Every finding on record at Willowbrooke Court at Azalea Trace

Based on observation, interview and record review, the facility failed to prevent 2 of 2 vulnerable residents at risk for elopement (Residents #1 and #2) from exiting the building unsupervised via the front entrance. Resident #1 was able to exit the building through a fire egress door on 2/23/22. Resident #2 exited through the same fire egress door on 3/27/22. This has the potential to effect 14 residents in the facility at risk for elopement. The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the road in-front of the facility, falling and injuring themselves, getting lost in the area surrounding the facility, or drowning in holding ponds located northwest of the facility within approximately 0.25 miles. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated, J. The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy findings on 4/7/2022 at 6:08 PM. The Immediate Jeopardy was determined to have begun on 2/23/22, the day resident #1 eloped from the facility. The Immediate Jeopardy was found removed on 4/8/22 at approximately 7:44 PM, when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity level of a D while the surveying team was onsite. The findings include: On 4/6/2022 at approximately 9:45 AM, the security video footage was reviewed for the elopements of Resident #1 and Resident #2. In attendance were the Administrator, Director of Plan Operations and Director of Nursing (DON). The angle of the footage was from a video camera inside the building facing the sliding doors exiting toward the front of the building. The Director of Plant Operations stated that the facility has 12 cameras on the campus, none of which show the outside entrance. Facility staff in attendance for review of the video confirmed the identity of residents #1 and #2. The following is the timeline for the two elopements that were observed on video: Elopement Timeline for Resident #1: A video with a time stamp of 2/23/22 at 8:11 PM, showed Resident #1 approaching the front entrance/exit sliding doors. The doors did not slide open when resident #1 walked up to the doors. Resident #1 was then observed to put her hands on the emergency exit push bar on the right fire egress door but did not attempt to exit at this time. At 8:11:38 PM, the resident was observed to place her hands on the push bar a second time and appears to turn around to see if anyone was watching her. Staff could not be seen within view of the video. At 8:11:43 PM, the Resident shakes the right fire egress door (this is an emergency exit feature for the sliding door, which would allow for the door to open outward if the bar is pushed) and appears to push and hold the bar on the door. The right fire egress door does not open. At 8:11:48 PM, the resident moves over and is observed pushing on the left fire egress door. At this time during the footage review, the Administrator and Director of Plant Operations explained that the door was not sliding open because the resident's wandering alert device had engaged thus preventing the door from sliding open. They clarified that the wandering device's audible alarm was not going off because the sliding doors had not opened. At 8:11:54 PM, as Resident #1 pushes the fire egress emergency exit feature of the left door, the door is observed to open outward, and the resident is able to exit the building to the outside and appears to turn right. The resident's direction and whereabouts cannot be determined beyond this point because there are no cameras on the outside of the building. In the video, the door remains ajar, and staff are not observed to be within the view. The door remained open, until 8:16:36 PM, when Resident #13 comes into view by the exit doors and pulls the egress door shut at 8:17:05 PM. The video supports that at approximately 8:55:27 PM, staff arrive at the door and are attempting to get out. The Administrator explained that the door will not slide open because the wander alert system had engaged and required the door to be reset with a code before it could function as intended. At approximately 8:56 PM, staff are seen going outside. At approximately 9:07:22 PM, the video shows resident #1 being escorted by staff and a security guard back into the building through the front entrance. Based on the timeline from the security video footage Resident #1 was absent from the building for approximately 56 minutes. In an interview on 4/6/2022 at approximately 9:58 AM, conducted during the review of the surveillance video of Resident #1's elopement, the Administrator and the Director of Plant Operations stated the fire egress alarm on the door did not go off because the fire egress door was not opened wide enough. The Administrator and Director of Plant Operations stated that they were informed the fire egress door must open ¾ - full in order for the fire egress alarm to engage, however they were not informed of this until after a second resident (Resident #2) eloped through the same doors in March. They explained that staff had received a telephone call at approximately 8:53 PM on 2/23/2022, that Resident #1 was at the security guard building at the entrance to the compound (the guard shack is ¼ mile away from the facility). Video review of the elopement timeline for Resident #2: On 3/27/22 at 1:06:45 PM, according to the time stamp on the video, Resident #2 was observed approaching the front entrance/exit sliding doors. These are the same doors that resident #1 exited on 2/23/22 and eloped from the building. The video shows the door does not automatically slide open when the resident approaches. At approximately 1:06:58 PM, Resident #2 was observed engaging the push bar by applying force or pushing on the right fire egress door and kicks the door. The door opened and Resident #2 was observed exiting the door. Resident #2 then shuts the door behind her. She was observed walking out and exiting right. The resident's direction and whereabouts cannot be determined beyond this point because there are no cameras on the outside of the building. At approximately 1:28:24 PM, a visitor, later identified as the resident's daughter-in-law, is seen approaching the sliding door from the outside and knocking on the door. The visitor can be seen talking to staff through the glass who had come to the door. The door was reset with the code and the visitor enters the facility and was observed talking to staff. At 1:31:30 PM, a male staff member is noted leaving the building. At 1:36:12 PM, the sliding door opens, and resident #2 was observed returning in a wheelchair escorted by the male staff. Based on the timeline from the video footage of Resident #2 departing until the time the daughter-in-law was noted at the facility doors is approximately 21 minutes. The total time that Resident #2 was absent the building was approximately 30 minutes. On 4/5/2022 at approximately 8:20 AM, a telephone interview with resident #2's daughter-in-law was conducted. She stated she and husband (the son of resident #2) had come to the facility on [DATE] to bring her mother-in-law some clothing. She reported that as they pulled into the parking lot, they saw Resident #2 lying on the curb next to the stop sign. The stop sign is across the parking lot approximately 45 feet from the entrance/exit that Resident #2 utilized to elope. Resident #2's daughter-in-law reported, she and her husband (son of resident #2 ) were unsure if she had fallen or was just lying down. At this time there did not appear to be any injuries, so they sat her up. The Resident told them she was waiting for the bus. The resident's son stayed with the Resident while the daughter-in-law went to the facility to inform staff that Resident #2 was outside. Record Review Resident #1 A review of the medical record for Resident #1 noted the resident was admitted on [DATE]. Diagnosis upon admission included Unspecified dementia with behavioral disturbance, other specified anxiety disorders, other specified persistent mood disorders, cognitive communication deficit, essential hypertension, [CONDITION(S)] and [CONDITION(S)]. A review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition and behaviors noted were delusions; however, the MDS indicated that wandering was not exhibited. A Wandering Assessment on 2/14/2022 concluded Resident #1 was at high risk to wander. The Wandering Assessment completed on 2/17/2022 concluded the resident was at risk to wander. The follow up Wandering Assessment completed on 3/16/2022 concluded the resident was at high risk to wander. A review of the facility policy titled Elopement/Wandering Risk Assessment issued in August 2007 with the latest revision March 2021, documented residents will be assessed upon admission, after 72 hours of admission, within one month of admission, quarterly and with any new behaviors related to exit seeking activities. A review of Resident #1's Care Plan dated on admission (2/14/22) noted the resident was at risk for wandering and included the following interventions: 1) I will wear a wander alert device on my right wrist 2) My Wander Alert device will be checked for function, placement and expiration, 3) My wander alert device will be worn while at risk for elopement. A review of the Medication and Treatment Administration Record noted documentation from admission on 2/14/2022 through present (4/07/22) that the wander alert device was in place. A review of the Nursing Progress Note from Staff J, Licensed Practical Nurse (LPN) dated 2/23/2022 at 10:52 PM, stated, Resident was by the med (medication) cart at 2030 (8:30 PM), this nurse offer her night time med and she refused x3 (three times). The security call at 2130 (9:30 PM) starting Resident walk at the woods (clarification note to follow) toward the guard shack, upon arrival at the guard shack, resident was standing outside the building with 2 guards, noted with a small scratch to left cheek and dirt on her clothes. Alarm did not sound prior to security call, Alarm didn't sound as resident return to (facility) A Late Entry Progress note from Staff J, LPN dated 2/24/2022 at 9:05 PM, with an event date of 2/23/2022 8:49 PM stated Security guard called me to come down to the guard shack stating a resident was down there bleeding. I spoke with resident and asked her what her name was. When she stated her name, I knew she was a resident (at the facility). The Resident stated someone stole her purse and that she told the lady to call the police. She stated the lady said no and then she took off running away from her. She stated that she didn't know if her husband was alive or dead. She also said she was not going back to where that lady was and asked me if I was going to call the police on her. Resident had a skin tear on her left cheek and also had grass stains and dirt on her knees. She stated she was in the bushes. I spoke to resident and told her she needed to come with me so I could clean her cut on her face. I placed the resident in the golf cart and our security guard drove us back up to the skilled unit. The facilities corrective action plan after Resident #1 eloped on 2/23/2022 stated that upon return to the facility, Resident #1 was assessed for injury. One-hour checks were initiated for Resident #1 on 2/25/2022 during the 3PM-11PM shift and 11PM-7AM shift until one-to-one was initiated through a home health agency on 2/26/2022. The facility immediately verified that no other residents were out of the community. The bed check of other residents noted all were present. Routine every 2-hour bed checks on other residents. Staff rounds were to be conducted at beginning and end of each shift and every two hours during the shift as a standard operating procedure to verify that residents are accounted for. Elopement pendants (wondering monitoring device) are verified daily on moderate to high-risk residents. There are currently 7 residents in the facility identified as moderate to high-risk. Staff training and education on Elopement was initiated on 2/24/22 and 100% of staff were re-educated on Elopement. Elopement Drills were increased to quarterly with 8 of 70 of the facility staff members participating in a drill on 3/4/2022 during the 7 AM - 3 PM shift. Elopement binders were developed and placed at the front gate and the Welcome House. Binders include pictures and location where at-risk residents reside as of 3/4/22. Binders provided to department heads and reviewed by each with their staff. On 3/4/22 a re-check completed of each resident to identify those at Medium or High Risk for elopement and ensure that an assigned designated transmitter was logged in to