported the incident to the DON the following day. Education provided to LPN #1 and CNA #2 on 11/07/24 on the importance of timely reporting. LPN was suspended effective 11/07/24 due to late reporting. DON and CNA #1 were suspended immediately and both resigned immediately during the pending investigation. Record review of CNA #2's Written Statement dated 11/08/24 revealed that on October 10, 2024 around lunch time she asked Resident #1 if she was done with her lunch and Resident #1 said, No I'm not finish with it. CNA # 2 proceeded to pick up her tray and Resident #1 threw her tray across the table and threw her cup. CNA #2 stated that CNA #1 got up from her seat and hit the resident (proper name) Resident #1 with her fist. CNA #2 responded to CNA #1 and LPN #1 also witnessed what she did and it was reported to DON. The statement was signed by CNA #2. Record review of LPN #1's Statement revealed, she was getting medicine ready to pass out to a resident, heard a commotion which caused her to turn around to see what was going on. She stated as she turned around, she noticed CNA #1 standing over the resident holding her wrists. She intervened by pushing CNA #1 away from the resident. After the incident, CNA #1 passed out trays and LPN #1 went down the hall to look for DON. DON was not in her office, LPN #1 got sidetracked by call light to help out with another resident. LPN #1 notified DON on October 11/2024 by text message. Interview on 02/03/25 at 2:10 PM by phone with the former DON stated that she had nothing to say because she did not know anything about the situation because it wasn't reported to her and that she was not made aware of an allegation of abuse. Record review of Resident #1's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Dementia, Schizophrenia, Restlessness and Agitation. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated that she had severe cognitive deficits. Validation of Past Non-Compliance The SA validated through interview and record review the facility began investigation into the incident on 11/07/24 and reported the allegation of abuse on 11/07/24. In-services regarding abuse/neglect and reporting began on 11/07/24. 100 percent body audits were conducted on all residents on 11/8/24. Residents with a BIMS of 12 or higher were interviewed to ensure they all felt safe and free of abuse. The SA, Attorney General 's Office, local law enforcement, Medical Director and Resident Representative were notified. The DON and CNA#1 were suspended and resigned from the facility on 11/7/24. The facility held a Quality Assurance meeting on 11/08/24 and continued to monitor abuse/neglect and reporting concerns throughout the next thirty days. Based on the implementation of the facility's corrective actions on 11/08/2024, the deficient practice was determined to be Past Non-Compliance, and the facility had put measures in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE].

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to ensure that a resident was free from a significant medication error as evidenced by one drop of mometasone furoate external scalp solution being instilled into a resident's left eye in place of the physician ordered eye drops for one (1) of three (3) residents reviewed. Resident #2. Findings Include: Record review of the facility policy titled Adverse Consequences and Medication Errors with reviewed date of 08/2023 revealed under Medication Errors, 1. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: d. Wrong route of administration (e.g., ear drops given in the eye). On 03/20/24 at 9:00 AM, an interview with Administrator (ADM), revealed that on 02/25/24, Licensed Practical Nurse (LPN) #1 worked on the medication cart, and she mistakenly instilled the wrong drops into Resident #2's left eye. ADM revealed that Resident #2 had a bottle of scalp drops setting on her bedside table and LPN #1 picked up the scalp drops by mistake instead of the physician ordered eye drops and instilled one drop into Resident #2's left eye. ADM revealed that LPN #1 called and reported the incident to the Medical Director immediately and he instructed her to rinse Resident #2's eye out with normal saline and assessed the medication situation and informed them that the scalp drops would not hurt her eye. ADM revealed that this incident shouldn't have happened and confirmed that this was a medication error and she stated, I'm glad it wasn't any worse than that. On 03/20/24 at 9:15 AM, an interview with LPN #1 revealed that she was the Minimum Data Set (MDS) nurse, and she normally did not work the medication cart, but that she was on call the weekend of 02/25/24 and due to a call-in, had to come in to work. LPN #1 revealed that she did medication pass, prepared Resident #2's medications by placing each pill in separate medication cups and labeled them just like resident requested. LPN #1 revealed that she had checked the medication labels against the Medication Administration Record (MAR) during preparation, gathered the medications including the eye drops and entered Resident #2's room. She revealed that Resident #2 was lying in her bed and she placed the eye drops on the bedside table on the right side of the resident's bed to prevent getting them mixed up with the scalp drops which were on her bedside table positioned over the bed. LPN #1 revealed that after she gave Resident #2 her oral medications, she picked up the scalp drops by mistake and instilled one drop into resident's left eye. LPN #1 revealed that after a few seconds, Resident #2 complained of her eye burning, LPN #1 looked at the bottle and realized she had administered the wrong medication. LPN #1 revealed that she called the Medical Director and he ordered her to flush her left eye with normal saline and that this medication would not cause damage to the eye, to keep flushing until the drops were cleared from the eye. LPN #1 revealed that she assessed the resident's eye and found no redness, no drainage and examined it two or three times during the night. On 03/20/24 at 10:50 AM, an observation and interview with Resident #2 revealed her lying in her bed with her head raised at 90-degree angle and her bedside table was within her reach and positioned over her legs as she lay in the bed. Resident #2 revealed that she gets eye drops put in her eyes in the morning and at night and that on 02/25/24, LPN #1 brought her medications in including the eye drops. Resident #2 revealed that she kept a box on her bedside table that had a steroid hair solution inside that she had recently gotten from a doctor's appointment. Resident #2 revealed that after she took her oral medications, LPN #1 picked up the scalp drops and put them in her left eye. She revealed that her left eye started burning, and she realized that LPN #1 had put the scalp drops into her eye. Resident #2 revealed that the nurse was supposed to check three times to make sure she had the right medication and she never looked at the box label. Resident #2 stated, This was a medication error and could have cost me my vision. Resident #2 revealed that LPN #1 called the doctor after it happened and flushed her eye out with saline. She revealed that her left eye had hurt for a couple days and she was still having issues with it now. She revealed that she made her own doctor appointments, and had went and was prescribed some different eye drops. On 03/20/24 at 1:00 PM, an interview with Director of Nursing (DON), revealed that she was familiar with the incident that occurred with Resident #2's eye drops. She revealed that LPN #1 who was on-call, was working on the weekend of 02/25/24 and that LPN #1 had mistakenly put scalp drops into Resident #2's left eye in place of her ordered eye drops. DON revealed that LPN #1 called the Medical Director, and he gave her orders to flush her eye and to monitor her. DON revealed that Resident #2 had received the prescription scalp oil drops from a prior dermatology appointment she had scheduled herself and that when she had returned to the facility she kept the scalp drops in her room on her overbed table. The DON stated that she had completed a one-on-one in-service on eye drop administration including the five rights with LPN #1 and the other administrative nurse who was not accustomed to doing medication pass. The DON revealed that she also observed medication passes with them which included eye drops. The DON revealed that the pharmacist also came in and in-serviced the med cart nurses on safely administering medications including eye drops and inhalers. DON revealed that the pharmacist observed medication passes with the nurses with 100% pass rate. The DON stated that leaving medications in a resident's room was a medication error waiting to happen. DON agreed that if the scalp drops had been locked up in the medication cart on 02/25/24, this medication error with Resident #2 receiving the wrong drops in her eye might have been avoided. Record review of Resident #2's Incident Note on 02/25/24 revealed: Note Text: During morning med pass this nurse went into residents room to administer medications and eye gtts (drops). This nurse placed eye gtts on right bedside table and medications on overbed bedside table and after recalling medications to resident and administering them this nurse picked up mometasone scalp tx (treatment) from the resident's overbed table and administered 1 gtt to the resident's left eye. Resident c/o (complained of) burning sensation and after realizing, this nurse immediately rinsed resident's eye and assessed for irritation. No redness abnormal drainage or irritation was noted. This nurse contacted proper name (Medical Director) and notified him of the situation. New order received to flush with saline as long as resident tolerates. This nurse flushed the resident's eye as ordered. The resident tolerated the flushing well. No c/o pain or discomfort during flushing. Resident states her eye continues to burn after the flushing. Stated its not the eyeball, the inner corner and lining still burns a little. Proper name (Medical Director) notified. New order received to check resident q (every) 2 hrs x 24 hrs (every two hours for twenty-four hours) then q shift x 3 (every shift for three days.) Medical Director informed this nurse to reassure resident flushing with saline is all that is recommended and it should eventually subside. Proper name (Medical Director) recommended administering scheduled eye lubricant gtts after flushing. This nurse notified the resident of the recommendation. Resident stated she does not want the lubricant gtts right now. Resident's eye was reassessed and remains normal color, no redness, drainage, or irritation noted. Resident is able to blink and move eyeball without discomfort. Resident's responsible party (RP) arrived to unit and was notified of incident. After several attempts to administer lubricant eye gtts, resident agreed to allow this nurse to administer gtts. Resident asked if her eye felt the same, resident stated it just feels more dry than usual. q 2 hrs (Every two hours) checks in progress. Resident continues to show no irritation or complications at this time. Administrator notified. This progress note was signed by LPN #1. Record review of Resident #2's Order Summary Report with active orders as of 3/20/24 revealed the following: 09/24/23 - Systane Ultra Ophthalmic Solution 0.4-0.3 % (percent) - Instill 2 drops in both eyes four times a day for dry eyes. 01/05/24 - Mometasone Furoate External Solution 0.1 % - Apply to Scalp topically every 24 hours as needed for Itching. Record review of Resident #2's Admission Record revealed an original admitted [DATE] and a readmitted [DATE] with the following diagnoses to include Segmental and Somatic Dysfunction of Cervical Region, Quadriplegia, and Morbid Obesity. Record review of Resident #2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/06/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive deficits.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure a medication was properly stored as evidenced by a tube of Hydrocortisone Topical Cream being left on a resident's overbed table for one (1) of three (3) residents reviewed. Resident #2. Findings Include: Record review of the facility policy titled Medication Storage in the Facility dated December, 2006, revealed under Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. An observation and interview on 03/20/24 at 10:50 AM, with Resident #2 revealed her lying in her bed with her head raised at 90-degree angle and she was on her phone. Resident #2's bedside table was within reach positioned over her legs and there was a tube of prescription steroid cream sitting on her bedside table. The tube was inside a prescription box with the following label: Hydrocortisone - External Cream 2.5% (topical) Apply to skin topically q (every) 12 hrs (hours) as needed for dermatitis. Apply to face and ears as needed. This prescription box was dated as filled on 01/05/24. Resident #2 confirmed that she makes her own doctor appointments and when she returns she keeps the medications in her room sometimes and that this medication was prescribed to her from an earlier appointment that she had made herself. On 03/20/24 at 12:00 PM, an interview with the ADM revealed that the only time a medication should be left in a resident's room was if the resident was considered appropriate to self-administer. ADM revealed that to qualify to self-administer medication, an evaluation had to be completed with the resident and the resident had to demonstrate competency. ADM confirmed that Resident #2 was not able to lift her arms and was unable to self-administer her own medications and that a previous medication error had occurred with this resident because she wants to keep her medications in her room. The ADM stated Resident #2's Hydrocortisone cream should not be kept in her room, that it should be locked up in the medication cart. On 03/20/24 at 12:25 PM, an interview with Registered Nurse (RN) #1 revealed that Resident #2 made her own doctor appointments and called the ambulance service for transportation to these appointments, and would often bring medications back with her from these appointments and not tell anyone. RN #1 revealed that they had explained to Resident #2 that she was not allowed to keep medication in her room. She also revealed that they have had to take medications from her room before and lock them up. RN #1 revealed that Resident #2 was manipulative and her mom had brought medications from home into the facility and left them in Resident #2's room before without letting the staff know. RN #1 revealed that the Director of Nurses (DON) completed an evaluation on Resident #2 and determined that the resident was not able to self administer her medications because she could not lift her arms or safely demonstrate competency with this. RN #1 entered Resident #2's room during the interview and confirmed that the hydrocortisone cream was laying on her bedside table in front of the resident. RN #1 revealed that another resident could come into Resident #2's room, get the medication, or someone could come into her room, give the medication to Resident #2 and the facility nurses not know. RN #1 stated, This throws up a lot of red flags. RN #1 confirmed that the hydrocortisone cream was ordered by the Medical Director and was dated 01/05/24 and that she would get the medication out of her room and lock it up in the medication cart. An interview with the DON on 03/20/24 at 1:00 PM, revealed that all medications were supposed to be under lock and key unless a resident had an evaluation for self-administration and was able to demonstrate safe self medication administration and stated, No one in here self-administers at this time. DON revealed that leaving medications in a resident's room was a medication error waiting to happen. DON agreed that if the scalp drops had been locked up in the medication cart on 02/25/24, the medication error with Resident #2 receiving the wrong drops in her eye might have been avoided. The DON also confirmed that the prescription steroid cream which was found on Resident #1's bedside table today should not be in her room and should be locked up in the medication cart. She revealed that they had some residents who walked around and stated, Another resident could get in there and get away with the medication before anyone could get it. Record review of Resident #2's Order Summary Report with active orders as of 3/20/24 revealed the following: 01/05/24 - Hydrocortisone External Cream 2.5% (percent) (Hydrocortisone (Topical) - Apply to skin topically every 12 hours as needed for dermatitis apply to face and ears as needed. Record review of Resident #2's Admission Record revealed an original admitted [DATE] and a readmitted [DATE] and she had the following diagnoses to include Segmental and Somatic Dysfunction of Cervical Region, Quadriplegia, and Morbid Obesity. Record review of Resident #2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/06/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated no cognitive deficits.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the spread of infection as evidenced by placement of a treatment cart inside a resident room during treatment care for one (1) of three (3) survey days. Findings include: Record review of facility policy titled, Standard Precautions dated May 30, 2012, revealed, Standard Precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, membranes may contain transmissible infectious agents . Record review of facility policy titled, Infection Control Program dated February 1, 2008, revealed, The facility will establish and maintain an Infection Control Program focused on preventing the transmission of infectious disease in the long-term care setting. Purpose: Decrease the risk of infection for residents and staff; Monitor for the occurrence of infections and implement control measures; Identify and correct improper infection control practices; Insure compliance with federal and state infection control guidelines . During the initial tour on 1/2/24 at 10:20 AM, an observation revealed Licensed Practical Nurse (LPN) #1 coming out of resident room [ROOM NUMBER]. The treatment cart with items on the top of the cart was inside the resident's room. LPN #1 then turned around and stepped back into the room and pushed the cart from the room into the hallway. During the interview, LPN #1 stated she was in resident's room to perform wound care and had taken the treatment cart into the room because the lock on the cart was broken and she did not want to leave the unlocked cart containing treatment supplies unattended in the hallway. She stated she had also taken this cart into other residents' rooms to do their treatments and she did not clean the cart between residents and she did not remove items from the open top of the cart. She stated that when she took the cart into the residents' rooms, she was focused on the safety concern of leaving an unlocked supply cart unattended and did not think about the infection control risk. She stated for proper infection control and for decreasing the spread of infection, she should have left the cart in the locked storage room and taken only the items needed for the resident's treatment into the room. Observation at that same time was made of LPN #1 attempting to lock the cart and when the lock was pressed in, it popped back out and did not remain in locked position. During an interview on 1/2/24 at 11:25 AM, the Director of Nursing (DON) stated that taking a medication cart or a treatment cart into a resident's room was a big no, no, and this could spread infections from one resident to another resident. She confirmed that by taking a treatment cart into residents' rooms, the facility failed to decrease the likelihood of the spread of infection. She also confirmed the facility failed to ensure the proper techniques for infection control were followed. She confirmed the lock on the cart was being repaired, but it had been broken for a while, and during that time to decrease the risk for the spread of infection, the cart should have been left in a locked room and only the necessary supplies should have been removed and taken into the resident's room.

