Pavilion Health Center At Brightmore

Penalty

Inspection fine: $16,985

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A severely cognitively impaired resident with a primary diagnosis of toxic encephalopathy, along with other significant medical conditions such as cardiac arrest, atherosclerotic heart disease, and chronic kidney disease, exited the facility without staff knowledge for over two hours. The resident, who required partial to moderate assistance with most activities of daily living and was known to be confused and unsteady on his feet, was last seen in his room by a nurse aide at approximately 9:30 AM. Video footage later revealed that the resident walked unassisted through the lobby and out the front door while the receptionist was present but engaged in conversation with a visitor. The receptionist did not recognize the resident as a resident and did not intervene as he exited the building. After leaving the facility, the resident walked along a heavily trafficked road, fell, and was assisted by strangers who transported him to a fire station 20 miles away. The facility staff became aware of the resident's absence only after a family member arrived for a visit and could not locate him. A search was initiated, and law enforcement was notified. The resident was eventually found and transported to the hospital, where he was noted to have abrasions and swelling consistent with a fall. Interviews with staff and family confirmed that the resident was consistently confused, required supervision for ambulation, and was not safe to walk unassisted. The facility's risk assessment and care plan for the resident did not identify wandering or elopement risk, as there was no prior history of such behaviors. However, the resident's cognitive impairment, confusion, and poor balance were documented. Staff interviews indicated that the resident typically remained in his room and had not previously attempted to leave the facility. The front entrance was unlocked due to the presence of a receptionist, but there was no effective process in place to ensure that residents could not exit unnoticed, especially when staff were unfamiliar with all residents or distracted.