the monitoring system for that resident. The Wander System Company installed additional antennas to improve coverage range and added 3 additional sensors to elopement monitoring system on 3/2/22. The Door repair company completed door repairs on 3/14/22, 3/16/22, 3/19/22, 3/23/22, 3/28/22 to repair breakaway function. The Maintenance department conducted preventative maintenance checks of doors weekly with no noted abnormalities and doors functioning properly per code. Ad hoc Quality Assurance and Performance Improvement (QAPI) sub-committee met on 3/4/22 to address resident elopement, and review action plans. In attendance was the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Nursing, and Director of Plant Operation. A QAPI meeting was held 3/11/22 in which the committee evaluated the action plans in place related to the elopement of Resident #1 and determined if additional actions needed to be taken. In attendance was the NHA, Medical Director, DON, Advanced Practice Nurse Practitioner (APRN), ADON, Nurse Representative, Social Worker, Care Coordinator, Registered Dietitian, Medical Records, Rehab Director, Maintenance, Home Health Director of Nursing. Record Review Resident #2 A record review of Resident #2 revealed the resident was admitted on [DATE]. The admission MDS assessment completed on 3/10/2022 identified the resident with a BIMS score of 1, indicating severe impairment, with inattention and disorganized thinking. The MDS also showed documentation of behaviors which included delusions and wandering behavior daily. A review of resident #2's Care Plan (dated 3/10/22) noted the resident was care planned to be at risk for wandering. Care Plan Interventions for the plan created on 3/10/2022 included a wander alert device that was to be worn while at risk of elopement. Wandering/Risk assessment was performed on 3/10/2022 (date of admission) and 3/13/2022 (72 hours post admission. Both Wandering Risk Assessments identified the resident was at high risk to wander. A review of a Nursing Progress Note for Resident #2 dated 3/13/2022 6:36 AM, by Staff O, LPN, noted exit seeking behaviors, Resident alert with confusion. Remained in the COVID unit (Coronavirus Disease) on droplet precautions . Resident stays up all night, walking in the hallway crying stating 'I want to go home, please call the police.' Resident refused to go to bed and tried to open the door constantly. Will continue to monitor. A review of a Nursing Progress Note for Resident #2 dated 3/16/2022 completed by Staff P, LPN stated, Resident has been combative and had altered mental status change. She refused medications and tried to hit me when trying to get her (blood sugar check). She has not had anything to drink or eat. Resident took her clothes off and her bed sheets along with her wander guard bracelet. She also took her pull up off. Spoke to her son which is the POA (Power of Attorney) told him provider wanted to send to ER (emergency room ) due to lab values possible DKA (Diabetic Ketoacidosis) and altered mental status A review of a Nursing Progress Note by Staff L, LPN on 3/27/2022 at 1:32 PM (Day of elopement) stated, This nurse was in another resident room, RN (Registered Nurse) Staff K, came to get me to let me know that (Resident #2) was lying in the grass across the parking lot by the stop sign out front. Assessed for injury, no injuries present. Sitter (for another resident) was coming into work, her husband was dropping her off. She noticed (Resident #2) was lying in the grass by the stop sign out front. She also stated that there was another car behind her. Her husband made a U-Turn, and the car behind her made a U-Turn also. It just so happened that the car behind (Staff M's car) was (Resident #2's) son's car, who was bringing her some clothes, and happened to see her also and the daughter-in-law was banging on the front door to report (Resident #2) outside and (Staff M), Sitter was coming into another door to report her outside. (Wandering alert device) in place. Resident was lying in the backseat of her son's car when this nurse went out. Wheelchair taken out to bring her back inside. Alarm sounded when she was brought back inside. Placed on 30 minute checks. A review of Resident #2 Nursing Progress Notes completed by Staff E, RN on 3/28/2022 at 7:37 PM stated, This resident's son was in this facility to visit, and to meet with a hospice nurse. Resident popped the front door open and exited the facility, staff immediately followed her, and was able to redirect her back into the building. (Wandering alert device) in place and functioning. Resident is ambulatory, and wanders throughout the facility exit seeking. Staff aware of exit seeking and have been checking on resident's location this shift. The facility's corrective action after Resident #1 eloped on 2/23/2022 stated that upon return to the facility, Resident #2 was assessed for injury with no apparent injury. Thirty-minute checks were put in place on resident #2 immediately upon return inside the building. A bed check of other residents was conducted and resulted in all residents accounted for. Routine every 2-hour bed checks were completed on other residents. Staff rounds are conducted at the beginning and end of each shift and every two hours during the shift as a standard operating procedure to verify that residents are present. Elopement pendants are verified daily on moderate to high-risk residents. A staff member was stationed 24/7 at front door where resident exited beginning 3/27/22 and continues to present. A one-to-one staff by home health agency was provided for resident #2 on 3/27/22 from 3 PM to 11 PM and 11 PM to 7 AM until 4/8/22. On 3/28/22, additional staff training and re-education on Policy and Procedures for Elopement and Unescorted Exit was conducted with 72% of staff in attendance. Nursing supervisor/charge nurse will ensure training and documentation of staff (including agency staff) coming on shift not previously trained on 3/28/22. On 3/28/22, the contracted Wander Guard company installed motion sensor that alarms for anyone who approaches front door and installed a requirement of an exit code to be entered, and was installed in the center, between the two sliding doors. The door only alarms when the exit code is not entered, you must be standing very close to the door for it to alarm. The motion sensor is positioned to capture directly under the door. The exterior doors are locked at 8 PM daily Additional repair of the breakaway function on the front door was completed by the contracted door repair company on 3/28/22. The Motion Sensor was installed to alarm door when a person is standing directly in front the door and an exit code has not been entered. This was a joint effort between the door repair company and the Wander Guard company. There were elopement attempts by Resident on 3/29/22 6:45 PM, 6:48 PM and 6:51 PM. On the 1st and 2nd attempt, upon approach of door by resident #2 staff responded to motion sensor alarms and staff redirected the resident before the resident breached door. On the 3rd attempt, Resident #2 was able to breach the door, however staff intercepted the resident and redirected her before she was able to exit the building. This was confirmed on 4/6/2022 at approximately 9:45 AM in the video review of Resident #2's elopement. A review of the Weekly Elopement Monitoring System Checks completed by the facility staff for the purpose of ensuring the wander alert system was functioning revealed documentation on 2/24/22 front breakaway has no alarm. Fire egress.; The Weekly Elopement Monitoring System Check was not available for the week of 2/28/22-3/04/22; on 3/11/22 the Weekly Elopement Monitoring System Check form did not have documentation that indicated concerns with the alarms on the fire egress doors, and no other concerns were identified. For the week of 3/18/22, the Weekly Elopement Monitoring System Check form revealed Door company to replace lock on front door on 3/19/2022. Notified supervisor of problem with alarm on Breakaway Part of Front Door, followed by the initial of Staff H, Facility Maintenance staff. On 4/06/2022 at approximately 12:47 PM, an interview was conducted with the Administrator and the Director for Plant Operations. The surveyor informed the staff members that based on previous discussions, it was this surveyor's understanding that the facility was unaware that the fire egress for the sliding glass door did not have the ability to alarm with the wander alarm system. Advised the administrator that based on the review of the Weekly Elopement Monitoring System check dated 2/24/2022, the form had documentation that the front breakaway has no alarm. The Administrator was asked if there was awareness of the fire door egress alarm not working. The Administrator and the Director for Plant Operations stated that there was a separate alarm associated with the fire egress door that alarms when it is opened. The Administrator stated in the elopement of Resident #1, the resident did not open the egress door far enough to alarm. The Director for Plant Operations stated what they failed to realize was that the breakaway feature will not activate the alarm unless the door is opened ¾ of the way or fully. He stated it (the fire egress door) will alarm, but it took us a bit to realize what was needed to activate the alarm on the fire egress door. At this time the Administrator was asked if after the elopement of Resident #1 and upon knowing the alarm for the egress door may not alarm if not opened far enough, what actions were put into place to ensure other residents identified at risk for elopement didn't exit the facility in a similar manner? The Administrator stated that Resident #1 was assigned a sitter on the evening shift and night shift to watch the resident and prevent attempts to elope. He was then asked what actions were put into place to prevent other residents at risk for elopement from leaving the building unattended without facility awareness? The Administrator stated you mean we should have put a guard or some kind of system in place to prevent exit out that door until it was safe? The surveyor clarified, Did you have a security guard or someone monitoring the door between the facility realizing the door didn't alarm each time it opened and up until a motion sensor was put into place on 3/28/2022? The Administrator stated that they did not have a security guard in place to monitor the entrance until after the elopement of Resident #2 on 3/27/2022. The corrective action summary dated 3/7/2022 following the elopement of resident #1 indicated there was an elopement in-service completed on 2/23/2022 which reviewed the policy and procedure Elopement, Unescorted Exit, Policy number E-03. A review of this in-service revealed a total of 28 individuals signed the roster as receiving the in-service. A review of the General Employee Listing noted that on 2/23/2022, the date of in-service, the facility had a total of 69 staff employed. A review of the staff elopement in-service completed on 3/28/2022 following the elopement of Resident #2, noted a review of the policies titled Elopement Criteria, Policy number E-01AL, and Elopement, Unescorted Exit, Policy number E-03. A total of 10 individuals signed the roster as receiving the in-service. At the time of the in-service, the facility had a total of 73 staff employed. The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions: A QAPI meeting was held at 10:45 AM on 4/8/22 to review the updated elopement plan. The actions were approved by the committee with no additional recommendations. In attendance were the Nursing Home Administrator, Medical Director, Director of Nursing, Registered Nurse representative, Social Worker, Registered Nurse, MDS, Activities Coordinator, Rehab Director, Medical Records, Director of Plant Operations Maintenance/Plant Services continued ongoing weekly checks of doors and system and found them to function properly per code. The nursing staff continued to perform daily bracelet placement checks and weekly functioning checks of transmitters with no identified issues. As of 4/8/22 the system has been updated so the staff pagers will alert every two minutes until a door alarm is cleared. Certified Nursing Assistants (CNAs), Nurses, and Administration carry pagers during their shift. Security was issued a pager as an added layer of response to any alert. All of these actions were verified by observation, record and staff interview. The facility also scheduled additional Elopement drills on 4/10/22, 7 AM to 3 PM shift, 4/11/22 11 PM to 7 AM shift and 4/12/22 3 PM to 11 AM shift.