Based on staff interview, record review, and facility policy review, the facility failed to update and revise a care plan with the appropriate ordered wound care for one (1) of three (3) resident care plans reviewed. Resident #1 Findings include: Record review of facility policy titled, Care Plan - Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The policy also revealed, 2 The comprehensive care plan had been designed to: .d. Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal and cultural preferences and wishes. The policy also revealed, Care plans are revised as changes in the resident's condition dictates. An observation of wound care for Resident #1 and an interview with the Registered Nurse Supervisor on 3/23/23 at 11:45 AM, revealed Resident #1 with an undated dressing on her right foot and ankle area. The dressing was removed by the Nursing supervisor. The Kerlix wrap was removed and a two inch by two inch blue foam like pad was noted covering the ankle area. The Nursing Supervisor stated, That's not ordered for this resident. She gently tried to remove the pad, but it was adhered to the skin on the ankle area. She then moistened the area slightly with the Normal Saline (NS), and gently attempted to remove the blue pad that had adhered to the resident's skin. Upon removal, it was noted that an area of skin had come off as well as was stuck to the blue pad. The Nursing Supervisor cleansed the area with Normal Saline and dressed the site and stated she would notify the physician to receive a new order for wound care for the now opened area of skin to the right ankle. She stated this pad is called Derma Blue Foam pad and it adheres to the skin or wound. The Nursing Supervisor stated that the resident's wound had been healed, but the skin covering the site was extremely thin and fragile and that she had seen the wound on Monday, 3/20/23, and at that time it was closed. Record review of Resident #1's Care Plan revealed an order dated on 9/21/22 and revised on 1/17/23 to clean with wound cleaner to right plantar area of right foot and pat dry, apply skin protectant to peri wound, apply hydrogel with derma blue and cover with ABD pad with bulked gauze daily. An interview with the Corporate Nurse Consultant serving as the Director of Nursing (DON) on 3/23/23 at 5:40 PM, confirmed the facility failed to ensure the care plan was updated and revised to reflect the current wound care orders and that it was being followed at the time of survey and that it was not current with the Physician's Orders for a wound care treatment for a resident with a Diabetic Ulcer Wound. She confirmed the DON is responsible for ensuring care plans are up to date, and this care plan had not been done to reflect the care that was needed for the diabetic ulcer. An interview with the Administrator on 3/23/23 at 5:45 PM, confirmed the care plan for a Physician's Order for wound care for Resident #1 was not updated and revised on her care plan and the Administrator confirmed that this led to an incorrect treatment being done on this resident and caused an open wound area of skin to a previously healed skin tissue by utilizing the wrong treatment to the skin area. Record review of Physician's Order on the Treatment Assessment Record (TAR) dated 12/15/22 revealed an order to cleanse diabetic wound to right plantar with normal saline, pat dry, and paint with betadine, cover with ABD (abdominal) pad and wrap with a kerlix one time daily. Record review of face sheet for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included Non-Pressure Chronic Ulcer of Right Ankle, Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus. Record review of Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating several mental impairments.

Based on staff interviews, observations, record review, and facility policy review, the facility failed to promote healing of a wound and to prevent the worsening of a wound as evidenced by the physician's ordered treatment not being followed for one (1) of three (3) residents with skin issues reviewed. Resident #1 Findings include: Review of the facility policy titled, Skin Care Process, dated 1/17/18, revealed, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur. The policy also revealed, Licensed Practical Nurse - Provides treatment according to physician's orders. An observation of wound care and an interview with the Registered Nurse (RN) Supervisor on 3/23/23 at 11:45 AM, revealed Resident #1 with an undated dressing on her right foot and ankle area. The dressing was removed by the RN Supervisor and was observed as a Kerlix wrap with a two-inch-by-two-inch blue foam like pad observed that was covering the ankle area. The RN Supervisor stated, That's not ordered for this resident, and she gently tried to remove the pad, but it was adhered to the skin that was surrounding the ankle area. She moistened the area slightly with the Normal Saline, and gently attempted further to remove the pad. Upon removal, it was noted that an area of skin had come off and was adhered to the dressing that was removed. The RN Supervisor cleansed the area with normal saline and stated she would notify the physician to receive new orders for the now opened wound area to the resident's ankle. She confirmed that this pad is called Derma Blue Foam pad and it adheres to the skin or wound. She stated she had observed the wound on Monday, 3/20/23, and at that time it was closed. With fragile skin and the wrong wound treatment, the skin was damaged while removing the dressing. A phone interview with Licensed Practical Nurse (LPN) #1 on 3/23/23 at 4:40 PM, revealed she changed Resident #1's dressing on 3/22/23. She stated that the area on the resident's skin was already opened and she put the Derma Blue foam pad on the area. She confirmed that she did not look at the physician's order to see that it had changed and confirmed that she was not aware that this was a concern for the resident's skin. An interview with the Corporate Nurse Consultant serving as Director of Nursing on 3/23/23 at 5:40 PM, confirmed the facility failed to ensure that Resident #1 received the Physician's ordered treatment for Resident #1's wound. She confirmed that the resident's skin was damaged by the order not being properly treated by the facility staff. An interview with the Administrator on 3/23/23 at 5:45 PM confirmed the facility failed to provide ordered wound care for Resident #1 and this led to damage to skin that had previously healed. Record review of Resident #1's Weekly Non-Pressure Wound Record dated 3/23/23, revealed a Diabetic Ulcer to right ankle measuring 3.5 centimeters by 1.5 centimeters. The SA verified that this wound assessment and measurements were the measurements after the improper skin treatment was removed and the skin was removed along with the wound dressing. Record review of Face Sheet for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included Non-Pressure Chronic Ulcer of Right Ankle, Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus. Record review of Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status of 0, indicating several mental impairment.

Based on staff interviews, record reviews, and facility policy review the facility failed to maintain adequate staffing numbers to assist the residents in getting the care needed for six (6) of the 24 days reviewed. Findings included: Review of facility policy titled, Staffing, dated October 2017, revealed, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment. Interview with Certified Nurse Assistant (CNA) #1 on 3/22/23 at 9:30 AM, stated staffing has been a concern. New people will come in and some of them will not stay. Other people quit and leave the facility. She stated a lot of staff will work extra shifts, come in early, or stay late to make sure there are enough people working, but it is still short at times. Stated they just work together and try to do everything that needs to be done as best we can. The residents gotta be taken care of. Interview on 3/22/23 at 9:40 AM, with the Resident in room [ROOM NUMBER]B stated it sometimes takes a little while for staff to assist. Interview on 3/22/23 at 9:50 AM, with the Resident in room [ROOM NUMBER]A stated the facility could use more staff, but they get the care even though it may sometimes take a while for staff to answer the light. She stated the facility has made some staffing changes and she and some of the other residents do not like it. She likes the staff that is familiar with her to be taking care of her. When new staff come in, it takes a while to get used to each other. She stated those that know her, know how she likes her care to be done. They know how she does her showers, and they know her other preferences and the other staff do not. She stated it's just not consistent and that has been a major problem. Interview with Certified Nursing Assistant (CNA) #2 on 3/22/23 at 10:20 AM, she tated they have had staff that have left their jobs at the facility and there are also call-ins, so they often work short. She stated there should be two (2) CNAs on each hall so that adequate care can be done, but they often work with less. They just work together and try to get everything done that the residents need, but it is a struggle. Interview with Licensed Practical Nurse (LPN) #2 on 3/22/23 at 10:20 AM, stated the shifts have been short and some of the staff have quit. They have to share staff with the Memory Unit. There should always be two (2) staff in that unit, but they are often pulled to help on other halls. It would be ideal to have three (3) LPNs working, but it is usually only 2 and they have to pick up and give meds to those in the Memory Unit. The facility does not have agency staff. She stated they want the best care for the residents, so the nurses try to assist the CNAs with the resident care as needed. Interview on 3/22/23 at 10:25 AM with the Nursing Supervisor, stated there have been some staffing concerns recently, but we are doing the best we can. Stated they have not had a Director of Nursing (DON) for about a month, and she tried to fill in for about a week or so, but she was unable to do this, so she stepped down from the Assistant Director of Nursing (ADON) position and is now the RN supervisor and works PRN (as needed). Interview with LPN #3 on 3/22/23 at 10:30 AM, stated she is normally on the 300 hall, but they are now rotating halls and this is not good for the staff or residents. Stated ideally, there are three (3) nurses and six (6) aids, but they have been working with less. Interview on 3/22/23 at 10:45 AM with CNA #3. stated she was hired to work the 300 hall, but the staff are having to rotate so she is in the Memory Care Unit today. They have been short staffed and about a week ago they only had three (3) CNAs in the building for a period of time on the 3-11 shift. She works with other good aids and they make sure they work together to get the residents cared for, but it is not always possible to do everything, so some things have to slide and that risks wounds and weight loss. Interview with CNA #4 on 3/22/23 at 11:40 AM, stated they have had staff shortages on and off. She stated when the facility is short staffed, the staff cannot do everything and residents don't get the care they need and deserve. Interview with CNA #5 on 3/22/23 at 11:55 AM, stated the facility is short staffed, with no Assistant Director of Nursing (ADON) or Director of Nursing (DON) and staff are leaving. She stated the remaining staff have been working extra hours to try to cover the shifts for the resident care. She worked 11-7 last night and now 7-3 today. A couple of weeks ago, the facility only had 3 aids and 2 nurses working for a little while. The staff pull together to try to meet the residents' needs. There was a shift she was by herself on the 200 hall until about 12 noon. Interview with the Business Office Manager and Human Resources Director on 3/22/23 at 3:00 PM, stated the facility has had some low staffing due to several leaving their job. They have tried to hire some new staff to fill positions. She stated they have multiple listings for job openings on (Proper Name of website). This is for the ADON, DON, as well as for nurses and CNAs. She stated they still have openings including a transport driver. An interview with the Corporate Director on 3/23/23 at 5:00 PM, confirmed the facility had concerns with adequately staffing the facility and for six (6) of the 24 days reviewed, the staff hours were not sufficient. He also confirmed this could lead to a lack of needed care of the residents. An interview with the Corporate Nurse serving as Director of Nursing (DON) on 3/23/23 at 5:40 PM, confirmed the facility failed to meet the minimum requirements for staffing and this could have a negative impact on resident care. An interview with the Administrator on 3/23/23 at 5:45 PM, revealed that due to being new to the facility, she was unaware there were so many days that the facility failed to provide adequate staffing for the care of the residents. She confirmed the facility failed to provide adequate staffing to ensure the residents' needs were met. Record review of Staffing Grid and the Employee Time Cards revealed from 2/27/23 through 3/22/22, there were six (6) days that the facility failed to provide sufficient qualified nursing staff. These dates were 2/28/23, 3/4/23, 3/6/23, 3/8/23, 3/12/23, 3/18/23.

CI MS # Based on interview, record review and policy review the facility failed to develop, review and revise a care plan for one (1) of five (5) sampled residents, Resident #1, as evidenced by not having a care plan and interventions in place for the resident's great toe and second toe overlapping. There was no care plan for anitembolism stockings with removal for two (2) hours each morning and checking pedal pulses for Resident #1. A wound to the resident's second toe was identified by the hospital upon transfer from the facility which was cultured and treated for [REDACTED]. Findings included: The facility's policy for Care Plans-Comprehensive dated June 1, 2000, revealed: It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. The policy further documents the care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; . f. Prevent declines in the resident's functional status and/or functional levels. 4. Care plans revised as changes in the resident's condition dictates. Review of Resident #1's care plan, dated 4/23/15, revealed: Resident has problems with [MEDICAL CONDITION] and is at risk for skin impairment. There was no care plan in place to include the use of antiembolism stockings and/or assessment for pedal pulses. There was no care plan for the overlap of Resident #'1 great and second toe or interventions to prevent skin impairment. (Interviews from staff revealed the overlapping of the toe was present). Review of the July 2015 Physician order [REDACTED]. Review of a hospital history and physical dated 7/29/15 revealed Resident #1 had an open lesion to the second toe left foot with a white center and [DIAGNOSES REDACTED]tous tissue surrounding the lesion. The Assessment and plan documentation included 1.[MEDICAL CONDITION]? (questionable) left great toe-WBC (White Blood Count) 12.8, [MEDICAL CONDITION], tachypnic upon presentation left second toe drainage cultured. Review of the discharge summary dated 8/3/15 revealed Resident #1 was admitted with signs and symptoms [MEDICAL CONDITION] and presented with and open lesion to the second left toe with purulent drainage. Drainage was cultured and showed Morganella. Interview with RN #1 on 9/24/15 at 10:25 AM revealed any care and treatment should be on the care plan and the nurses update the care plan with any new orders or changes. RN #1 stated she updated the care plan quarterly, annually and with significant changes. Interview with the Nurse Consultant on 9/24/15 at 12:40 PM and Director of Nursing (DON) on 9/23/15 at 1:00 PM verified there was no care plan in place for the antiembolism stockings. The DON verified there was no care plan for the toe overlapping for Resident #1. The facility admitted Resident #1 on 4/23/15 with [DIAGNOSES REDACTED]. Resident #1 was dependent upon staff for Activities of Daily Living (ADLs).

CI MS # Based on interview, record review and policy review the facility failed to ensure one (1) of five (5) sampled residents, Resident #1, received care and services to identify and treat any skin issues prior to transport to the hospital. Resident #1 was transferred to the hospital on [DATE] with fever and shortness of breath (SOB). The facility failed to identified a lesion to the left second toe which had drainage and a [MEDICATION NAME] skin rash to the right upper arm and right [MEDICATION NAME] side. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 had a [DIAGNOSES REDACTED]. Findings included: Review of the facility's policy Skin Care Process dated October 17, 2013, revealed It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur. Review of an emergency room report dated 7/28/15 revealed Resident #1's chief complaint was SOB, Fever, and Decreased Level of Consciousness. Resident #1 had an [DIAGNOSES REDACTED]tous [MEDICATION NAME] rash on the right upper arm and right [MEDICATION NAME] side. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a hospital History and Physical dated 7/29/15 revealed Resident #1 had a dermatonmal vesicular rash to the right side/back to midline and right upper arm; open lesion to second toe left foot with a white center and [DIAGNOSES REDACTED]tous tissue surrounding lesion-[DIAGNOSES REDACTED] and scaling between toes on both feet and TED (Antiemolism) stockings in place. The Assessment and Plan [MEDICAL CONDITION]? (questionable) left great toe-WBC (white blood count) 12.8, [MEDICAL CONDITION], tachypneic upon presentation-left second toe drainage cultured and left great toe ulcer X-ray showed no osteo[DIAGNOSES REDACTED]. Review of the Discharge Summary dated 8/3/15 revealed Resident #1's culture of the toe grew Morganella Morganii and was treated. The [DIAGNOSES REDACTED]. The shingles test was reported as negative. Review of a Physical Therapy (PT) evaluation dated 7/29/15 revealed an ulcer on the dorsum of left second toe originating from pressure exerted by the left great toe. Wound measurements were 1 cm (centimeter) x 0.9 cm x 0.2 cm with some slough with possible tendon exposure (?). No indication for PT. Review of Resident #1's medical record including Treatment Administration Records (TARs), Medication Administration Records (MARs), Weekly Body audits through 7/23/15, and physician's orders [REDACTED]. Review of a Nursing Home to Hospital Transfer Form dated 7/28/15 revealed Resident #1 was sent to the emergency room at 4:00 PM. There was no documentation of the skin condition for Resident #1. Resident #1's Blood Pressure was 130/81, Pulse 120, Respirations 34 and Temperature 99.9 with an Oxygen Saturation of 91% and the reason for transfer was documented as SOB and decreased oxygen saturation. Interview with the Interim Administrator #1 (IA) on 9/23/15 at 9:20 AM revealed there had been a complaint about quality of care for Resident #1 after the transfer to the hospital. IA #1 stated the family member complained about positioning and a wound on the resident's toe next to the big toe because that toe had laid on the big toe. The family member reported she didn't know about the toe and the facility didn't know about the toe. The IA stated the facility had not identified the toe wound before the resident was sent to the hospital and the hospital called the Nurse Supervisor to ask about Resident #1's toe. (Same day of transfer). Interview with Registered Nurse (RN) #2 on 9/23/15 at 4:30 PM revealed she sent Resident #1 to the hospital because of shallow rapid respirations, increased heart rate and decreased oxygen saturation. RN #2 was unaware of any skin issues. RN #2 stated the nurse from the hospital called to say Resident #1 was admitted with a [DIAGNOSES REDACTED]. RN #2 stated the hospital nurse reported a small place on the 2nd toe that looked like it had rubbed against the big toe and thinks the nurse reported the area was oozing. RN #2 stated the Certified Nursing Assistants (CNAs) did ask about whether or not to pull apart toes if they were together during an in-service and they were advised to gently pull apart toes and wash and dry between the toes. RN #2 stated a skin assessment was usually done before transfer of a resident but she did not perform a skin assessment on Resident #1 prior to transfer due to the seriousness of her condition. Interview with Resident #1's Responsible Party (RP) on 9/23/15 at 5:55 PM revealed she was not aware of any wounds or sore on the resident's toe until they got to the hospital. The RP stated the Intensive Care Unit (ICU) Nurse reported the toe wound was basically caused by not keeping the area clean. The RP stated Resident #1's big toe had always crossed over the second toe and there had never been a problem with sores. The RP stated hospital staff told her the toe was infected and [MEDICAL CONDITION] and she stayed in ICU the night she was sent to the hospital. The RP was also unaware of the rash on the resident's back and the was never notified of a rash at the facility. The RP stated shingles was never confirmed. The RP stated she did not think Resident #1 received good care and the facility should have seen the toe sore and rash and notified her. Interview with Certified Nurses Assistant (CNA) #2 and CNA #3 on 9/24/15 at 11:20 AM revealed they had provided care for Resident #1 the morning of 7/28/15. Both CNAs reported they did not see a rash on Resident #1's back and they did not see a sore on her toes. Both CNAs reported Resident #1's big toe and second toe did cross over each other. CNA #2 stated she did not pull the resident's toes apart because the resident whined about that leg and she was scared to pull the toes apart. CNA #3 stated she did not pull Resident #1's toes apart but put the towel between the toes and pulled through to wash and dry them. Both CNAs admit to not pulling Resident #1's toes apart to view them while bathing the resident. Interview with Licensed Practical Nurse (LPN) #1 on 9/24/15 at 1:20 PM revealed she did not recall seeing a rash nor a sore on Resident #1's toes on the last body audit she performed. (Documented audit on 7/23/15) Interview with LPN #3 on 9/24/15 at 12:30 PM revealed she knew Resident #1 had one toe over the other one and she did not pull them apart when she took the TED stockings off/on. LPN #3 stated she just rolled the stockings. LPN #3 stated she did not recall anyone reporting sores on Resident #1's toes. The facility admitted Resident #1 on 4/23/15 with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 7/28/15 revealed she required total assistance with Activity of Daily Living (ADL) and had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure that three (3) of seven (7) resident's reviewed were adequately assessed and supervised to prevent the potential for falls. This is for Resident #2, #4 and #7. Resident #2 had history of falls sustained on 9/28/11, 12/28/11, and on 1/23/12. There were no updates to the care plan with additional interventions for two (2) of the three (3) of the falls. Resident #2 fell from the wheelchair on 1/23/12 and sustained a hematoma to the forehead. Resident #2 was transferred to the emergency room for evaluation and treatment. The facility had no documented neurochecks on file after the fall. An observation during the survey revealed that Resident #2 had the chair alarm in place on the wheelchair however, the alarm was not connected to the Resident to alert staff if she attempted to rise with out assistance. Resident #4 had a history of [REDACTED]. On 8/20/11, Resident #4 became agitated in the shower and fell from the shower chair. The shower chair did not have a safety belt. Resident #4 sustained injury to her face and a laceration to the forehead. Resident #4 was transferred to the emergency room for evaluation and treatment. Resident #7 sustained a fall on 1/29/12 and the fall assessment was not up to date. Findings: Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/2012 revealed that the Brief Interview for Mental Status (BIMS) Score identified that Resident #2 was severely impaired in cognitive skills for daily decision making. Resident #2 required extensive assistance with Activities of Daily Living (ADL's) and was totally dependent on staff regarding toileting needs. Resident #2 was not steady on her feet, and was only able to stabilize with human assistance with regards to balance. Resident #2 required the use of a wheelchair as a mobility device. Observation on 2/8/12 at 3:55 p.m. revealed that Resident #2 was sitting in a wheelchair leaning forward against a lap buddy. Observation revealed that there was an alarm in place to the wheelchair, but was not connected to the resident. Record review indicated that Resident #2 had three (3) falls since 8/4/2011. The dates of the falls were 9/28/2011, 12/28/2011, and 1/23/2012. There were no care plan changes for two (2) of three (3) of the falls. Record review of the "Incident Report" for 9/28/11 indicated that Resident#2 fell out of her chair onto the floor and was discovered on the floor in the 200 Hall break room. Activities Person #1 was in the Activity Room and heard the wheelchair alarm sound, and went to the break room where she found Resident #2 on the floor. Interview with Activity Person #1 on 2/10/12 at 2:45 p.m. revealed that she had become aware of the incident (9/28/11) because she heard that the wheelchair alarm sound. When Activity Person #1 entered the 200 Hall Break Room she saw Resident #2 on the floor - "it appeared to her that Resident #2 had slid out of her chair". Interview on 2/10/12 at 2:50 p.m. with CNA #2 revealed that Resident #2 was on the floor (9/28/11) and she went to get RN #1 and another CNA to assist with lifting Resident #2. CNA #2 revealed that she saw Resident #2 lying on her left side on the floor. CNA #2 stated that RN #1 checked Resident #2 before lifting her into the wheelchair. Interview on 2/10/12 at 3:00 p.m. with RN #1 revealed that when he entered the Activity Room that he found Resident #2 (9/28/11) sitting on the floor. RN #1 stated that he assessed Resident #2 for pain by touching areas where resident had made contact from the fall, and that resident exhibited no signs or complaints of pain. Review of the Care Plan for Resident #2 indicated that no new interventions were put into place after Resident #2 had sustained the fall. The Care Plan stated that on 9/28/11 the new intervention was to utilize a chair alarm. The chair alarm was already in place and was how staff were alerted to the incident; therefore, it was not a new intervention. Review of the Fall Risk Assessments revealed that prior to the fall on 9/28/11 the next fall assessment was completed on 10/18/11. Review of the "Incident Report" for 12/28/11 indicated that Resident #2 had fallen out of her wheelchair, and was found on the floor next to her wheelchair. Review of the Care Plan indicated that no new interventions were implemented after Resident #2 had fallen out of her wheelchair. There were no additional fall assessments completed after the 12/28/11 fall. Review of the "Incident Report" on 1/23/12 indicated that Resident #2 had fallen out of her wheelchair while being transported by staff to the dining room. The Incident Report stated that Resident #2 leaned forward and fell to the floor which caused a hematoma to the left side of her head. The Incident Report section for Site of Injury listed: "Head - start Neuro. Assessment Flowsheet for any suspected head injury." Review of chart for Resident #2 indicated that no Neurological Checks were documented. There was no fall assessment completed after the fall on 1/23/12. Review of the