Based on observation, interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to a resident elopement that occurred on 2/23/22 (resident #1) which resulted in a second resident elopement via the same door on 3/27/22 (Resident #2). The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm for all 14 residents identified as risk for elopement: Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15. The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the road in front of the facility, falling and injuring themselves, getting lost in the area surrounding the facility, or drowning in holding ponds located northwest of the facility within approximately 0.25 miles. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated, J. The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy findings on 4/7/2022 at 6:08 PM. The Immediate Jeopardy was determined to have begun on 2/23/22, the day the first resident eloped from the facility. The Immediate Jeopardy was found removed on 4/8/22 at approximately 7:44 PM when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity level of a D while the surveying team was onsite. The findings include: Resident #1 On 4/6/2022 at approximately 9:45 AM, the security video footage was reviewed for the elopement of Resident #1. In attendance were the Nursing Home Administrator (NHA), Director of Plan Operations and Director of Nursing (DON), The angle of the footage was from a video camera inside the building facing the sliding doors exiting toward the front of the building. The Director of Plant Operations stated that the facility has 12 cameras on the campus, none of which show the outside entrances. The video, timestamped 2/23/22 at 8:11 PM, showed Resident #1 approaching the front entrance/exit sliding doors. The doors did not slide open when resident #1 walked up to the doors. Resident #1 was then observed to put her hands on the emergency exit push bar on the right fire egress door but did not attempt to exit at this time. At 8:11:48 PM, the resident moves over and is observed pushing on the left fire egress door. At this time during the footage review, the Administrator and Director of Plant Operations explained that the door is not sliding open because the resident's wandering alert device had engaged thus preventing the sliding door from sliding open. In addition, the audible wandering device alarm is not going off because the sliding of the door has not been engaged which triggers a breakaway on the sliding door to start the alarm. The audible alarm for the wandering alert system is engaged if the sliding door is opened as it would normally open, in a sliding fashion. In this case, the wander alert device engaged as the resident approached the door and locked the sliding mechanism of the door, preventing it from sliding open. At 8:11:54 PM, Resident #1 is observed on the video pushing the fire egress emergency exit feature of the hinged portion of the left door, in which the door is observed to open, and resident # 1 was observed to exit the building to the outside heading right. Resident #1 was observed by the security staff approaching the guard shack located at the entrance to the compound approximately ¼ mile away from the facility. The security staff notified the facility of the resident's location. At approximately 9:07 PM, the video shows staff escorting the resident who is walking, into the building with a security guard. Based on the video timeline the total time that Resident #1 was absent the building was approximately 56 minutes. At no point during the video is staff noted to be in the area of the door and the wandering guard system does not alert. According to review of the facility's immediate corrective action, the facility immediately assessed Resident #1 for injury following the resident's return to the building on 2/23/22. The facility immediately verified that no other residents were out of the community. The bed check of other residents noted all were present. Cross Reference F689. Resident #2 On 4/6/2022 at approximately 9:45 AM, the security video footage was reviewed for the elopement of Resident #2. In attendance were the Administrator, Director of Plan Operations and Director of Nursing (DON). The angle of the footage was from a video camera inside the building facing the sliding doors exiting toward the front of the building. The video, timestamped 3/27/22 at 1:06:45 PM, showed Resident #2 approaching the front entrance/exit sliding doors. These are the same doors that resident #1 exited on 2/23/22 and eloped from the building. The video shows the door does not automatically slide open when the resident approaches. At approximately 1:06:58 PM, Resident #2 was observed engaging the push bar by applying force or pushing on the right fire egress door and kicking the door. The door opened and Resident #2 was observed to exit the door the outside of the building. Resident #2 then shuts the door behind her. She was observed walking out and exiting right. The resident's direction and whereabouts cannot be determined beyond this point because there are no cameras on the outside of the building. Resident #2 was later found outside laying on the ground by family members arriving for a visit. Based on the video timeline the total time that Resident #2 was absent the building was approximately 30 minutes. At no point during the video is staff noted to be in the area of the door and the wandering guard system does not alert. The facility failed to address the limited capability of the sliding doors alarming when opened by a resident wearing a wandering alert device by assigning staff to monitor the door until after Resident #2 eloped on 3/27/22. A staff member was stationed 24 hours a day/7 day a week at the front door where both resident #1 and 2 had exited beginning 3/27/22 and continues to present. On 3/28/22, additional Staff training and re-education was conducted on the 'Policy and Procedures for Elopement and Unescorted Exit' with 72% of staff in attendance. The Nursing supervisor/charge nurse was listed as the responsible personnel to ensure training and documentation of staff (including agency staff) coming on shift not previously trained on 3/28/22. On 3/28/22, the contracted Wander Guard company installed motion sensors that alarmed for anyone who approaches the front door and installed a requirement of an exit code to be entered, which was installed in the center, between the two sliding doors. The door only alarms when the exit code is not entered, and you must be standing very close to the door for it to alarm. The motion sensor was positioned to capture directly under the door. The exterior doors are locked at 8 PM daily. Additional repair of the breakaway function on the front door was completed by the contracted door repair company on 3/28/22. The motion sensor was installed to alarm door when a person is standing directly in front the door and an exit code has not been entered. This was a joint effort between the door repair company and the Wander Guard company. There were documented elopement attempts by Resident #2 on 3/29/22 6:45 PM, 6:48 PM and 6:51 PM. On the 1st and 2nd attempt, upon approach of door by resident #2 staff responded to motion sensor alarms and staff redirected the resident before the resident breached door. On the 3rd attempt, Resident #2 was able to breach the door, however staff intercepted the resident and redirected her before she was able to exit the building. On 4/6/22 at approximately 1:30 PM, an interview was conducted with Staff G, QAPI Nursing Representative, during which she stated there had been two scheduled QA meetings this year on 1/21/22 and 3/11/22. She reported that the meeting from January included discussion and implementation of a Performance Improvement Plan (PIP) that was primarily for maintenance to ensure the front entry doors and wander alert system were functioning properly and that the audits were being conducted weekly. Staff J showed this surveyor a copy of the minutes that reflected a reference to a PIP regarding the doors and identified and audit tool for continued system checks. She stated they completed those tasks and continue to monitor the doors. Staff G further reported that in the meeting on March 11, 2022, after the elopement of Resident #1, a new PIP was initiated to update the elopement binders, complete staff training, and elopement drills. She reported that the facility was actively in the middle of the PIP as it started last month (March). She confirmed that the facility had not conducted a meeting since the March 11, 2022 meeting and had not discussed the elopement of resident #2 with the QA committee. The PIP for the elopement of Resident #1 did not include anything related to the front entrance/exit sliding doors from which the resident had eloped. On 4/06/22 at approximately 12:47 PM, an interview was conducted with the Administrator and the Director for Plant Operations, during which the Weekly Elopement Monitoring System check dated 2/24/2022, was reviewed. The form documented that the front breakaway has no alarm. The Administrator was asked if there was awareness of the fire door egress not working. The Administrator and the Director for Plant Operations stated that there was a separate alarm associated with the fire egress door that alarms when it is opened, but the Administrator and Director for Plant Operations reported that it must be opened a certain amount in order for the alarm to go off. In the case of the elopement of Resident #1, she did not open it far enough to activate the alarm. The Director for Plant Operations stated what they failed to realize was that breakaway feature will not activate the alarm unless the door is opened ¾ of the way or fully. He stated it will alarm, but it took us a bit to realize what was needed (to activate the alarm on the fire egress door). At this time the Administrator was asked if after the elopement of Resident #1 and upon knowing the alarm for the egress door may not alarm if not opened far enough, what actions were put into place to ensure other residents identified at risk for elopement didn't exit the same way? The Administrator reported that Resident #1 was assigned a sitter on the evening shift and night shift to watch the resident and prevent attempts to elope following Resident #1 elopement on 3/23/2022. He was then asked what actions were put into place to prevent other residents at risk for elopement from leaving the building unattended without facility awareness? The Administrator stated you mean we should have put a guard or system in place to prevent exit out of that door until it was safe? The surveyor clarified, Did you have a security guard or someone monitoring the door between the facility realizing the door didn't alarm each time it opened and up until a motion sensor was put into place on 3/28/2022? The Administrator stated that they did not have a security guard in place to monitor the entrance until after the elopement of Resident #2 on 3/27/2022. On 4/7/2022 at approximately 3:45 PM, a follow up interview was conducted with the Administrator regarding the QAPI Performance Improvement Plan (PIP) started in January, which identified concerns with the alarms with the front entrance sliding door. The surveyor informed the Administrator that the January QAPI minutes showed a performance improvement plan (PIP) in place for the doors, and this was confirmed by Staff G, QAPI Nursing Representative. The surveyor asked if the Administrator felt the PIP was effective or ineffective. The Administrator stated he would state it wasn't effective because we didn't know what the problem was. The wander alert system was functioning and the door company kept stating the alarms were functioning, but Resident #1 was able to elope. The alarm company kept coming back to work on the doors and stated they were functioning, so that was our assumption. They never advised us how wide the door needed to be opened to alarm until Resident #2 eloped. Then we put actions into place that would protect all residents. The surveyor informed the Administrator that on the wander alert system checks form dated the day after the Resident #1 eloped, 2/24/2022, there was a note that the breakaway locks were not functioning and on 3/18/2022 the form noted that the supervisor was informed that there was a problem with a breakaway part of the door. The surveyor asked, How was this addressed in your QAPI meeting in March? The Administrator responded that it wasn't a part of the PIP because the door company kept saying it was fixed. We kept bringing them out and they would state it was working. The Administrator stated At no point did they let us know that the door needed to be opened a certain amount to alarm until the elopement of Resident #2. We then put measures into place like the security guard and the motion sensor that was installed the day after Resident #2 elopement (3/27/2022). After the notification of Immediate Jeopardy on 4/7/22 at 6:08 PM the facility implemented the following measures in addition to the measures implemented after the elopement of Resident #2 which are ongoing: A QAPI meeting was held at 10:45 AM 4/8/22 to review the updated elopement plan. The actions were approved by the committee with no additional recommendations. In attendance were the NHA, Medical Director, DON, RN representative, Social Worker, RN MDS, Activities Coordinator, Rehab Director, Medical Records, Director of Plant Operations. The corrective actions included but were not limited to the following: 1. Maintenance/Plant Services continues ongoing weekly checks of doors and system and found them to function properly per code. 2. The nursing staff continued to perform daily bracelet placement checks and weekly functioning checks of transmitters with no identified issues. 3. As of 4/8/22 the system has been updated so the staff pagers will alert every two minutes until a door alarm is cleared. CNAs, Nurses, and Administration carry pagers during their shift. Security was issued a pager as an added layer of response to any alert. 4. Elopement drills were scheduled on 4/10/22, 7 AM to 3 PM shift, 4/11/22 11 PM to 7 AM shift and 4/12/22 3 PM to 11 AM shift.