nurse's notes for 1/23/12 at 6:30 a.m. indicated that the hematoma was the size of a goose egg to the left side of Resident #2's head. Resident was sent to the emergency roiagnom on [DATE] at 7:30 a.m. for evaluation and treatment. Resident #2 returned at 10:30 a.m. Interview on 2/10/12 at 3:20 p.m. with the DON regarding the three (3) falls that Resident #2 had sustained revealed that she was not able to locate the Neuro Check Sheets after the fall on 1/23/12. The DON confirmed that the Neuro Checks should have been completed after the fall on 1/23/11. Review of "Neurological Checks" Policy dated April 18, 2011, stated that, "Purpose - To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. Observed on the floor even if there is no injury obvious at the time of the event). Resident #4 Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #4 was severely cognitively impaired. The MDS documented that Resident #4 was a one (1) person assist with bathing/showering. The care plan documented that Resident #4 was a one (1) person assist with her Activities of Daily Living (ADL's) in August 2011. Record review revealed that Resident #4 had a fall with no injury on 8/2/2011 when she attempted to rise from a wheel chair and fell while she was in the television room. After the assessment, it was determined that Resident #4 had no injuries from the fall. On 8 /20/11 at 6:50 a.m. Resident #4 had a fall with injury to the face and head consisting of bruises and bleeding from a laceration to the head. Resident #4 was sent to the emergency room and required sutures for closure of the laceration. Review of the nurse's notes dated 8/20/11 at 9:00 a.m. revealed that Resident #4 returned to the facility. Observation on 2/8/12 at 4:04 p.m. revealed that Resident #4 was in bed with the head of the bed elevated. Resident #4 was thrashing about in the bed with constant body movement. There was a full sized mattress on the floor beside the bed. The other side of the bed was pushed against the wall and was padded. Record review revealed that Resident #4 had been agitated on 7/28/11. The Nurse's Note's stated on 7/28/11 at 12:15 p.m. "Resident crawled out of bed at the foot of bed between the side rail and foot board. All of residents body except Left side of face was on floor mat. Resident has been noted to be very agitated and/or experiencing anxiety with attempts to get out of bed all a.m. No apparent injury noted at this time. No complaints of pain noted at this time." The Nurse's Notes dated 7/29/11 at 3:15 p.m. stated: "Resident noted on mat beside bed positioned with head down. Resident able to move all extremities and was "crawling" across floor. ST (skin tear) noted to left elbow and previous ST (skin tear) to right elbow reopened. When asked what happened resident mumbled incoherently about trying to "go over there" NO (new order) to cleanse ST (skin tear) with NS (regular saline) pat dry and clear. Will notify RP (responsible party) and MD (medical director)." Review of the nurse's notes dated 8/2/11 at 8:00 a.m. stated: "Resident noted on floor mat several times Ativan given. No change noted. Resident crawling from mat to floor. This nurse and CNA placed resident back into bed." Record review revealed that Resident #4 did have documented nurse's notes that she was agitated on 7/28/11 and 7/29/11 and had been found on the mat beside her bed crawling on the floor on 7/29/11 and 8/2/11. Resident #4 had a fall with no injury documented on 8/2/11 on an Accident and Incident Report. Interview on 2/9/12 at 3:30 p.m. with the Responsible Party (RP) of Resident #4 revealed that he was told that Resident #4 was in the last stages of Alzheimer's. RP stated that Resident #4 had several falls and had received several injuries as a result of her falls. RP stated that the facility called him regularly and kept him informed of her falls and treatments. RP stated that he visited the facility three (3) to four (4) times per week. The RP stated that Resident #4 had not had a significant change in her behavior in over a year or longer. RP stated that Resident #4 had fallen in the shower and had received severe bruises to the face and head. RP stated that the fall in the shower occurred in August or September of 2011 and resulted in a hospitalization of at least five (5) days. RP stated that the bruising to Resident #4's face was severe after that fall. Interview on 2/9/12 at 5:45 p.m. with the Director of Nursing (DON) revealed that Resident #4 was a one (1) person assist with showers until the incident on 8/20/11, when Resident #4 fell out of the shower chair in the shower. The DON stated that on 8/20/11 the CNAs had followed the care plan and had utilized one (1) person to place Resident #4 in a shower chair. The DON stated that since the fall on 8/20/11 that Resident #4 was changed to a two (2) plus person assist with all Activities of Daily Living (ADL's). The DON stated that the shower chair does not have a restraint or seat belt. The DON stated that the facility only had one (1) shower bed and that Resident #4 was not a candidate for the shower bed. The DON stated that Resident #4 was re-assessed and was a two (2) plus person assist with all her ADL's. Interview on 2/10/12 at 9:20 a.m. with CNA #1 revealed that she had never had any problems with Resident #4 in the shower before 8/20/11. CNA #1 stated that when and when she took Resident #4 to the shower to bathe her, she became combative and fell from the shower chair striking her face and head on the door and wall of the shower room. CNA #1 stated that Resident #4 was a one (1) person assist for showers at the time of the incident on 8/20/11. Review of the facility policy and procedure entitled "Falls Potential And Prevention Protocol" dated January 19, 2011 stated: "It is the policy of this facility to reduce the number of falls by assessing residents for the potential for falls and identifying factors that might contribute to falls. Addressing those factors identified help prevent falls. A fall is defined as a sudden or unexpected change in position usually involving the floor. Observing a resident on the floor, or lowering (assisting) a resident to the floor is considered a fall." The facility did not appropriately re-assess and supervise Resident #4 after the incidents on 7/28/11, 7/29/11, and 8/2/11 at 8:00 a.m. and 8/2/11 at 4:40 p.m. Resident #4 was noted to be agitated and was observed on the floor crawling around and was not appropriately assessed to prevent the potential for future falls. Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/18/2011 revealed that Resident #7 was severely impaired in cognitive skills for daily decision making. The MDS indicated that Resident #7 had unclear speech, sometimes understood and sometimes understands. The MDS indicated that Resident #7 required extensive assistance of two (2) or more persons with bed mobility and transfers. Resident #7 required the use of a wheelchair for locomotion on and off the unit. Observation on 2/8/12 at 10:30 a.m. revealed that Resident #7 was seated in a wheelchair with a lap buddy in place. Review of Resident #7's Fall Risk Assessment Form revealed that a Fall Risk Assessment was completed on 4/21/2011, 6/7/2011, 8/26/2011 and 2/8/2012. The Fall Risk Assessments revealed that Resident #7 was at high risk for falls. Review of "Incident and Accident Form" dated 1/19/2012 revealed that Resident #7 had a fall with no apparent injury. Review of Resident #7's Care Plan with the problem listed as: "Potential for Injury: Falls R/T (related to) Limited Mobility Secondary to DX (diagnosis): CVA (Cerebral Vascular Accident)" revealed that an intervention for Resident #7 was "fall assessment quarterly and prn (as needed)". Review of the Physician's orders for February 2012 revealed that Resident #7 had an order for [REDACTED]. Interview with the Director of Nursing (DON) on 2/10/2012 at 4:09 p.m. confirmed that a falls assessment should have been done quarterly and after each fall for Resident #7. The DON confirmed that it had been approximately six (6) months between Resident #7's Fall Risk Assessment. Review of an inservice conducted on 02/10/2012 (during the survey) revealed that the topic discussed was: "Shower Assistance". The information stated: "Effective Friday February 02/10/2012. All Residents will require 2 person assist in shower until further notice. All daily care guides for nurse aides have been updated to reflect this change. At current time we will proceed with a 100% re-assessment on residents to determine the amount of assistance needed to care for each resident. The team involved in this process will include nurses, nurse aides and therapy. All staff currently being inserviced to reflect this change and staff will be updated when this procedure is complete. Nurse Aides if at any time your residents level of assistance or care needs change, you must communicate this with your immediate supervisor. At that time it is the responsibility of that supervisor to make the change on the careplan, assessment form, MD and RP notification. To reflect this change, any further questions to be directed to DON." The statement/training was signed by the DON.

CI MS # Based on observation, interview, record review and facility policy review, the facility failed to ensure that an investigation was conducted to determine how Resident #3, one (1) of six (6) residents reviewed for wandering/elopement, exited the facility without an alarm being audible to the staff. Resident #3 exited the facility on 1/6/12 at approximately 3:00 p.m. and was found approximately 3:30 p.m. in the facility parking lot by a staff member returning to the facility. The facility failed to conduct an investigation. The lack of evidence that the wandering/elopement incident of Resident #3 was thoroughly investigate to prevent further occurrences was deemed Substandard Quality of Care (SQC) and Immediate Jeopardy (IJ) on 1/31/12 at 2:45 p.m. The Administrator was notified at that time. The SQC and IJ was determined to begin on 1/6/12 and was removed on 2/1/12. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m.. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Resident #3 Review of Resident #3's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/5/12 revealed a Brief Interview for Mental Status (BIMS) score of three (3) which indicated Severe Cognitive Impairment and that wandering was a behavior that had occurred for one (1) to three (3) days prior to the Assessment. Observation of Resident #3 on 1/31/12 at 12:15 p.m. revealed that Resident #3 was in a wheelchair in the Therapy Department with a board, with cards attached to the board, and Resident #3 was matching cards to those cards on the board. Resident #3 stated that he had been at the facility "a good while. I'm intending on going back home". Resident #3 could state his name. Review of the Care Plan for Resident #3 revealed a "Problem Onset: 12/29/2011 Elopement, High Risk for R/T (related to) Wandering in hall. Wandering in & out of others rooms. 1-6-12 Wandered out into parking lot look(ing) for car. Goal & Target Date: Resident Will Not Wander Out of Facility x's (times) next 90 days. Approaches- wander bracelet and transfer to 400 hall Secure Unit." Review of Resident #3's Social Progress Notes revealed: "1/5/12, (name of Resident #3) is a new admit to WPCLC (West Point Community Living Center). He is alert & oriented to person. Able to make needs known. Periods of confusion, Disorganized thinking fluctuates, may miss intent of message. BIMS Score 03 (three), indicates severe impairment. Wanders with no rational purpose in and out of other residents rooms. Noted 1/2/12 walked the hall and got lost, assisted back to bed. Dx: Dementia. Has a wander guard bracelet." "1/6/12 at 3:50 pm, SW (Social Worker) informed by staff, that (Resident #3) was seen in the parking lot wandering around by staff member (name of Medical Records Assistant). (Medical Records Assistant) brought (Resident #3) back into the building. SW called RP (Responsible Party) and informed her of this matter. SW explained that (Resident #3) will be moved to 400 hall Secure Unit, room [ROOM NUMBER] B." Review of an Incident Report for Resident #3 revealed: "Incident Date 01/06/12. Incident Time 3:35 PM. (name of Medical Records Assistant) saw resident in parking lot, walked him in & reported to RN (Registered Nurse) Supervisor resident was in parking lot. Additional Comments and Measures Taken to Prevent Reoccurrences: Resident RP agreed to move resident to secure unit Rm (room) 4 (four). Doors checked by (Maintenance Staff #1) and codes (triangle indicating changed)." This document was signed by the Assistant Director of Nursing (ADON) on 1/6/12. Interview on 1/31/12 at 12:33 p.m. with Medical Records Assistant confirmed that upon returning to the facility on [DATE] a little after 3:00 p.m. Resident #3 was observed in the parking lot in front of the facility. "I stopped the car and parked where I was. I jumped out and asked him what he was doing. You wanna go in here with me? I assisted him back in (the building). Buzzer alarmed (wanderguard alarm) when we came back in." Observation of the area where Resident #3 was found, was conducted during the interview with the Medical Records Assistant, revealed that Resident #3 was approximately 36 steps from the front door of the facility or five (5) parking spaces to the right of the entrance (if looking forward at the building). The Medical Records Assistant stated that the weather was "probably in the 50's". Review of the Nurses Notes revealed: 1/6/12 at 3:30 p.m., "(Resident #3) is escorted to supervisors office by staff member (name of Medical Records Assistant) - who states she brought him in from the parking lot. (Resident #3) was alert and was talking stating looking for my car - that's all, looking for my car. (Resident #3) was taken to his room but he came back into hallway pacing. Speaks to staff about something, not sure of what he was referring. (Resident #3) informed that he was moving to another room - states alright, that's ok." 1/6/12 at 4:10 p.m., "(Resident #3) is escorted to secure unit by writer and male staff - he chatted as we walked to the unit states he has a sister down here and he was going to see her. (Resident #3) went into assigned room and sat on the bed." Interview on 1/31/12 at 1:10 p.m. with the Administrator confirmed that the facility did not conduct an investigation because Resident #3 did not have a wanderguard on and "someone let him out". The Administrator stated that Resident #3 was just in the parking lot looking for his car and that Resident #3 was not going anywhere. Review of Resident #3's handwritten Physician Orders, dated 12/29/11, revealed "Wandering alert bracelet check placement and proper function q (every) shift." (Note physician's order was written prior to Resident #3 leaving the facility unsupervised.) Review of the facility policy "Accidents and Incidents", dated 12/2/02, revealed "Accidents & Incidents Process 3. It is the policy of this facility to provide a safe and healthful environment. Therefore, all accidents or incidents occurring on our premises must be reported to the administrator. Category 4. Investigative Action a. The charge nurse and the department director must conduct an immediate investigation of the accident or incident". Immediate Jeopardy was identified on 1/31/12 at 2:45 p.m. The Administrator of the facility was notified at that time. Resident #3 left the faciity on [DATE] unsupervised. Please note that Resident #1 exited the facility through a door with an audible alarm that should have sounded to alert nursing staff on 1/21/12 at approximately 5:00 a.m. Resident #1 was housed on a unit designated by the facility as a Secure Unit, the residents on that unit were contained within that unit by locking doors. The Certified Nursing Assistant (CNA), who was the only staff member in the Secure Unit, did not hear the alarm sound when Resident #1 exited the facility unsupervised. A Registered Nurse (RN) who was leaving the facility due to illness discovered Resident #1 on the outside of the facility. Resident #1 was discovered approximately 27 steps from the facility and was returned into the facility through the same door exited. The outside temperature was approximately 62.6 degrees Fahrenheit on 1/21/12 at 5:00 a.m. Resident #1 was found outside in rainy weather. Resident #1 when found was limping, covered in mud and wet. Resident #1 was sent to the hospital emergency department by ambulance on 1/21/12 and returned to the facility with a [DIAGNOSES REDACTED]. The Administrator was notified by the ADON of the elopement of Resident #1 and was onsite by 8:00 a.m. on 1/21/12 and took over the investigation at this time. Resident #1 returned to the facility at 8:30 a.m. on 1/21/12 and was placed on one to one supervision by various Certified Nursing Assistants (CNAs). The one to one supervision continued until 10:45 a.m. at (on) 1/25/12. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m. Credible Allegation of Compliance: "The Medical Records Assistant was coming into the parking lot in her car and observed Resident #3 in the parking lot on 1/6/12 at 3:30 pm. Resident #3 was brought back into the facility from the front parking lot by the Medical Records Assistant on 1/6/12 at 3:30 pm. The Assistant Director of Nursing was in the lobby when the resident was brought in and took the resident back to the nursing unit and informed the Register Nurse Supervisor #2. The resident's wander guard alarmed on re-entry and was found to be in working order. Resident #3 was found to be without physical injury. At 4:10 pm the resident was transferred to the Secure Unit on 400 Hall. The MD was notified by Registered Nurse Supervisor #2 and the Responsible Party for Resident #3 was notified by the Social Worker on 1/6/12 at 4:00 pm. An investigation was not completed according to the Accident Incident Policy. The Administrator was re-inserviced by the Vice President of Clinical Services regarding event management and incident investigation on 1/25/12. The ADON and RN supervisors were inserviced on the event management and incident investigation by the Administrator on 2/1/12. RN supervisors will not work until inserviced. Resident #1 was returned to the facility at 5:10 am on 1/21/12 by the Registered Nurse (RN) Supervisor #1 and Licensed Practical Nurse #1 (LPN). Resident #1 was assessed and found to have an injury to the left foot. Resident #1 was sent to the hospital emergency room at 5:20 am 1/21/12 via emergency transport. The [DIAGNOSES REDACTED]. Final [DIAGNOSES REDACTED]. RN Supervisor #1 notified Assistant Director of Nursing (ADON) who is Acting Director of Nursing (DON) while DON is on leave, of occurrence at 5:30 am on 1/21/12. Maintenance Man #1 was also notified by RN Supervisor #1 at approximately 5:35 am and was on site by 5:50 am to assess functioning of doors and alarms. All facility exit doors were checked by opening and closing doors to verify alarm sounding. ADON arrived on site at 6:20 am. ADON posted a staff member at the 400 hall doors at 6:30 am and a staff member remained in place until 10:00 am. Beginning at 6:30 am 1/21/12, the ADON inserviced the Nursing, Laundry, Dietary and Housekeeping staff onsite regarding door security and responding to alarms. Staff was educated that in the event of an alarm to secure the resident they might be working with, go to the panel in the 200 hall nursing station to see the location of the alarm, go to the area of the alarm, look out the door in the immediate area to see if a resident is outside. Then account for the presence of assigned residents. Also if the reason for the alarm isn't obvious, report to the supervisor. Inservices continued throughout the day conducted by the Administrator and the RN supervisor. A notice was posted at the time clock at 7 am on 1/21/12 by the ADON to staff alerting them that they had to be inserviced by the ADON or RN Supervisor on duty prior to working or they would not be allowed to work. The Administrator was notified by the ADON of the elopement of Resident #1 and was onsite by 8:00 am on 1/21/12 and took over the investigation at this time. Resident #1 returned to the facility at 8:30 am on 1/21/12 and was placed on one to one supervision by various Certified Nursing Assistants (CNAs). The one to one supervision continued until 10:45 am at (on) 1/25/12. At 10:00 am on 1/21/12, the Alarm Security Company was onsite to check door and alarm function. The company determined the system was functioning properly. Starting at 10:00 am on 1/21/12 the Administrator and RN Supervisors started every two-hour door checks and these continued until 1/31/12. On 1/24/12, the Administrator began unannounced elopement drills on all shifts. On 1/31/12, a locking security cover was installed on the alarm/enunciator panel. This panel is in the 200 Hall nurses station and has the reset button and switches controlling the volume of the alarms. On 1/21/12, the elopement investigation for Resident #1 was completed. The codes for the mag-lock panels on both exits 400 hall were changed by the alarm security company on 1/21/12 at 10:15 am. On 1/24/12, The Alarm Security Company extended the amount of time the door alarm would sound on the mag-lock doors. The alarm was changed on the two 400 hall exit doors from 45 seconds to continuous until manually reset. Residents at risk for elopement have the potential to be affected. On 1/25/12, the ADON and the Clinical Care Coordinator review 79 of 79 residents to determine who was at risk for elopement. 5 residents were identified at that time. The ADON and Clinical Care Coordinator ensured photos and identification bracelets were in place for these residents. On 1/31/12 beginning at 5 pm and completing at 9 pm, 82 of 82 residents were reassessed/ re-evaluated by licensed nursing staff (RN #2, LPNs #2, #3 and #4) for elopement/wandering risks using the Wander Data Collection Tool. 8 residents were identified at risk. ADL flow sheets, ADL care plans and care plans were updated to reflect the risk for elopement and the presence of alarms or security devices. Wanderguard presence and functioning of the alarm device were placed on the Medication Administration records for the licensed nursing staff to verify daily. Beginning 1/31/12 at 8 pm the Administrator and ADON re-inserviced licensed nursing staff on duty regarding how to monitor functioning of the wanderguard devices. The licensed nursing staff is to physically take the resident to the sensor to ensure functioning once a day on the day shift and to check the presence of the alarm each shift. Portable tester was ordered 2/1/12. As of 1/31/12 at 4 pm, an employee was posted on the front door on all shifts to observe and respond to the wanderguard alarm until an additional enunciator panel for the system can be installed closer to the nursing unit and the system revised on 2/1/12. Placing a new wanderguard alarm at the enunciator panel will provide a louder alarm for the direct care staff to hear easily on the nursing unit. On 1/31/12, staffing for the Secure Unit was reviewed. As of 1/31/12, an additional CNA has been added to all three shifts for the Secure Unit The licensed nurse for that unit has been designated as dedicated to that unit alone and will not leave the unit to perform duties on other units. The licensed nurse on duty on the secure unit will only leave the unit when relieved by the RN Supervisor or another licensed nurse-who in turn will remain on the Secure Unit until the assigned licensed nurse returns. Additional in-services, given by the Administrator and ADON, regarding resident safety and supervision for all departments began on 1/31/12 at 8 pm and will continue until all staff have been inserviced. No staff will be allowed to work until in-serviced." The AoC was signed by the facility Administrator. Verification of the AoC:Random observations, interview and review of in-service records was conducted. Observation of all exit doors verified that all exit doors functioned and a new alarm enunciator installation for the wanderguard alarm at the front door was in progress. All residents with a wanderguard were observed to have a wanderguard in place. Wander/elopement assessments had been completed, ADL (Activity of Daily Living) sheets, Medication Administration Records and Care Plans were in place. A cover had been placed over the alarm enunciator panel at the 200 Hall Nurses station to prevent the alarm from easily being turned off. The staffing on the Secure Unit was reviewed and verified. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

CI MS # Based on observation, interview, record review and facility policy review, the facility failed to ensure exit doors functioned properly and failed to ensure that measures were put into place to prevent two (2) of six (6) residents, Resident #1 and Resident #3, from exiting the facility unsupervised and without staff knowledge. The facility had previous knowledge, via staff, of an exit door malfunction and failed to maintain proper functioning of the exit door. This was evident by a reported staff concern that the door would open just by being pushed. Resident #1 exited the facility through a door with an audible alarm that should have sounded to alert nursing staff on 1/21/12 at approximately 5:00 a.m. Resident #1 was housed on a unit designated by the facility as a Secure Unit, the residents on that unit were contained within that unit by locking doors. The Certified Nursing Assistant (CNA), who was the only staff member in the Secure Unit, did not hear the alarm sound when Resident #1 exited the facility unsupervised. A Registered Nurse (RN) who was leaving the facility due to illness discovered Resident #1 on the outside of the facility. Resident #1 was discovered approximately 27 steps from the facility and was returned into the facility through the same door exited. The outside temperature was approximately 62.6 degrees Fahrenheit on 1/21/12 at 5:00 a.m. Resident #1 was found outside in rainy weather. Resident #1 when found was limping, covered in mud and wet. Resident #1 was sent to the hospital emergency department by ambulance on 1/21/12 and returned to the facility with a [DIAGNOSES REDACTED].#1 with a left calcaneal fracture. Resident #3 exited the facility on 1/6/12, (time undetermined), unsupervised and without staff knowledge. Resident #3 was discovered in the front parking lot of the facility by an employee returning to the facility about 3:30 p.m. Resident #3 was wearing a wanderguard bracelet and went out a door that had a key pad code for exit and an audible alarm to notify staff that a resident with a security alert bracelet had passed through the door. The door failed to lock down and an alarm failed to sound to alert the nursing staff that a resident with a wanderguard had passed through the door. The lack of implementation of adequate supervision and safety measures to ensure exit doors functioned properly for Resident #1 and Resident #3 was deemed as Substandard Quality of Care (SQC) and Immediate Jeopardy (IJ) on 1/31/12 at 2:45 p.m. The Administrator was notified at that time. The SQC and IJ was determined to begin on 1/6/12 and was removed on 2/1/12. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m.. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Resident #1 Review of a report received by the State Agency on 1/24/12 revealed: "Date of Occurrence: 1/21/2012, Time 5:10 AM (Name of Resident #1), Brief Summary of Incident: (Resident #1) was observed by staff member at the edge of the property @ 5:10 am. (Resident #1) was brought back to the building by staff. (Resident #1) observed to be limping and was sent to ER (emergency room ) for evaluation. ER report indicated possible ankle sprain or fracture. DON (Director of Nursing), Administrator, MD (Medical Doctor & (and) RP (Responsible Party) notified. Investigation begun. (Resident #1) to be seen by orthopedic surgeon on 01/24/12. Interventions: 1. 1-1 (one on one) supervision of resident begun 2. alarm system inspected by alarm company and facility maintenance. 3. Every two hour observations of exit doors & alarm system panel begun. 4. Staff inservices started regarding responding to alarms & use of approved exit doors. 