Based on observation, record review, and interview, the facility failed to store and prepare food in a sanitary manner which has the potential to affect all residents being served. The findings include: On 7/31/2019 at approximately 12:30 PM, during tour of the kitchen with the facility's Certified Dietary Manager (CDM), it was noted that the resident milk cooler which contained several gallons of milk, prepackaged thickened liquids, other prepackaged beverages, and cold desserts, was found to have an internal temperature of 46 degrees Fahrenheit as read by the internal thermometer. At this time it was acknowledged that frequent access to the cooler or a faulty thermometer could have contributed to an elevated temperature, it was agreed upon with the CDM to return to check the cooler after completion of the tour. On 7/31/2019 at approximately 1:30 PM during a follow-up visit of the resident milk cooler it was noted that the thermometer read 44 degrees Fahrenheit which was confirmed by the CDM. At that time the CDM pulled a partially emptied gallon of milk out of the refrigerator, poured some into a cup and took the temperature using the facility's kitchen thermometer which read 50 degrees Fahrenheit. The CDM then took a gallon from the back of the refrigerator, sampled some to take the temperature which read 47.3 degrees Fahrenheit. The CDM confirmed that this temperature was too warm for the milk to be kept at and stated that all items in the refrigerator are to be disposed of at that time as a result of the elevated temperatures. On 7/31/2019 at approximately 1:00 PM, during tour of the kitchen with the CDM and Executive Chef, it was observed that there was a metal pan of raw shrimp contained in a plastic bag being thawing under running water. The running water was warm to touch. The Executive Chef took a temperature of the water using the facility's kitchen thermometer at which point it read 80.6 degrees Fahrenheit. The Executive Chef and CDM confirmed that raw shrimp should be thawed under cold running water. On 8/1/2019 at approximately 8:30 AM during record review of facility policy and procedure titled Food temperatures it was noted that cold products should not reach temperatures greater than 41 degrees Fahrenheit. Additionally, it was noted in facility policy and procedure titled Food Thawing that foods that have not completely thawed by production time may be thawed under cold running water and that at no time food will be thawed at room temperature, in standing warm water, or in ovens.

Based on observation, staff interview and policy review, the facility failed to provide adequate accommodations to cover body parts for 1 of 1 resident (#55) observed being transported to the shower room. The findings are: On 7/11/17 at 9:59 am an observation was made of Certified Nursing Assistant (CNA) Employee E transporting Resident #55 in a shower chair to the shower room. This required the resident to be pushed in the shower chair from her room on one end of the hallway to the other end of the hallway where the shower room was located. As the resident passed the surveyor the resident was observed to be uncovered in the back exposing her bare buttocks. An interview was conducted with CNA Employee E on 7/11/17 at 10:30 am. She stated the normal process for transporting residents to the shower room was to make sure they were adequately covered during transportation. A review of the policy Bath/Tub/Shower/Spa B-04 page 1 of 3 was reviewed. The policy stated to help the resident out bed and assist into a bathrobe and slippers. If the resident does not have a bathrobe, wrap the resident in a bath blanket. Make sure the resident is appropriately covered An interview was conducted with the Director of Nursing (DON) on 7/11/17 at 11:20 am. She stated the expectation was that the dignity of residents would be upheld by making sure all private areas were covered. She confirmed that the policy of the facility also indicated that the resident should be appropriately covered during transport to public areas.

Based on observation, record review, staff interview, and review of facility policy and procedures, the facility failed to implement the plan of care for 1 of 16 residents reviewed (resident #4). The findings are: On 07/11/2017 at approximately 2:11PM, resident #4 was observed in bed with an oxygen concentrator at his bedside. The oxygen concentrator was on, and set to deliver two liters of oxygen per minute through attached tubing that had a nasal cannula at one end to allow for oxygen delivery to the resident. The tubing and cannula were observed to be on the floor next to the resident's bed. At approximately 3:00 PM, a subsequent observation showed the tubing and cannula still on the floor at the bedside of resident #4. Another observation at approximately 3:25 PM revealed the tubing and cannula were still on the floor at the resident's bedside. On 7/11/17 at approximately 3:30 PM Staff C (the unit nurse) was asked if she was taking care of the resident, and she replied yes. She was asked if she had a pulse oximeter (used to test the oxygen levels), and she replied yes. She was asked to accompany the surveyor to the room of resident #4. Prior to entering the room, she was informed that 3 observations had been conducted over the past hour and the resident's oxygen tubing and cannula had been on the floor during each observation. The nurse approached the resident and aroused him. The nurse checked the oxygen saturation of resident #4 using a pulse oximeter and the results were 81%, which is low. The nurse left the room and returned very quickly with a new (packaged) oxygen tubing with nasal cannula. She opened the package, connected the tubing to the oxygen concentrator, and placed the nasal cannula on the resident. The nurse again checked the oxygen saturation of resident #4, and within one minute, the resident's oxygen saturation returned to 96%. The nurse was asked if the CNAs (certified nursing assistants) were expected to be aware of which residents require oxygen, and she replied yes. On 07/11/2017 at approximately 4:09 PM the same nurse was again interviewed. She was asked if the resident was on continuous, or as needed (PRN) oxygen, and if there were any parameters for maintaining the resident's oxygen saturation. The nurse referred to the Medication Administration Record [REDACTED]. Clinical record review revealed a physician order [REDACTED].@ 2L PRN to keep Sats > 92% (oxygen at 2 liters as needed to keep oxygen saturation greater than 92%) On 07/12/2017 at approximately 10:00:36 AM an interview was conducted with the facility ARNP (Advanced Registered Nurse Practitioner). The ARNP stated that she was not the practitioner who wrote the order for the PRN oxygen. She stated that the expectation was that the nurses would monitor the O2 saturation as needed. She stated that the staff should be periodically checking to make sure the resident was keeping the oxygen cannula in place when in use. She stated resident #4 was recently placed on hospice, and the oxygen was added when he had developed an upper respiratory issue, for which he also received [MEDICATION NAME] (a medicated breathing treatment) for [DIAGNOSES REDACTED]. On 7/12/17 a new order was found in the resident's clinical record which read: Order Clarification: O2 @ 2L for comfort/SOB/Dyspnea (Oxygen at 2 liters for comfort/shortness of breath/difficult or labored breathing). The facility plan of care for resident #4 was reviewed and found to contain a plan of care for Pneumonia with an intervention initiated 6/30/17 for oxygen as ordered, and for staff to observe for any shortness of breath, and changes in coloring, especially lips and nail beds. The facility policy and procedures for Oxygen Administration/Safety was reviewed. The policy purpose was To strive to improve oxygenation, provide comfort to resident's experiencing respiratory difficulties, and provide safety precautions during the administration of oxygen. The procedure for compliance with the policy read Check the resident and the oxygen flow frequently to assure the maintenance of the correct flow rate and the proper functioning of the concentrator/cylinder.