5. Care plan & risk assessment updated." Review of a facility document titled "Incident Report", dated 1/21/12, revealed that the incident time was "5 AM". The incident was described as "RN (Registered Nurse) Supervisor notified this nurse that (Resident #1) is outside assist resident back into facility. Assessment (assessed) resident for injuries resident has small cut on (L) (left) palm of hand. ST (skin tear) palm of hand. ST on (L) forearm. C/O (complaining of ) pain/foot Can't stand on it ER notified." Record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/11 revealed a Brief Interview for Mental Status (BIMS) score of two (2) which was defined as severely impaired. Resident #1's transfer, walking ability and locomotion on and off unit was scored as independent with no setup or physical help from staff. Review of Resident #1's Elopement Risk Assessment, dated 8/27/11 and 11/24/11, confirmed that Resident #1 was considered an elopement risk due to wandering and exit seeking. Resident #1 was to remain on the secure unit and to be closely monitored. On 11/24/11 an update was added which revealed that Resident #1 was still at risk for elopement. Resident #1's Care Plan revealed a Problem Onset date of 8/12/09 for "At risk for elopement; wanders r/t (related to) dx (diagnosis) Alzheimer's Disease" with a goal that Resident #1 would not leave the facility unattended. The approaches included Resident #1 would reside on the secure unit and would not be left unattended near an exit. Review of staff statements revealed that RN Supervisor #1 was exiting the building on 1/21/11 at 5:10 a.m. when Resident #1 was noted to be in an area beside the facility and "with the assistance of another nurse we called the resident name several times and he begin (began) walking toward us. Resident was assisted back into (the) facility. DON notified and Maintenance notified. Resident is alert and continued to be confused. Pupil equal and reactive to light. No concerns to face noted. Didn't see any possible trauma to head. Noted resident limping on (L) foot. Asked resident did he fall; unable to understand resident speech. Asked resident why he was outside. Unable to understand resident speech. Nurses present and continuing to monitor." Interview on 1/30/12 at 2:05 p.m. with RN Supervisor #1 confirmed that on 1/21/12 upon exiting the facility, that outside the facility, was dark. The RN Supervisor #1 stated that she was very aware of the surroundings. Review of RN Supervisor #1's timecard for 1/21/12 confirmed a clock out time of 5:07 a.m. An observation of someone walking was made by the RN Supervisor #1 who then went back into the facility to get another staff member, Licensed Practical Nurse (LPN) #1. The RN Supervisor #1 stated that she needed help to attempt to determine who the person was that was walking outside the facility. LPN #1 determined that the person was Resident #1 and the two (2) nurses began to call the Residents name, after several times they were able to obtain his attention. RN Supervisor #1 and LPN #1 began to wave for him to come toward them. When they got to Resident #1's side they assisted him back into the facility through a side door on the Secure Unit. The door was opened easily and no alarm sounded when the door was opened. RN Supervisor #1 reported that rain had been falling the night of 1/21/12 and Resident #1 was wet with mud on his clothes. Observation of the area where Resident #1 was found was conducted with RN Supervisor #1 on 1/31/12 at 2:05 p.m., which revealed the area to be approximately 27 steps from the facility exit door. There was a concrete drainage ditch that was crossed by Resident #1. Interview with LPN #1 on 1/30/12 at 3:44 p.m. confirmed that RN Supervisor #1 had alerted her on the morning of 1/21/12 that a Resident (Resident #1) was outside the building. LPN #1 was in the area of the Rotunda on the main Nursing Unit, which was located outside of the Secure Unit, when alerted. LPN #1 stated that she ran down the hall to the front and joined RN Supervisor #1 and they both ran over to see who was out and determined the person to be Resident #1. "We got him, he (Resident #1) was hopping could hardly walk. I think we went in the same door he came out because it was open. He was wet. Kept telling about (his) foot. (He) Tried to take sock and shoe off and saw (he) was in pain." LPN #1 confirmed that Resident #1 was a wanderer and went to the door often and that there was no alarm that sounded when Resident #1 exited the facility nor when Resident #1 was assisted back into the facility. LPN #1 stated that the code to open the door was unknown to staff that only the Administrator and Maintenance staff are aware of what the code was. Interview on 1/30/12 at 3:53 p.m. with CNA #1, (who was the only staff member on the Secure Unit when Resident #1 exited the facility on 1/21/12), revealed that around 5:00 a.m. (1/21/12) she was in the room with the door closed assisting another resident to get up. CNA #1 confirmed that no alarm was heard. CNA #1 confirmed that Resident #1 would go to the exit door, shake and kick the door. CNA #1 confirmed that several staff members had complained about the exit door and that upon checking the door several months ago the door was able to be opened by pushing against the door and the key pad did not have to be used. Interview on 1/31/12 at 5:20 a.m. with LPN #1 revealed that the nurse on the Secure Unit was also responsible for Residents who resided outside the Secure Unit. LPN #1 would leave the Secure Unit around 5:00 a.m. and not return to the Secure Unit until around 6:00 a.m. when medication pass had been completed. LPN #1 confirmed that the only staff member left on the Secure Unit from 5:00 a.m. until 6:00 a.m. would be the CNA #1. LPN #1 confirmed that on the morning of 1/21/12 when Resident #1 exited the facility that she was not on the Secure Unit and there was no alarm that sounded in the Rotunda Area. There were 13 residents on the Secure Unit. Upon the return of Resident #1 to the facility there was a scrape on his left hand, a skin tear on his left upper arm and his clothes were muddy. LPN #1 had assisted Resident #1 in dressing that morning and had donned a long sleeve shirt, jeans, socks and tennis shoes. Interview continued at 6:05 a.m. and LPN #1 stated that Resident #1 had to be assisted back over the concrete ditch and was hopping. LPN #1 stated "I could not understand what he was trying to tell me. I knew he was saying he hurt his foot. When we got socks and shoes off it hurt worse. He said "Ouch that hurts". " Observation of Resident #1 on 1/31/12 revealed: At 6:15 a.m. Resident #1 had an alarm sounding and he was attempting to stand at the bedside. A CNA immediately responded and assisted Resident #1 back to the bed. At 6:27 a.m. Resident #1 was in a wheelchair with a lap buddy, and chair alarm in place. In a span of 13 minutes Resident #1 took the lap buddy off six (6) times. At 6:47 a.m. the two CNA's on the Secure Unit brought Resident #1 to the Nurses Station for the LPN to observe so that other residents could be assisted up for breakfast. A bandage was observed on Resident #1's left foot and LPN #1 described the bandage as a Jones splint. Interview on 1/31/12 at 6:50 a.m. with LPN #1 confirmed that Resident #1 had a sitter in attendance 24 hours a day from 1/21/12 until the past weekend. At 7:00 a.m. on 1/31/12 Resident #1 was observed to propel the wheelchair to the double doors. Interview conducted on 1/31/12 at 11:10 a.m. with CNA #1 confirmed that no alarm sounded on the morning of 1/21/12 when Resident #1 exited the facility. CNA #1 confirmed that if an alarm had been heard then staff would have immediately responded to the alarm. Interview conducted with Maintenance Staff #1 on 1/31/12 at 11:22 a.m. revealed that the RN Supervisor had called on 1/21/12 and informed him that the door on the Secure Unit need to be checked because a Resident (Resident #1) had exited the facility and the alarm did not sound. Maintenance Staff #1 then came to the facility and went to the Nurses Station, near the Rotunda Area, where the alarm enunciator panel was located. That panel had switches that could be turned "up" for on, or "down" for off. "On" would have allowed the alarm to be heard throughout the facility, and "down" would have prevented the alarm from being heard except for on the Secure Unit. The switch to the exit door that Resident #1 went out was in the "down", or off, position when viewed by Maintenance Staff #1 on 1/21/12. Therefore, when Resident #1 exited the facility there was no alarm heard by the staff on the Nursing Unit. The Maintenance Staff #1 stated "At that time you could force the door open and it would alarm for 45 seconds then turn off. We changed from a 45 second alarm to a continuous alarm." The Maintenance Staff #1 confirmed that if the door alarm did sound the alarm would have only been audible for 45 seconds only. Interview with LPN #5 on 1/31/12 at 1:35 p.m. revealed that the exit door on the Secure Unit had been a cause for concern in the past. On 1/8/12 at the change of shift a concern was reported that the door would open just by being pushed. LPN #5 stated that the Maintenance Director was contacted by personal cell phone, because there was no facility telephone on the Secure Unit. The Maintenance Staff was informed of the concern of the exit door being opened by pushing. The Maintenance Director responded that there had been a problem with the door before but all that could be done was to monitor the door. LPN #5 also noted that the door concern had been reported that the door opened three (3) times without the aide of the key pad. (Note: Resident #1 who had been independently ambulatory prior to the exiting of the facility at 5:00 a.m. on 1/21/12 was able to propel self around the facility in a wheelchair after that time. On 1/24/12 an orthopedic surgeon assessed and diagnosed Resident #1 with a left calcaneal fracture.) Resident #3 Review of Resident #3's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's admission MDS with an ARD of 1/5/12 revealed a BIMS score of three (3) which indicated Severe Cognitive Impairment. Wandering was a behavior that had occurred for one (1) to three (3) days prior to the Assessment. Observation of Resident #3 on 1/31/12 at 12:15 p.m. revealed that Resident #3 was in a wheelchair in the Therapy Department with a board, with cards attached to the board. Resident #3 was matching cards to those on the board. Resident #3 stated that he had been at the facility "a good while. I'm intending on going back home". Review of the Care Plan for Resident #3 revealed "Problem Onset: 12/29/2011 Elopement, High Risk for R/T (related to) Wandering in hall. Wandering in & out of others rooms. 1-6-12 Wandered out into parking lot look(ing) for car. Goal & Target Date: Resident Will Not Wander Out of Facility x's (times) next 90 days. Approaches -wander bracelet and transfer to 400 hall Secure Unit." Review of Resident #3's Social Progress Notes revealed: "1/5/12, (name of Resident #3) is a new admit to WPCLC (West Point Community Living Center). He is alert & oriented to person. Able to make needs known. Periods of confusion, Disorganized thinking fluctuates, may miss intent of message. BIMS Score 03 (three), indicates severe impairment. Wanders with no rational purpose in and out of other residents rooms. Noted 1/2/12 walked the hall and got lost, assisted back to bed. Dx: Dementia. Has a wander guard bracelet." "1/6/12 at 3:50 pm, SW (Social Worker) informed by staff, that (Resident #3) was seen in the parking lot wandering around by staff member (name of Medical Records Assistant). (Medical Records Assistant) brought (Resident #3) back into the building. SW called RP (Responsible Party) and informed her of this matter. SW explained that (Resident #3) will be moved to 400 hall Secure Unit, Room 405 B." Review of an Incident Report for Resident #3 revealed: "Incident Date 01/06/12. Incident Time 3:35 PM. (name of Medical Records Assistant) saw resident in parking lot, walked him in & reported to RN (Registered Nurse) Supervisor resident was in parking lot. Additional Comments and Measures Taken to Prevent Reoccurrences: Resident RP agreed to move resident to secure unit Rm (room) 4 (four). Doors checked by (Maintenance Staff #1) and codes (triangle indicating changed)." This document was signed by the Assistant Director of Nursing (ADON) on 1/6/12. Interview on 1/31/12 at 12:33 p.m. with Medical Records Assistant confirmed that upon returning to the facility on [DATE] a little after 3:00 p.m. Resident #3 was observed in the parking lot in front of the facility. "I stopped the car and parked where I was. I jumped out and asked him what he was doing. You wanna go in here with me? I assisted him back in (the building). Buzzer alarmed (wanderguard alarm) when we came back in." Observation of the area where Resident #3 was found, was conducted during the interview with the Medical Records Assistant, revealed that Resident #3 was approximately 36 steps from the front door of the facility or five (5) parking spaces to the right of the entrance (if looking forward at the building). The Medical Records Assistant stated that the weather was "probably in the 50's". Review of the Nurses Notes revealed: 1/6/12 at 3:30 p.m., "(Resident #3) is escorted to supervisors office by staff member (name of Medical Records Assistant) - who states she brought him in from the parking lot. (Resident #3) was alert and was talking stating looking for my car - that's all, looking for my car. (Resident #3) was taken to his room but he came back into hallway pacing. Speaks to staff about something, not sure of what he was referring. (Resident #3) informed that he was moving to another room - states alright, that's ok." 1/6/12 at 4:10 p.m., "(Resident #3) is escorted to secure unit by writer and male staff - he chatted as we walked to the unit states he has a sister down here and he was going to see her. (Resident #3) went into assigned room and sat on the bed." Interview on 1/31/12 at 1:10 p.m. with the Administrator confirmed that the facility did not conduct an investigation because Resident #3 did not have a wanderguard on and "someone let him out". The Administrator stated that Resident #3 was just in the parking lot looking for his car and that Resident #3 was not going anywhere. Review of Resident #3's handwritten Physician Orders, dated 12/29/11, revealed "Wandering alert bracelet check placement and proper function q (every) shift." (Note physician's order was written prior to Resident #3 leaving the facility unsupervised.) Review of the facility policy "Accidents and Incidents", dated 12/2/02, revealed "Accidents & Incidents Process 3. It is the policy of this facility to provide a safe and healthful environment. Therefore, all accidents or incidents occurring on our premises must be reported to the administrator. Category 4. Investigative Action a. The charge nurse and the department director must conduct an immediate investigation of the accident or incident". Immediate Jeopardy was identified on 1/31/12 at 2:45 p.m. The Administrator of the facility was notified at that time. Resident #3 exited the facility on 1/6/12 (time undetermined). Resident #1 exited the facility through a door with an audible alarm that should have sounded to alert nursing staff on 1/21/12 at approximately 5:00 a.m. Resident #3 and Resident #1 both left the facility unsupervised and without staff knowledge. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m. Credible Allegation of Compliance: "The Medical Records Assistant was coming into the parking lot in her car and observed Resident #3 in the parking lot on 1/6/12 at 3:30 pm. Resident #3 was brought back into the facility from the front parking lot by the Medical Records Assistant on 1/6/12 at 3:30 pm. The Assistant Director of Nursing was in the lobby when the resident was brought in and took the resident back to the nursing unit and informed the Register Nurse Supervisor #2. The resident's wander guard alarmed on re-entry and was found to be in working order. Resident #3 was found to be without physical injury. At 4:10 pm the resident was transferred to the Secure Unit on 400 Hall. The MD was notified by Registered Nurse Supervisor #2 and the Responsible Party for Resident #3 was notified by the Social Worker on 1/6/12 at 4:00 pm. An investigation was not completed according to the Accident Incident Policy. The Administrator was re-inserviced by the Vice President of Clinical Services regarding event management and incident investigation on 1/25/12. The ADON and RN supervisors were inserviced on the event management and incident investigation by the Administrator on 2/1/12. RN supervisors will not work until inserviced. Resident #1 was returned to the facility at 5:10 am on 1/21/12 by the Registered Nurse (RN) Supervisor #1 and Licensed Practical Nurse #1 (LPN). Resident #1 was assessed and found to have an injury to the left foot. Resident #1 was sent to the hospital emergency room at 5:20 am 1/21/12 via emergency transport. The [DIAGNOSES REDACTED]. Final [DIAGNOSES REDACTED]. RN Supervisor #1 notified Assistant Director of Nursing (ADON) who is Acting Director of Nursing (DON) while DON is on leave, of occurrence at 5:30 am on 1/21/12. Maintenance Man #1 was also notified by RN Supervisor #1 at approximately 5:35 am and was on site by 5:50 am to assess functioning of doors and alarms. All facility exit doors were checked by opening and closing doors to verify alarm sounding. ADON arrived on site at 6:20 am. ADON posted a staff member at the 400 hall doors at 6:30 am and a staff member remained in place until 10:00 am. Beginning at 6:30 am 1/21/12, the ADON inserviced the Nursing, Laundry, Dietary and Housekeeping staff onsite regarding door security and responding to alarms. Staff was educated that in the event of an alarm to secure the resident they might be working with, go to the panel in the 200 hall nursing station to see the location of the alarm, go to the area of the alarm, look out the door in the immediate area to see if a resident is outside. Then account for the presence of assigned residents. Also if the reason for the alarm isn't obvious, report to the supervisor. Inservices continued throughout the day conducted by the Administrator and the RN supervisor. A notice was posted at the time clock at 7 am on 1/21/12 by the ADON to staff alerting them that they had to be inserviced by the ADON or RN Supervisor on duty prior to working or they would not be allowed to work. The Administrator was notified by the ADON of the elopement of Resident #1 and was onsite by 8:00 am on 1/21/12 and took over the investigation at this time. Resident #1 returned to the facility at 8:30 am on 1/21/12 and was placed on one to one supervision by various Certified Nursing Assistants (CNAs). The one to one supervision continued until 10:45 am at (on) 1/25/12. At 10:00 am on 1/21/12, the Alarm Security Company was onsite to check door and alarm function. The company determined the system was functioning properly. Starting at 10:00 am on 1/21/12 the Administrator and RN Supervisors started every two-hour door checks and these continued until 1/31/12. On 1/24/12, the Administrator began unannounced elopement drills on all shifts. On 1/31/12, a locking security cover was installed on the alarm/enunciator panel. This panel is in the 200 Hall nurses station and has the reset button and switches controlling the volume of the alarms. On 1/21/12, the elopement investigation for Resident #1 was completed. The codes for the mag-lock panels on both exits 400 hall were changed by the alarm security company on 1/21/12 at 10:15 am. On 1/24/12, The Alarm Security Company extended the amount of time the door alarm would sound on the mag-lock doors. The alarm was changed on the two 400 hall exit doors from 45 seconds to continuous until manually reset. Residents at risk for elopement have the potential to be affected. On 1/25/12, the ADON and the Clinical Care Coordinator review 79 of 79 residents to determine who was at risk for elopement. 5 residents were identified at that time. The ADON and Clinical Care Coordinator ensured photos and identification bracelets were in place for these residents. On 1/31/12 beginning at 5 pm and completing at 9 pm, 82 of 82 residents were reassessed/ re-evaluated by licensed nursing staff (RN #2, LPNs #2, #3 and #4) for elopement/wandering risks using the Wander Data Collection Tool. 8 residents were identified at risk. ADL flow sheets, ADL care plans and care plans were updated to reflect the risk for elopement and the presence of alarms or security devices. Wanderguard presence and functioning of the alarm device were placed on the Medication Administration records for the licensed nursing staff to verify daily. Beginning 1/31/12 at 8 pm the Administrator and ADON re-inserviced licensed nursing staff on duty regarding how to monitor functioning of the wanderguard devices. The licensed nursing staff is to physically take the resident to the sensor to ensure functioning once a day on the day shift and to check the presence of the alarm each shift. Portable tester was ordered 2/1/12. As of 1/31/12 at 4 pm, an employee was posted on the front door on all shifts to observe and respond to the wanderguard alarm until an additional enunciator panel for the system can be installed closer to the nursing unit and the system revised on 2/1/12. Placing a new wanderguard alarm at the enunciator panel will provide a louder alarm for the direct care staff to hear easily on the nursing unit. On 1/31/12, staffing for the Secure Unit was reviewed. As of 1/31/12, an additional CNA has been added to all three shifts for the Secure Unit The licensed nurse for that unit has been designated as dedicated to that unit alone and will not leave the unit to perform duties on other units. The licensed nurse on duty on the secure unit will only leave the unit when relieved by the RN Supervisor or another licensed nurse-who in turn will remain on the Secure Unit until the assigned licensed nurse returns. Additional in-services, given by the Administrator and ADON, regarding resident safety and supervision for all departments began on 1/31/12 at 8 pm and will continue until all staff have been inserviced. No staff will be allowed to work until in-serviced." The AoC was signed by the facility Administrator. Verification of the AoC:Random observations, interview and review of in-service records was conducted. Observation of all exit doors verified that all exit doors functioned and a new alarm enunciator installation for the wanderguard alarm at the front door was in progress. All residents with a wanderguard were observed to have a wanderguard in place. Wander/elopement assessments had been completed, ADL (Activity of Daily Living) sheets, Medication Administration Records and Care Plans were in place. A cover had been placed over the alarm enunciator panel at the 200 Hall Nurses station to prevent the alarm from easily being turned off. The staffing on the Secure Unit was reviewed and verified. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.

CI MS # Based on observation, interview and record review, the facility failed to ensure that adequate nursing staff was present on the Secure Unit, 400 Hall, to provide the supervision of Resident #1, one (1) of six (6) residents reviewed for Elopement/wandering. Resident #1 exited the facility without staff being aware and unsupervised. Resident #1 was housed on a unit designated by the facility as a Secure Unit, the residents on that unit were contained within that unit by locking doors. Resident #1 exited the facility through a door with an audible alarm that should have sounded to alert nursing staff on 1/21/12 at approximately 5:00 a.m. When Resident #1 exited the facility on 1/21/12 at approximately 5:00 a.m. Certified Nursing Assistant (CNA) #1 was the only staff member on the Unit. That CNA #1 was in another residents room with the door closed, assisting the other resident out of the bed and assisting with their morning Activities of Daily Living (ADL's). Resident #1 was found outside across a concrete ditch, in rainy weather approximately 27 steps from the facility. Resident #1 was found by a staff member who was leaving work early due to illness. Resident #1 was found limping, covered with mud and wet. The outside temperature was approximately 62.6 degrees Fahrenheit on 1/21/12 at 5:00 a.m. Resident #1 was found outside in rainy weather. Resident #1 was sent to the hospital emergency department by ambulance on 1/21/12 and returned to the facility with a [DIAGNOSES REDACTED].#1 with a left calcaneal fracture. The lack of implementation of adequate nursing staff to be present on the Secure Unit, 400 Hall, for Resident #1 was deemed an Immediate Jeopardy (IJ) on 1/31/12 at 2:45 p.m. The Administrator was notified at that time. The IJ was determined to begin on 1/6/12 and was removed on 2/1/12. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m.. Based on the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions. Findings Include: Review of a report received by the State Agency on 1/24/12 revealed: "Date of Occurrence: 1/21/2012, Time 5:10 AM (Name of Resident #1), Brief Summary of Incident: (Resident #1) was observed by staff member at the edge of the property @ 5:10 am. (Resident #1) was brought back to the building by staff. (Resident #1) observed to be limping and was sent to ER (emergency room ) for evaluation. ER report indicated possible ankle sprain or fracture. DON (Director of Nursing), Administrator, MD (Medical Doctor & (and) RP (Responsible Party) notified. Investigation begun. (Resident #1) to be seen by orthopedic surgeon on 01/24/12. Interventions: 1. 1-1 (one on one) supervision of resident begun 2. alarm system inspected by alarm company and facility maintenance. 3. Every two hour observations of exit doors & alarm system panel begun. 4. Staff inservices started regarding responding to alarms & use of approved exit doors. 5. Care plan & risk assessment updated." Review of a facility document titled "Incident Report" date 1/21/12 revealed that the incident time was "5 AM". The incident was described as "RN (Registered Nurse) Supervisor notified this nurse that (Resident #1) is outside assist resident back into facility. Assessment (assessed) resident for injuries resident has small cut on (L) (left) palm of hand. ST (skin tear) palm of hand. ST on (L) forearm. C/O (complaining of ) pain/foot Can't stand on it ER notified." Record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/11 revealed a Brief Interview for Mental Status (BIMS) score of two (2) which was defined as severely impaired. Resident #1's transfer, walking ability and locomotion on and off unit was scored as independent with no setup or physical help from staff. Review of Resident #1's Elopement Risk Assessment, dated 8/27/11 and 11/24/11, confirmed that Resident #1 was considered an elopement risk due to wandering and exit seeking behavior. Resident #1 was to remain on the secure unit and be closely monitored. On 11/24/11 an update was added which revealed that Resident #1 was still at risk for elopement . Resident #1's Care Plan revealed a Problem Onset date of 8/12/09 for "At risk for elopement; wanders r/t (related to) dx (diagnosis) [MEDICAL CONDITION]" with a goal that Resident #1 would not leave the facility unattended. The approaches included Resident #1 would reside on the secure unit and would not be left unattended near an exit. Review of staff statements revealed that RN Supervisor #1 was exiting the building on 1/21/11 at 5:10 a.m. when Resident #1 was noted to be in an area beside the facility and "with the assistance of another nurse we called the resident name several times and he begin (began) walking toward us. Resident was assisted back into (the) facility. DON notified and Maintenance notified. Resident is alert and continued to be confused. Pupil equal and reactive to light. No concerns to face noted. Didn't see any possible trauma to head. Noted resident limping on (L) foot. Asked resident did he fall; unable to understand resident speech. Asked resident why he was outside. Unable to understand resident speech. Nurses present and continuing to monitor." Interview on 1/30/12 at 2:05 p.m. with RN Supervisor #1 confirmed that on 1/21/12 upon exiting the facility, that outside the facility, was dark. The RN Supervisor #1 stated that she was very aware of the surroundings. Review of RN Supervisor #1's timecard for 1/21/12 confirmed a clock out time of 5:07 a.m. An observation of someone walking was made by the RN Supervisor #1 who then went back into the facility to get another staff member, Licensed Practical Nurse (LPN) #1. The RN Supervisor #1 stated that she needed help to attempt to determine who the person was that was walking outside the facility. LPN #1 determined that the person was Resident #1 and the two nurses began to call the Residents name, after several times they were able to obtain his attention. RN Supervisor #1 and LPN #1 began to wave for him to come toward them. When they got to Resident #1's side they assisted him back into the facility through a side door on the Secure Unit. The door was opened easily and no alarm sounded when the door was opened. RN Supervisor #1 reported that rain had been falling the night of 1/21/12 and Resident #1 was wet with mud on his clothes. Observation of the area where Resident #1 was found was conducted with RN Supervisor #1 on 1/31/12 at 2:05 p.m., which revealed the area to be approximately 27 steps from the facility exit door. There was a concrete drainage ditch that was crossed by Resident #1. Interview with LPN #1 on 1/30/12 at 3:44 p.m. confirmed that RN Supervisor #1 had alerted her on the morning of 1/21/12 that a Resident was outside the building. LPN #1 was in the area of the Rotunda on the main Nursing Unit, which was located outside of the Secure Unit, when alerted. LPN #1 stated that she ran down the hall to the front and joined RN Supervisor #1 and they both ran over to see who was out and determined the person to be Resident #1. "We got him, he (Resident #1) was hopping could hardly walk. I think we went in the same door he came out because it was open. He was wet. Kept telling about (his) foot. (He) Tried to take sock and shoe off and saw (he) was in pain." LPN #1 confirmed that Resident #1 was a wanderer and went to the door often and that there was no alarm that sounded when Resident #1 exited the facility nor when Resident #1 was assisted back into the facility. LPN #1 stated that the code to open the door was unknown to staff that only the Administrator and Maintenance staff are aware of what the code was. Interview on 1/30/12 at 3:53 p.m. with CNA #1, (who was the only staff member on the Secure Unit when Resident #1 exited the facility on 1/21/12), revealed that around 5:00 a.m. (1/21/12) she was in the room with the door closed assisting another resident to get up. CNA #1 confirmed that no alarm was heard. CNA #1 confirmed that Resident #1 would go to the exit door, shake and kick the door. CNA #1 confirmed that several staff members had complained about the exit door and that upon checking the door several months ago the door was able to be opened by pushing against the door and the key pad did not have to be used. Interview on 1/31/12 at 5:20 a.m. with LPN #1 revealed that the nurse on the Secure Unit was also responsible for Residents who resided outside the Secure Unit. LPN #1 would leave the Secure Unit around 5:00 a.m. and not return to the Secure Unit until around 6:00 a.m. when medication pass had been completed. LPN #1 confirmed that the only staff member left on the Secure Unit from 5:00 a.m. until 6:00 a.m. would be the CNA #1. LPN #1 confirmed that on the morning of 1/21/12 when Resident #1 exited the facility that she was not on the Secure Unit and there was no alarm that sounded in the Rotunda Area. There were 13 residents on the Secure Unit. Upon the return of Resident #1 to the facility there was a scrape on his left hand, a skin tear on his left upper arm and his clothes were muddy. LPN #1 had assisted Resident #1 in dressing that morning and had donned a long sleeve shirt, jeans, socks and tennis shoes. Interview continued at 6:05 a.m. and LPN #1 stated that Resident #1 had to be assisted back over the concrete ditch and was hopping. LPN #1 stated "I could not understand what he was trying to tell me. I knew he was saying he hurt his foot. When we got socks and shoes off it hurt worse. He said "Ouch that hurts". Observation of Resident #1 on 1/31/12 revealed: At 6:15 a.m. Resident #1 had an alarm sounding and he was attempting to stand at the bedside. A CNA immediately responded and assisted Resident #1 back to the bed. At 6:27 a.m. Resident #1 was in a wheelchair with a lap buddy, and chair alarm in place. In a span of 13 minutes Resident #1 took the lap buddy off six (6) times. At 6:47 a.m. the two CNA's on the Secure Unit brought Resident #1 to the Nurses Station for the LPN to observe so that other residents could be assisted up for breakfast. A bandage was observed on Resident #1's left foot and LPN #1 described the bandage as a Jones splint. Interview on 1/31/12 at 6:50 a.m. with LPN #1 confirmed that Resident #1 had a sitter in attendance 24 hours a day from 1/21/12 until the past weekend. At 7:00 a.m. on 1/31/12 Resident #1 was observed to propel the wheelchair to the double doors. Interview with CNA #1 on 1/31/12 at 11:10 a.m. confirmed that no alarm sounded on the morning of 1/21/12 when Resident #1 exited the facility. CNA #1 confirmed that if an alarm had been heard then staff would have immediately responded to the alarm. Interview conducted with Maintenance Staff #1 on 1/31/12 at 11:22 a.m. revealed that the RN Supervisor had called on 1/21/12 and informed him that the door on the Secure Unit need to be checked because a Resident (Resident #1) had exited the facility and the alarm did not sound. Maintenance Staff #1 then came to the facility and went to the Nurses Station, near the Rotunda Area, where the alarm enunciator panel was located. That panel had switches that could be turned "up" for on, or "down" for off. "On" would have allowed the alarm to be heard throughout the facility, and "down" would have prevented the alarm from being heard except for on the Secure Unit. The switch to the exit door that Resident #1 went out was in the "down", or off, position when viewed by Maintenance Staff #1 on 1/21/12. Therefore, when Resident #1 exited the facility there was no alarm heard by the staff on the Nursing Unit. The Maintenance Staff #1 stated "At that time you could force the door open and it would alarm for 45 seconds then turn off. We changed from a 45 second alarm to a continuous alarm." The Maintenance Staff #1 confirmed that if the door alarm did sound the alarm would have only been audible for 45 seconds only. Interview with LPN #5 on 1/31/12 at 1:35 p.m. revealed that the exit door on the Secure Unit had been a cause for concern in the past. On 1/8/12 at the change of shift a concern was reported that the door would open just by being pushed. LPN #5 stated that the Maintenance Director was contacted by personal cell phone, because there was no facility telephone on the Secure Unit. The Maintenance Staff was informed of the concern of the exit door being opened by pushing. The Maintenance Director responded that there had been a problem with the door before but all that could be done was to monitor the door. LPN #5 also noted that the door concern had been reported that the door opened three (3) times without the aide of the key pad. (Note: Resident #1 who had been independently ambulatory prior to the exiting of the facility at 5:00 a.m. on 1/21/12 was able to propel self around the facility in a wheelchair after that time. On 1/24/12 an orthopedic surgeon assessed and diagnosed Resident #1 with a left calcaneal fracture.) Immediate Jeopardy was identified on 1/31/12 at 2:45 p.m. The Administrator of the facility was notified at that time. The facility provided a credible Allegation of Compliance (AoC) on 2/1/12 at 1:56 p.m. Credible Allegation of Compliance: "The Medical Records Assistant was coming into the parking lot in her car and observed Resident #3 in the parking lot on 1/6/12 at 3:30 pm. Resident #3 was brought back into the facility from the front parking lot by the Medical Records Assistant on 1/6/12 at 3:30 pm. The Assistant Director of Nursing was in the lobby when the resident was brought in and took the resident back to the nursing unit and informed the Register Nurse Supervisor #2. The resident's wander guard alarmed on re-entry and was found to be in working order. Resident #3 was found to be without physical injury. At 4:10 pm the resident was transferred to the Secure Unit on 400 Hall. The MD was notified by Registered Nurse Supervisor #2 and the Responsible Party for Resident #3 was notified by the Social Worker on 1/6/12 at 4:00 pm. An investigation was not completed according to the Accident Incident Policy. The Administrator was re-inserviced by the Vice President of Clinical Services regarding event management and incident investigation on 1/25/12. The ADON and RN supervisors were inserviced on the event management and incident investigation by the Administrator on 2/1/12. RN supervisors will not work until inserviced. Resident #1 was returned to the facility at 5:10 am on 1/21/12 by the Registered Nurse (RN) Supervisor #1 and Licensed Practical Nurse #1 (LPN). Resident #1 was assessed and found to have an injury to the left foot. Resident #1 was sent to the hospital emergency room at 5:20 am 1/21/12 via emergency transport. The [DIAGNOSES REDACTED]. Final [DIAGNOSES REDACTED]. RN Supervisor #1 notified Assistant Director of Nursing (ADON) who is Acting Director of Nursing (DON) while DON is on leave, of occurrence at 5:30 am on 1/21/12. Maintenance Man #1 was also notified by RN Supervisor #1 at approximately 5:35 am and was on site by 5:50 am to assess functioning of doors and alarms. All facility exit doors were checked by opening and closing doors to verify alarm sounding. ADON arrived on site at 6:20 am. ADON posted a staff member at the 400 hall doors at 6:30 am and a staff member remained in place until 10:00 am. Beginning at 6:30 am 1/21/12, the ADON inserviced the Nursing, Laundry, Dietary and Housekeeping staff onsite regarding door security and responding to alarms. Staff was educated that in the event of an alarm to secure the resident they might be working with, go to the panel in the 200 hall nursing station to see the location of the alarm, go to the area of the alarm, look out the door in the immediate area to see if a resident is outside. Then account for the presence of assigned residents. Also if the reason for the alarm isn't obvious, report to the supervisor. Inservices continued throughout the day conducted by the Administrator and the RN supervisor. A notice was posted at the time clock at 7 am on 1/21/12 by the ADON to staff alerting them that they had to be inserviced by the ADON or RN Supervisor on duty prior to working or they would not be allowed to work. The Administrator was notified by the ADON of the elopement of Resident #1 and was onsite by 8:00 am on 1/21/12 and took over the investigation at this time. Resident #1 returned to the facility at 8:30 am on 1/21/12 and was placed on one to one supervision by various Certified Nursing Assistants (CNAs). The one to one supervision continued until 10:45 am at (on) 1/25/12. At 10:00 am on 1/21/12, the Alarm Security Company was onsite to check door and alarm function. The company determined the system was functioning properly. Starting at 10:00 am on 1/21/12 the Administrator and RN Supervisors started every two-hour door checks and these continued until 1/31/12. On 1/24/12, the Administrator began unannounced elopement drills on all shifts. On 1/31/12, a locking security cover was installed on the alarm/enunciator panel. This panel is in the 200 Hall nurses station and has the reset button and switches controlling the volume of the alarms. On 1/21/12, the elopement investigation for Resident #1 was completed. The codes for the mag-lock panels on both exits 400 hall were changed by the alarm security company on 1/21/12 at 10:15 am. On 1/24/12, The Alarm Security Company extended the amount of time the door alarm would sound on the mag-lock doors. The alarm was changed on the two 400 hall exit doors from 45 seconds to continuous until manually reset. Residents at risk for elopement have the potential to be affected. On 1/25/12, the ADON and the Clinical Care Coordinator review 79 of 79 residents to determine who was at risk for elopement. 5 residents were identified at that time. The ADON and Clinical Care Coordinator ensured photos and identification bracelets were in place for these residents. On 1/31/12 beginning at 5 pm and completing at 9 pm, 82 of 82 residents were reassessed/ re-evaluated by licensed nursing staff (RN #2, LPNs #2, #3 and #4) for elopement/wandering risks using the Wander Data Collection Tool. 8 residents were identified at risk. ADL flow sheets, ADL care plans and care plans were updated to reflect the risk for elopement and the presence of alarms or security devices. Wanderguard presence and functioning of the alarm device were placed on the Medication Administration records for the licensed nursing staff to verify daily. Beginning 1/31/12 at 8 pm the Administrator and ADON re-inserviced licensed nursing staff on duty regarding how to monitor functioning of the wanderguard devices. The licensed nursing staff is to physically take the resident to the sensor to ensure functioning once a day on the day shift and to check the presence of the alarm each shift. Portable tester was ordered 2/1/12. As of 1/31/12 at 4 pm, an employee was posted on the front door on all shifts to observe and respond to the wanderguard alarm until an additional enunciator panel for the system can be installed closer to the nursing unit and the system revised on 2/1/12. Placing a new wanderguard alarm at the enunciator panel will provide a louder alarm for the direct care staff to hear easily on the nursing unit. On 1/31/12, staffing for the Secure Unit was reviewed. As of 1/31/12, an additional CNA has been added to all three shifts for the Secure Unit The licensed nurse for that unit has been designated as dedicated to that unit alone and will not leave the unit to perform duties on other units. The licensed nurse on duty on the secure unit will only leave the unit when relieved by the RN Supervisor or another licensed nurse-who in turn will remain on the Secure Unit until the assigned licensed nurse returns. Additional in-services, given by the Administrator and ADON, regarding resident safety and supervision for all departments began on 1/31/12 at 8 pm and will continue until all staff have been inserviced. No staff will be allowed to work until in-serviced." The AoC was signed by the facility Administrator. Verification of the AoC:Random observations, interview and review of in-service records was conducted. Observation of all exit doors verified that all exit doors functioned and a new alarm enunciator installation for the wanderguard alarm at the front door was in progress. All residents with a wanderguard were observed to have a wanderguard in place. Wander/elopement assessments had been completed, ADL (Activity of Daily Living) sheets, Medication Administration Records and Care Plans were in place. A cover had been placed over the alarm enunciator panel at the 200 Hall Nurses station to prevent the alarm from easily being turned off. The staffing on the Secure Unit was reviewed and verified. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AoC), the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 2/1/12 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's Quality Assurance (QA) to evaluate the corrective actions.