Based on resident observation, staff interview, clinical record review and policy review, the facility failed to provide adequate supervision to prevent accidents in the shower room for 1 of 5 residents reviewed for accidents (#55). The findings are: On 7/11/17 at 9:59am, resident #55 was observed being transported to the shower room in a shower chair by a certified nursing assistant (CNA) employee E. The shower room remained under constant visualization by the surveyor. Employee E was observed to leave the shower room at 10:11 am. She returned to the shower room at 10:13am. The surveyor entered the shower room with the CNA when she returned at 10:13 am. Resident #55 was observed to be sitting in the shower chair partially clothed. Her pants were sitting on her thighs and needed to be pulled up. It was noted that no other staff member was present in the shower room. An interview was conducted with Employee E on 7/11/17 at 10:30 am. She confirmed she had left Resident # 55 alone in the shower room. She said that someone had taken the lift needed to transfer resident #55 from the shower chair to the wheelchair. She then stated, Yes I left her in the shower chair alone while I went to search for the lift. No one has ever told me I could not leave anyone in the shower chair alone. A review of the clinical record for resident #55 revealed she was cognitively impaired. The care plan for resident #55 indicated she needed total care for bathing and hygiene. She was also a fall risk because she needed total care for transfers and did not have use of her legs according the fall risk care plan. The last fall recorded in the nurses notes for #55 was 11/16/16, when she was found on the floor in her room and she told staff she had slipped out of her wheelchair. A review of the manufacturer instructions for the shower chair stated to never leave an at risk user unattended in the shower. An interview was conducted with the Director of Nursing (DON) on 7/12/17 at 11:20 am. She said residents who are cognitively impaired, or who are unable to walk should not be left unattended in the shower room.

Based on observation, record review and staff interview the facility failed to prevent the potential spread of infection by not following facility policy related to staff not changing gloves between resident rooms after touching soiled linen, and not cleaning resident equipment or changing oxygen equipment on 2 of 3 hallways. The findings are: 1. Observation on 5/28/14 at 3:30 pm noticed laundry staff C with 2 barrels going from one resident's room to another. She went into the bathroom with gloves on and pulled soiled linen from clothes hampers to put into large barrels in the hallway. Upon leaving the room she did not remove her gloves. She then moved to the next room and entered, knocking on the door and opening the door with the soiled gloves on. Interview with laundry aide C at 3:47 pm on 5/28/14 indicated she is picking up soiled personal clothing from all the rooms. She takes it to the laundry for washing. Interview with Director of Environmental Services on 5/29/14 at 12:30 pm indicated his staff is to wear gloves while picking up soiled personal clothing from resident's rooms. They are to move the clothes from the basket to the barrel to take to laundry. He indicated he doesn't have a policy for laundry staff to change gloves between rooms. Review of policy Infection Control B-B PATH-12 related to gloves indicated gloves must be worn during tasks involved with touching body fluids. When gloves are utilized they shall be used only once and discarded. Disposable gloves shall be replaced as soon as possible when contaminated. Interview with the Director of Nursing who is also in charge of Infection Control Program on 5/29/14 at 2:15 pm indicated standard of practice would be for staff to change gloves and wash hands before leaving residents room which is facility policy. 2. Observation in room [ROOM NUMBER] on 5/27/14 at 1:30 pm noticed a suction machine covered in dust. A service sticker was dated 4/2004. Observation in room [ROOM NUMBER] 5/29/14 at 12:00 noon noticed a nebulizer machine soiled. The service sticker was dated 1998 or 2008. The mask was in a plastic bag dated 2/16/14. Observation in room [ROOM NUMBER] on 5/29/14 at 12:05 pm found a nebulizer machine without a sticker noting a service date. The mask was in a plastic bag dated 4/21/14. Observation in room [ROOM NUMBER] found nebulizer machine without sticker with service date. The mask was in a plastic bag without a date. Interview with aide E on 5/28/ 14 at 10:40 am indicated the suction machine is used for the resident in case she chokes. She hasn't needed it in the last few months. She confirmed the machine was dusty and had service date as of 4/2002. Interview with nurse F at 10:05 am on 5/29/14 indicated night shift are to clean equipment every night. She confirmed the machine was soiled. Review of policy for use and care of equipment Infection Control POL-11 refers to the masks, tubing etc... should be wiped clean and stored in plastic bag. These are changed monthly. The policy does not mention who and how often the machines are cleaned. Interview with the administrator on 5/29/14 at 1:40 pm indicated the facility has a policy for changing the tubing monthly. Interview with Director of Nursing/Infection Control Director at 2:15 pm on 5/29/14 indicated we should follow our policy that says equipment is cleaned by night shift monthly and equipment is to be changed out monthly.

Based on staff interview with Director of Nursing (DON) and Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator and clinical record review the facility failed to provide a care plan to address restoring normal bladder function for 1 of 3 residents reviewed for urinary incontinence ( # 89) The findings are: Resident #89 was identified in Stage II for triggering incontinence on 90 day assessment. The Admission MDS (Minimum Data Set) Assessment: 01 - Admission assessment 5-day scheduled assessment on 02/07/2014 indicated the resident was always continent. The next assessment dated [DATE] indicated the resident was occasionally incontinent. A review of Resident #89's closed clinical record revealed the following:[AGE] year old male admitted [DATE] and discharged on [DATE]. The history and physical shows history of [MEDICAL CONDITION] and treated with anticoagulation. On 2/3/14 note by physician shows the resident was visiting family and had bedtime headache. He woke up unable to move and had left sided weakness. A CT (Computerized Tomography) of the head showed a massive right frontal bleed with herniation requiring right frontal craniotomy with partial lobectomy on 1/8/14. The care plan for the resident's bladder function was initiated on 2/3/14 after the indwelling catheter was discontinued. The intervention #4 bladder training - clamp Foley X 2, unclamp for 15 minutes. Attempt to discontinue Foley Thursday am 2/6/14. Goal # 2 2/6/14 I am frequently incontinent of bladder and need to be toileted every two hours: interventions #1 need to be toileted every 2 hours and when needed, #2 I wear protective undergarments. The admission status information completed on admission indicates Resident #89 was admitted with a #16 Foley catheter (Indwelling urinary catheter). The indwelling catheter was discontinued on 2/6/14. A review of record failed to reveal any documentation of assessment regarding bladder function after the Foley catheter was discontinued. A policy for bowel and bladder training was requested and reviewed. An interview was conducted with the DON on 5/29/14 about 2:05 pm. She was asked how bladder function would be restored after removal of a Foley catheter. She stated, " It is up to the doctor who will sometimes order the catheter clamped off and on for 48 hours before the catheter is discontinued. When asked about evaluation for restoring bladder function she stated, " At this point we do not have a formal bladder retraining program. The items are in place but are not being utilized at this time. " An interview was also conducted on 5/29/14 about 2:10 pm with the LPN MDS/ Care Coordinator regarding restoring bladder function. She stated, " We will ask doctor before the catheter is discontinued what they want to do. Some want the catheter to be clamped routinely and unclamped and other doctors just want it to be removed as soon as possible. Once it is removed we check to make sure they are voiding by having the Certified Nursing Assistant (CNA) report to the nurse if the resident has not urinated. They will report to nurse for evaluation of bladder-- to empty bladder. They have not put people on bladder retraining program for a while not sure of how long. We have not have had a Bowel and Bladder program. When I complete the MDS assessment I I run the Bowel and Bladder records and talk to the residents No it is not documented or put on a program to see what times of the day the resident is actually voiding. Yes, I feel this type of program should be done and in place. Resident #89 was using adult briefs and toileted every two hours prior to discharge. He was discharged wearing adult briefs for incontinence. " On 5/29/14 about 3:00 pm the LPN MDS/Care Coordinator was requested to review closed record for documentation of any evaluation of Resident #89 ' s bladder function after the indwelling catheter was discontinued, she confirmed no evaluation could be found.

Based on staff interview with Director of Nursing (DON) and Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Care Coordinator and clinical record review the facility failed to provide services to restore normal bladder function for 1 of 3 residents reviewed for urinary incontinence (# 89) The findings are: 1. Resident #89 was identified in Stage II for triggering incontinence on 90 day assessment. The Admission MDS (Minimum Data Set) Assessment: 01 - Admission assessment 5-day scheduled assessment on 02/07/2014 indicated the resident was always continent. The next assessment dated [DATE] indicated the resident was occasionally incontinent. A review of Resident #89's closed clinical record revealed the following: [AGE] year old male admitted [DATE] and discharged on [DATE]. The history and physical shows history of [MEDICAL CONDITION] and treated with anticoagulation. On 2/3/14 note by physician shows the resident was visiting family and had bedtime headache. He woke up unable to move and had left sided weakness. A CT (Computerized Tomography) of the head showed a massive right frontal bleed with herniation requiring right frontal craniotomy with partial lobectomy on 1/8/14. The admission status information completed on admission indicates Resident #89 was admitted with a #16 Foley catheter (Indwelling urinary catheter). The indwelling catheter was discontinued on 2/6/14. A review of record failed to reveal any documentation of assessment regarding bladder function after the Foley catheter was discontinued. A policy for bowel and bladder training was requested and reviewed. An interview was conducted with the DON on 5/29/14 about 2:05 pm. She was asked how bladder function would be restored after removal of a Foley catheter. She stated, "It is up to the doctor who will sometimes order the catheter clamped off and on for 48 hours before the catheter is discontinued. When asked about evaluation for restoring bladder function she stated, " At this point we do not have a formal bladder retraining program. The items are in place but are not being utilized at this time." An interview was also conducted on 5/29/14 about 2:10 pm with the LPN MDS/ Care Coordinator regarding restoring bladder function. She stated, " We will ask the doctor before the catheter is discontinued what they want to do. Some want the catheter to be clamped routinely and unclamped and other doctors just want it to be removed as soon as possible. Once it is removed we check to make sure they are voiding by having the Certified Nursing Assistant (CNA) report to the nurse if the resident has not urinated. They will report to nurse for evaluation of bladder-- to empty bladder. They have not put people on bladder retraining program for a while not sure of how long. We have not have had a Bowel and Bladder program. When I complete the MDS assessment, I run the Bowel and Bladder records and talk to the residents. No, it is not documented or put on a program to see what times of the day the resident is actually voiding. Yes, I feel this type of program should be done and in place. Resident #89 was using adult briefs and toileted every two hours prior to discharge. He was discharged wearing adult briefs for incontinence. " On 5/29/14 about 3:00 pm the LPN MDS/Care Coordinator was requested to review closed record for documentation of any evaluation of Resident #89's bladder function after the indwelling catheter was discontinued, she confirmed no evaluation could be found.

Based on observation of medication administration, interview with the unit nurse administering medications, and record review of the Medication Administration Record [REDACTED]. The findings are: A medication pass observation was conducted during the hours of 9:00 a.m. and 10:15 a.m. on 5/29/14. During the course of the medication pass observation staff "F" was observed to administer medications to resident #25. Staff "F" was observed to administer the following medications to resident #25: 1. Staff "F" was observed to check the Medication Administration Record [REDACTED]. The bag was labeled with the patient identifying information, followed by "[MEDICATION NAME] 1.000 MCG/ML (microgram per milliliter) with the instructions to INJECT 0.5 ML (500 MCG) INTRAMUSCULARLY EVERY MONTH". The syringe was observed to contain 1 milliliter of the medication. The nurse was observed to inject the full contents of the syringe into the resident's left hip. 2. Staff "F" was observed, after checking the MAR, to select a stock bottle of ASA (aspirin) from the medication cart. The bottle was observed to be labeled with manufacturer's label stating "Aspirin, [MEDICATION NAME] coated, 81 mgs (milligrams). The nurse was then observed to give the medication to resident #25, with a cup of water, and the resident was observed to take and swallow the medication, along with other oral medications. A record review was conducted of resident #25's physician orders [REDACTED]. The physician order [REDACTED]. INJECT 0.5 ML INTRAMUSCULARLY EVERY MONTH". The order was dated 5/16/14. The physician order [REDACTED]. GIVE 1 TABLET BY MOUTH EVERY MORNING [MEDICAL CONDITION](CARDIOVASCULAR ACCIDENT) PREVENTION". The MAR for the month of May 2014 was noted to have the following instructions: "VIT B12 500 MG IM Q MONTH" (Vitamin B-12 is an alternate name for the medication [MEDICATION NAME], IM is abbreviation for INTRAMUSCULARLY, Q-MONTH is an abbreviation for EVERY MONTH). The MAR indicated [REDACTED]. The medical record (physician orders [REDACTED]. On 5/29/13 at approximately 10:20 a.m. an interview was conducted with staff "F". The nurse was asked the following questions: 1. What dose of vitamin B-12 was given to resident #25 during the medication pass observation? The nurse replied "500 mg per the MAR indicated [REDACTED] 2. How was the dose packaged (units per milliliter in the syringe)? The nurse examined the packaging and agreed the label stated to "inject 0.5 ml (500 mcg dose)". 3. When she administered the injection, were the full contents of the syringe infused? The nurse stated she injected the entire contents of the syringe (1 ml which equaled a 1,000 mcg dose) 4. Was any portion of the contents of the syringe removed from the syringe prior to the injection? The nurse answered "No". 5. What does the Medication Administration Record [REDACTED]? The nurse stated 500 mcg. 6. What is the dose of the order change for vitamin B-12 dated 5/16/14? The nurse read the order from the chart which clearly stated the dose to be decreased to 500 mcg intramuscularly every month. The nurse acknowledged the order change. 7. Do you consider this to be a medication error? The nurse agreed this was a medication administration error. 8. What is your next action concerning this medication error going to be? The nurse stated she will report it to the supervisor and a medication error report will be done. The nurse then stated she would inform the physician. The physician was in the room at the time of this discussion. The nurse was observed to immediately inform the physician of the medication error. The physician acknowledged the medication error. 9. The nurse was asked what the purpose of [MEDICATION NAME] coated medication was, and she responded it was to "protect the stomach". The nurse admitted at that time that the contents of the bottle and the order on the MAR indicated [REDACTED]. The nurse did remove a bottle of 81 mg aspirin from the medication cart and pointed out the label indicating the aspirin in this bottle was the "chewable form" of the medication. The nurse admitted she administered the wrong form of the medication.

Based on observations in the memory care unit for three meals observed, 5 of 11 residents observed (#51,68, 69, 78, 87) were not provided meal service in a dignified/ respectful manner during the dining experience. The findings are: Observations during the evening meal on 8/19/13 from 4:30PM to 6:10 PM on the memory care unit revealed Resident #68 sitting alone in her wheel chair with a lap buddy hanging loosely from the hand rails of the chair. The Resident was seated way from the table at the periphery of the dining area, facing the dining tables. Other residents were observed eating or being fed soup, salad, and beverages. Resident #68 had no food and was not offered any. The dining room was noted to have four tables, each capable of seating four residents. The back section of the room is furnished with a sofa, several chairs, and a television (which was not on at any time during the meal). Eleven residents were present in the dining room or adjacent sitting area. Two of the residents (#68, 69) were seated in the adjacent sitting area, the other residents were seated at the tables. Not all residents at each table were served at the same time; Resident #51 was seated at a table doing nothing while staff fed another resident at same table and third resident at the table fed herself; staff finished feeding a resident at another table, then began to feed resident #51. Four staff were present with eleven residents; two residents (#69, #68) were not seated at a table while other residents were being fed green bean salads and soup. They were observed sitting at the edge of the dining room occasionally watching others being fed, other times not seeming to notice the others. Resident#69 was moved up to the table and fed salad and soup, then removed from table again to sit alone at edge of dining room while Resident #68 moved up to the table to be fed (at 4:56 PM). At 4:35 PM staff stood beside resident #78, verbally cued the resident to eat, when resident #78 did not respond, staff began spoon feeding the resident while standing beside her. The staff stood at her side for several minutes feeding her, did not sit beside the resident and did not speak to her. Resident #51 was served/fed her hot meal approximately 25 minutes after her tablemates began eating. Resident #68 was handed a cup of what appeared to be a milkshake when she was seated at the table, she drank that unassisted and then sat at the table for another 30 minutes watching one tablemate being fed while she sat and held her empty cup. Resident #78, seated at the same table also sat watching while third resident at the table was fed, she had no food in front of her during this time. While these residents sat watching others eat, the unit nurse #F completed her med pass at approximately 5:20 PM and then sat just outside the dining room watching the residents eat, nurse #F did not offer or attempt to feed either resident #78 or resident #68 during this time and they continued to sit with no food watching the other resident at their table being fed. Resident #69 sat in her geri chair during this time with eyes closed at the edge of the dining room. At 5:30 PM staff prepared a plate for resident #78 and sat down to feed her, Resident #68 still had no food and sat watching resident #78 being fed. AT 5:42 PM Resident #68 was served her hot food and began feeding herself, she fed herself several spoonfuls of food, then staff came back, removed the spoon from her and began feeding her; resident #68 resisted being fed, staff stopped feeding her and the resident picked up the spoon and began feeding herself again unassisted. Staff sat down again, took the spoon and began feeding the resident again, this time the resident allowed it. The staff member feeding resident #69 and staff member feeding resident #68 sat carrying on a conversation together, barely spoke to either resident, occasionally asking if they were ready for another bite. At 5:55 PM Resident #69 was moved back up to a table, staff brought a container of Boost and held it for her to drink. The resident finished the Boost, then was moved back in front of the TV, she was never offered any hot food. Observations on 8/20/13 at 8:45 AM revealed Resident #78 sitting in a gerichair at the table for the breakfast meal with no food in front of her while another resident at the table was being fed. At 9:03AM, CNA # E was observed feeding resident #78 grits, scrambled eggs and ground meat spooning a over flowing amount of food into the residents mouth spilling the majority of the food on the residents face, CNA # E scraped the food off Resident #78's face with the spoon, tapped it back into the plate and refed it to resident #78. CNA # E did not interact with resident#78 or ask her if she would like a bite of food or a drink of orange juice but continued to push the spoonfuls of food into her mouth. Observations on 8/21/13 at 11:20 AM in the memory care unit dining room revealed staff already serving residents drinks and fruit cups. At 11:25AM the hot food arrived and was placed on the steam table. Four staff were present with eleven residents present. All but two residents were seated at tables. Resident #87 was seated in a wheelchair at the edge of the dining room rocking in her wheelchair with her back to the tables, not eating, no food set at any table for her. Resident #69 was seated in the TV area in her geri chair with a large laptray in place, eyes closed, appeared to be asleep. Resident #68 was feeding herself pureed fruit, then dozing off before hot food was served. Staff began cueing/prompting resident #68 to eat, then attempting to feed her. When she did not wake up and eat, they left her sitting at the table asleep while her food grew cold. Observations on 8/21/13 at 11:51AM revealed Resident # 34 propel himself in his wheel chair away from the table, telling the CNA #E that he had to go to the bathroom. CNA #E stopped him saying he would need to wait a minute because she had to feed resident #78, that the resident had not finished eating. The CNA offered resident #34 cookies and Ice Cream to encourage him to stay in the dining room until she had time to take him to the bathroom.

Based on resident and staff interviews the facility failed to ensure sufficient nursing staff were available on a daily basis to meet residents' needs for nursing care in a manner and in an environment which promotes each residents' physical, mental and psychosocial well-being for 5 of 11 resident in the memory care unit and 5 of 10 resident interviewed regarding staffing (#6, 24, 51, 65, 68, 69, 73, 76, 78, 87) Relevant Findings: On 8/20/13 at approximately 9:10a.m. an interview was conducted with resident #6. Resident #6 was asked if staff were available to provide care without the residents having to wait a long period of time, and stated, "Not all the time. Some times you have to wait a long time. I don't know how long but it's not during a particular shift ." On 8/20/13 at approximately 9:22 a.m. an interview was conducted with resident #76. Resident # 76 was asked if staff were available to provide care without the residents having to wait a long period of time, and stated, "I am paralyzed from the waist down and I have to wait a long time between lunch and dinner service because staff are busy helping others." On 8/20/13 at approximately 11:59a.m. an interview was conducted with resident #73. Resident #73 was asked if staff were available to provide care without the residents having to wait a long period of time, and stated, "The staff is always saying that they need more help between cleaning resident and waiting on the rest of us. Some days we have to wait long periods of time because they just don't have enough staff." On 8/20/13 at approximately 1:46p.m. an interview was conducted with Resident # 65. Resident #65 was asked if staff were available to provide care without the residents having to wait a long period of time, and stated, "I think they are very understaffed, I see these poor girls knocking themselves out trying to care for everybody. Not any particular shift or day. They get busy with someone else and you just have to wait your turn. Staff responds to call lights, and respond to emergencies right away, but some things just have to wait." On 8/21/13 at approximatelyy 9:48am an interview was conducted with staff # G Certified Nursing Assistant (CNA) , who stated, "I usually work in the memory care unit and sometimes I feel I need more help and I think that patient care suffers due to the lack of staff. There are two CNAs and an Activity CNA staff during 7a-3p shift. The nurses do assist and will help if we need them but I think assistance is needed throuhghout the shift. I have worked here for 5 years and on this unit for a year. It has always been like this for the year I have been here." On 8/21/13 at approximately 11:21a.m. an interview was conducted with staff #B Licensed Practical Nurse (LPN) who stated, "Staffing varies inside the memory units because sometimes the residents are hyper and we have a lot of residents on that unit that require assistance with eating. I do not think resident care suffers but sometimes in the morning the staff have difficulty with meal times because they haven't had any additional staff to help in the last couple of days. I think the issue is mostly with breakfast service/assistance because the activity CNA comes in around 9:30a.m. so there is someone there to aid the staff with lunch. I will also assist if I am available." On 8/21/13 at approximately 3:03p an interview was conducted with resident #24, who stated, "I have a problem with having to wait a long time to get assistance. Sometimes if I turn my call light on and they never come. I have a constipation problem and when I have to go I have to go but that is the only problem. I do understand that sometimes they can't get to us right away. I think they are just under staffed. The staff that are here do a good job, it's just not enough staff. I think the person that makes the schedule just doesn't do it right. At times I have had to use the bathroom in my diaper and I don't like it, I am embarrassed because I am a big girl." Resident # 24's medical record was reviewed and she does require assistance with toileting. On 8/21/13 at approximatley 3:39p.m. an interview was conducted with staff #D CNA, who stated, "staffing is an issue sometimes, not all the time. I do think that resident care suffers when there is not enough staff. The problems arise usually during diner service in the main dining room and transporting residents to the dining room. The nursing staff that are here to help will assist. This is a recent issue and I think it is occuring because two people on the 3p-11p shift left and went to weekends " . On 8/22/13 at approximately 2:57p.m. an interview was conducted with staff #E CNA, who stated, "we do not have enough staff to feed all the residents requiring full assistance with meals. There are 5 residents on this unit that really need extensive assistance with eating and only 3 of us (staff). We sit the residents that need assistance at one table and other two are seated in the tv area. Once we finishing feeding one resident we move that resident from the table and bring one of the residents watching tv to the same table to assist them. We do the best we can back here." On 8/22/13 at approximately 2:59 p.m. an interview was conducted with staff # G CNA, who stated, "we do not have enough staff to assist all the residents reuiring assistance at one time. During the week there is three staff on the unit and on the weekend there is only two staff so it is even worse. There are five residents on the unit that require assistance so we assist them according to the number of staff able to help. We have transfer the residents from the table after assisting them so that we can bring another resident needing assistance to the table. We feel like we are pretty much on our own back here and they never send anybody to help us."

Based on observation, interview and record review, the facility failed to provide an accurate, complete MDS assessment on the quarterly reviews conducted on 1/13/13, 4/7/13 and 6/23/13, on 1 of 20 residents sampled, for whom assessments were reviewed(#38). Findings include: Observations of resident #38 conducted on 8/19/13, 8/20/13 and 8/21/13, indicated that she had an approximately 1 cm (centimeter) bloody lesion on her nose, and a 0.5 cm bloody lesion on her forehead and chin. Interview was conducted with Staff C on 8/21/13 at 11:00 am. She is one of resident #38's primary caregivers. She stated that the resident has been in the facility for 3 years. She was asked how long the resident has had the [MEDICAL CONDITION] on her face. She stated "for 7-8 months". Interview was conducted with Staff A on 8/21/13 at approximately 11:20 am. She was asked about the opened, bloody areas on the face and nose of resident #38, particularly how long the resident has had the condition. She stated, "yeah, (the resident #38) has had those [MEDICAL CONDITION] since late December, I believe. Yeah, that's right, for about 8 months". Interview was conducted on 8/21/13 at approximately 2:30 pm with the MDS Coordinator. She was asked if she is aware of Resident #38's skin conditions, related to what the Advanced Registered Nurse Practitioner (ARNP) referred to in her notes as picking of skin when she is experiencing high levles of anxiety. She stated "yes, I am." She was asked if she knew why the MDS assessments for skin conditions other than ulcers was assessed at M1040-Z indicating no skin conditions on the quarterly assessments in January, April and June of 2013. She looked at the assessment and stated, "no, I sure don't. We missed it. We just missed it. I was out at the time and my trainee was doing them, but we both missed it". Review of Record: Physician Assessment and Progress notes, beginning on 12/7/12, completed by the ARNP, indicated that Resident #38 has a high level of anxiety, and picking at her skin, causing bleeding, and ordered treatment for [REDACTED].#38 was assessed on 12/7/12, 2/11/13, 3/18/13, 5/10/13 and 7/8/13 by the ARNP, for the skin wounds related to the picking of the skin. The Physician Orders, which were reviewed from January 1, 2013 through current date (8/22/13), indicated that treatments were ordered for the condition, and updated frequently and review of the Treatment Log indicated that the treatments are being provided by the staff. Review of the MDS Quarterly Assessments for Resident #38 for 1/13/13, 4/7/13 and 6/23/13 indicated that M0140 for other ulcers, wounds and skin conditions, was marked "Z" nor None of the Above, indicating that the resident did not have any skin conditions. These assessments inaccurately reflected the condition of the resident at those times.

Based on staff interview and clinical record review the facility failed to document the necessity for an indwelling catheter (Foley) for 1 of 2 residents (#78). The findings are: During Stage I investigation it was determined that Resident #78 had a Foley catheter with unknown reason. Stage II review of MDS determined that the resident had Minimum Data Set (MDS) quarterly assessment on 2/24/13 and she did not have an indwelling catheter. She was sent out to the hospital for altered mental status on 3/23/13 and returned on 3/27/13. A significant change was completed on 3/31/13 and did not indicate the resident had a Foley catheter. On 6/30/13 the MDS indicates HO 100 that the resident has an indwelling catheter. A review of the Resident 78's clinical record revealed the resident came back to the facility from the hospital on [DATE]. The admission note does not mention an indwelling catheter but the Resident Status Information sheet dated 3/27/13 indicates there is a Foley under [MEDICAL CONDITION]. There are nursing notes dated 3/28/13 430 am Foley patent and draining without difficulty and another note 3/28/13 indicating the resident has a Foley is no documentation in written notes that the Foley was discontinued. There is a telephone order on 3/29/13 to insert a #16 Foley for [MEDICAL CONDITION] . The standing orders for Resident 78's primary physician provided by the RN Supervisor Employee A indicates that for a resident not voiding in an 8 hour period an in and out catheterization should be done with a #16 French indwelling catheter with a 5 cc balloon. If there is a residual of greater than 400 ml leave in the indwelling catheter and notify the physician. The nursing note dated 3/29/13 3:00 pm indicates a Foley catheter was inserted. There is no documentation to determine if [MEDICAL CONDITION] has occurred by documentation of post void residuals, how long it had been since the previous Foley was discontinued, or how long it had been since Resident #78 voided. An interview was conducted with RN Supervisor (Employee A) on 8/21/13 about 10:52 am. She was asked for the policy for [MEDICAL CONDITION]. This surveyor was given a standing order form from Employee A for urinary not voiding by Resident #78's physician. The form indicates -- if your resident has not voided in an 8 hour period you may write the following order. In and out catheterization using a #16 french indwelling catheter with 5 ml balloon if there is no voiding in 8 hours. May leave in place if residual greater than 400 ml and notify MD. Write catheter orders. If less than 400 ml remove catheter document results and notify doctor or nurse practitioner. Employee A stated, "No we did not follow the standing orders for Resident #78 and confirmed that the Foley catheterization on 3/29/13 did not have an amount of urine when it took place. " The LPN (Licensed Practical Nurse) staff nurse Employee B was interviewed on 8/22/13 about 11:15 am. She confirmed the resident had a Foley on return from the hospital. There was an order to discontinue when she returned from the hospital. The 11-7 shift usually discontinues the Foley when ordered and documents in the chart. She stated,"The resident was unable to void on 3/29/13. She had plenty of fluids." She confirmed she re-inserted the foley on 3/29/13 with an instant return of amber urine. She was asked if she documented the post void residual for Resident #78 according to standing orders. She confirmed she had not and stated, "I should check the standing order to see what needs to be done". She agreed she did not perform residual when she catheterized Resident #78 to determine if [MEDICAL CONDITION] occurred.

Based on observation,record review and staff interview, the facility staff did not offer substitutes for meals not eaten during the supper meal for two of 28 (#40 and #33) residents in the stage two sample. Findings include: During the supper meal on 8/19/13 resident # 40 was observed during the supper meal in the main dining room. She did not eat her soup, nor did she eat her meal which consisted of mashed potatoes and meat in sauce. The resident was observed pulling herself away from the table throughout the meal, not eating. No staff offered the resident any cueing to eat for at least half hour (450PM-520PM). At 525 PM, the resident was wheeled out of the dining room by staff, without staff offering the resident an alternate meal, in place of the meal she did not eat. Staff "D" then stated during an interview at 5:25 PM that evening that resident #40 does not eat much at meals & she will get a boost (a nutrition drink) instead. Based upon review of the 6/7/13 Minimum Data Set (MDS) the resident requires supervision, oversight, and cueing during meals. During this same evening meal observation on 8/19/13, resident #33 was observed from approximately 5:10 PM - 5:25 PM to repeatedly state loudly she does not like her food. No staff responded to this resident's comments. She had mashed potatoes and pureed meat on her plate. The resident was assisted out of the dining room by staff at approximately 5:25 PM with no staff offering the resident any alternative to her meal. The July MDS for this resident indicates she needs limited assistance with dining. The facility culinary manager was interviewed on 8/19 at approximately 1145 AM. She stated that if a resident who is eating a pureed diet does not like the meal, the staff should call to culinary to request the alternate be pureed for the resident.

Based on observation and staff interview the facility failed to post nurse staffing data in a prominent place readily accessible to residents and visitors. Relevant Findings: A tour of the facility on 8/19/13, starting at approximately 2 PM revealed that the only place the staffing is posted is on a wall, around the corner from the entrance of the facility. This is not a placement which is prominent to the public and is inaccessible to persons in the facility's locked unit. On 8/19/13 approximately 2:50 p.m. surveyor was informed by Unit Assistant that the staffing listing was posted on the side wall close to entrance door by the Director of Nursing's (DON) office. On 8/19/13 approximately 2:51 p.m. and interview was conducted with Staff #A who stated they don't post staffing list at desk, it is kept by on the wall by the door. On 8/21/13 approximately 2:39 p.m. an interview as conducted with staff #E, who stated, "the staff listing is up front right beside the DON's office, we do not have a listing here on the unit". On 8/22/13 approximately 9:14 a.m. an interview was conducted with DON who stated, "The posting is outside my door. If someone wanted to know who was working with a particular resident they would go the desk and ask. The area on the wall outside of my office is the only place where staff listing is kept. We use to have something posted by the nursing station and we got cited for it so we moved it where it is now so it can be more visible. What we had by the nursing station was pretty much similar to what we have now. We have remodeled and taken the nursing station out of the center of things. We would post the staffing in the center by the nursing station and we were cite and told that it had to be moved".

Based on observation and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident by maintaining expired biological's in 2 of 4 medication carts and in 1 of 1 medication storage rooms checked. Findings: 1) Observation of the medication cart on the North Hall revealed that in the overflow drawer, the Meclizine was found to have expired in June, 2012. 2) Observation of the medication cart on the East Hall, in the locked, controlled substance drawer, it was noted that the Zolpidem Tartrate 5 mg tablets had expired on [DATE] 3) Observation of the medication storage room was conducted and it was found, in the locked, controlled substance cabinet, Zolpidem Tartrate 5 mg tablets had expired on [DATE]. 4) On [DATE] at approximately 9:45 am, an interview was conducted with Employee B. She was asked who checks the medications for expiration dates. She stated "we do that". 5) On [DATE] at approximately 9:00 am, an interview was conducted with Employee C. She was asked who is responsible for checking medications for expiration dates in the medication carts and also in the medication storage room. She stated, "well, we check them ourselves. There are so many, I guess it's almost impossible not to miss something".

Based on observation of the resident, interviews with staff and residents, and record review of the plan of care, the facility failed to provide services to accommodate the needs of the resident, in accordance with the plan of care for 1 of 20 resident's in the sample (resident #36). The findings include: During the initial resident observation on 7/10/2012 at approximately 10:30 am the call light was observed hooked on a wall outlet out of the reach of the resident. Observations on 7/11/2012 at approximately 2:19 pm, and 3:30 pm revealed the resident was resting in her bed with her eyes closed. The call light was hanging on the wall, not in reach of the resident. On 7/11/2012 at approximately 3:35 pm, a staff interview was conducted with Certified Nursing Assistant (CNA) "A". The CNA confirmed that the call light was hooked on the wall and she stated the call light should be within the reach of the resident, and then she placed it on the resident's bed. An interview on 7/12/2012 at approximately 9:02 am with the resident revealed the resident stated she is able to use the call light and knows she is supposed to use it to call for help. A record review on 7/11/12 of the plan of care revealed the resident to be a high risk for falls due to her unsteady gait, [MEDICAL CONDITION](stroke) diagnosis, and takes blood pressure medications with an onset date 4/7/09, and the last update 5/8/12. The interventions included to keep the call light within reach of the resident.

Based on observation of the resident, interviews with staff and residents, and record review of the plan of care, the facility failed to provide services in accordance with the plan of care for 1 of 20 resident's in the sample (resident #36). The findings include: During the initial resident observation on 7/10/2012 at approximately 10:30 am the call light was observed hooked on a wall outlet out of the reach of the resident. Observations on 7/11/2012 at approximately 2:19 pm, and 3:30 pm revealed the resident was resting in her bed with her eyes closed. The call light was hanging on the wall, not in reach of the resident. On 7/11/2012 at approximately 3:35 pm, a staff interview was conducted with Certified Nursing Assistant (CNA) "A". The CNA confirmed that the call light was hooked on the wall and she stated the call light should be within the reach of the resident, and then she placed it on the resident's bed. An interview on 7/12/2012 at approximately 9:02 am with the resident revealed the resident stated she is able to use the call light and knows she is supposed to use it to call for help. A record review on 7/11/12 of the plan of care revealed the resident to be a high risk for falls due to her unsteady gait, [MEDICAL CONDITION](stroke) diagnosis, and takes blood pressure medications with an onset date 4/7/09, and the last update 5/8/12. The interventions included to keep the call light within reach of the resident.

Based on record review and staff interview the facility failed to ensure resident's medication regime was free from unnecessary medications by not adequately monitoring the use of medications for 2 of 10 sampled residents. (#14, 22). The findings are: 1. Review of physician orders [REDACTED].#14 indicated the resident to receive Losartan Potassium 25 milligrams for a [DIAGNOSES REDACTED]. Review of the medication record (MAR) for the month of June 2012 indicated on the following dates the medication was given when the resident's systolic blood pressure was less than 120: 6/1/12-116/70, 6/3/12-118/60, 6/9/12-118/64, 6/11/12-118/64, 6/16/12-118/60, 6/22/12-118/62. Interview with the assistant director of nursing (ADON) on 7/12/12 at 10:21 am stated our policy is when the order says to hold medication if less than 120 systolic blood pressure the nurse will take the blood pressure note in on the medication record, sign her initials and then circle her initials indicating the medication was held. She will then document this on the back of the MAR. She reviewed the MAR and stated the nurses should have held the medication and noted this on the MAR. 2. On 7/12/12 at 8:58 am during medication administration a Licensed Practical Nurse (LPN) was seen giving [MEDICATION NAME] 10 milligrams to resident #22 which is given for Hypertension. She gave the medication without checking the resident's blood pressure. The order was written to hold the medication as needed if systolic blood pressure is less than 110. Review of the medication record for June 2012 and July 2012 indicated the medication was given without taken the resident's blood pressure. Interview with the LPN on 7/12/12 at 10:30 am stated the resident's blood pressure is taking on Wednesdays and it was 124/64 yesterday. Interview with assistant director of nursing (ADON) on 7/12/12 at 10:45 am stated she didn't have any pharmacy recommendations regarding nurses not taking blood pressures prior to giving medication as ordered per physician.