Removal Plan

• A head count was completed by Nurse Supervisor #1 for 100% of residents. All residents in facility were accounted for with no issues identified.
• The Director of Nursing reviewed clinical alerts dashboard and nursing notes for all residents for the past 30 days to identify any exit seeking behaviors. No issues identified.
• The Director of Nursing audited 100% of residents wandering risk assessments. All residents with low wandering risk were reviewed for changes in condition/function that may put them at risk to exit the facility. No issues identified.
• Risk assessments are completed upon admission by the admitting nurse, quarterly and any time a change of condition is noted by staff nurse or nurse manager.
• All residents at high-risk for wandering charts were reviewed by the Director of Nursing to ensure that they had appropriate wander prevention strategies in place to include wander guard bracelet in place and functioning properly, daily battery checks and every shift placement checks were present on the MAR and that care plan was current and appropriate interventions were on the care plan.
• The Nurse Supervisor checked 100% of current residents with wander guards for placement and function by observing that wander guard was on resident's person and utilized the wander guard checker device to ensure proper function. No issues were noted.
• All exit doors were checked by the Director of Nursing and Nurse Supervisor #1 to ensure they were functioning properly.
• Staff interviews were initiated for all staff by the Director of Nursing to identify any exit seeking behaviors. Interviews identified no other new onset of exit seeking behaviors.
• The QA Nurse Consultant rechecked all entrance/exit doors to include door with wander guard system, squealer boxes and on/off switches for mag lock doors (doors with keypad entry/exit) and all were functioning properly. No issues were identified.
• A Quality Assurance Performance Improvement meeting held with the Interdisciplinary Team members to discuss incident findings and plan to correct.
• The Director of Nursing began education of all full time, part time, and as needed staff including agency on the following topics: Elopement Prevention and Missing Person Policy. Education included what to do if resident was exhibiting wandering/exit seeking behaviors especially for those residents who normally stayed in their rooms. Staff educated to stop and communicate with the resident and redirect, ensure safety of the resident and immediately notify the nurse.
• The Administrator will ensure that any of the above identified staff who did not complete the in-service training will not be allowed to work until the training is completed.
• This in-service was incorporated into the new employee facility orientation for the above identified staff and will be provided by the Staff Development Coordinator during orientation and prior to working in patient care areas.
• The Administrator educated all receptionists that all visitors will need to sign in and out and wear a badge to identify them as a visitor when entering the facility through main entrance designated for visitor entry.
• All other exit doors are locked with signage above directing visitors to go to the main entrance to enter and exit the facility.
• All receptionists and nurses were educated by the Administrator that receptionists are to lock the main entrance door upon leaving front desk for any reason and nurses are to let visitors into and out of facility in receptionist's absence from receptionist area.
• Receptionists were educated to have all persons exiting facility to be identified prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility to ensure they are not a resident displaying exit seeking behaviors.
• If the person is noted to be a resident, receptionist is to maintain resident safety and immediately notify nurse assigned to resident to come assist resident.
• The Administrator will ensure that any newly hired receptionist or nurse will receive this education prior to working and this in-service was incorporated into the new employee facility orientation for the above identified staff.
• Visitors will be required to sign in and out and wear visitor badge while in the facility.
• Receptionists were educated that they are to lock the main entrance door upon leaving front desk area for any reason and if no one is available to provide coverage until they return, they are to notify nursing staff via phone that they will be leaving front desk area prior to leaving.
• Upon hearing doorbell ringing, nurses are to go to front entrance area and let visitor into the facility, have visitor sign in and provide them with a visitor's badge.
• For visitors leaving facility, nurse is to identify person prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility.
• A receptionist is scheduled to work 7 days a week. In the event that there is no receptionist available, facility front entrance doors will be locked and nurses on duty will be responsible for allowing visitors entry or exit to facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident had an appropriate indication and diagnosis for the use of an antipsychotic medication, specifically Seroquel (Quetiapine Fumarate). The resident in question was admitted with multiple diagnoses, including cerebral infarction, hemiplegia, aphasia, benign neoplasm of cerebral meninges, adult failure to thrive, and vascular dementia with mood disturbance and anxiety. Physician orders for Seroquel were present, and the care plan referenced its use for dementia with behavioral disturbances. However, the quarterly MDS assessment did not indicate potential indicators of psychosis, and staff interviews revealed that the resident did not exhibit behavioral disturbances or symptoms such as yelling, hitting, or pulling at medical devices. Observations showed the resident was largely non-responsive, unable to move extremities, and required significant assistance with care. A pharmacy review noted that the resident lacked an allowable diagnosis to support the use of Seroquel, and the provider subsequently documented indications such as hiccups and nausea associated with cancer, though staff had not observed these symptoms. Orders for Seroquel were updated to reflect these indications, but staff interviews and observations did not confirm the presence of behavioral disturbances, hiccups, or nausea. The medication continued to be reordered upon each readmission without clear evidence of a supporting diagnosis or observed need, leading to the deficiency related to the use of unnecessary psychotropic medication as a potential chemical restraint.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for three residents. One resident was discharged to an assisted living facility, but the discharge MDS was incorrectly coded as a discharge to a hospital. The MDS Coordinator, who was new to the role, acknowledged the error and stated that the discharge status should have reflected the actual destination. Both the DON and Administrator confirmed that the MDS should be coded accurately, but were unaware of the reason for the incorrect coding. Another resident was admitted to hospice services prior to admission, but the admission MDS did not reflect hospice care due to an oversight by the MDS Coordinator. Additionally, a third resident with a history of CVA, hemiplegia, and oxygen dependence was not coded for oxygen use on the quarterly MDS assessment, and their functional status was inaccurately documented. Staff interviews confirmed the resident's dependence on oxygen and total care needs, but these were not accurately captured in the MDS. The Administrator and clinical staff indicated that information from therapy, nursing, and physician orders should be used for accurate MDS coding.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive, individualized care plans for two residents with specific clinical needs. For one resident with congestive heart failure, pneumonia, and a dependence on supplemental oxygen, the care plan did not include any interventions or care area addressing the resident's continuous oxygen therapy, despite physician orders and documentation showing ongoing use of oxygen since admission. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that the resident's need for continuous oxygen was not reflected in the care plan due to oversight. For another resident with chronic respiratory failure, hypoxia, diabetes, and epilepsy, the care plan inaccurately included the use of bilateral hand mitts in addition to an abdominal binder for protection of a feeding tube. However, medical records, staff interviews, and the resident's MAR confirmed that only the abdominal binder was used, and there were no physician orders for hand mitts. The inclusion of hand mitts in the care plan was identified as a mistake by the MDS Coordinator, and staff confirmed that the resident never used them. The DON and Administrator both expected the care plan to accurately reflect the resident's current interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for one resident. The resident was admitted with multiple diagnoses, including a left humerus fracture, history of falls, and urinary tract infection. The admission MDS assessment indicated significant care needs, such as upper extremity impairment, partial to moderate assistance with ADLs, frequent incontinence, risk for pressure ulcers, and a history of falls. The Care Area Assessment (CAA) identified several triggered care areas, including ADL function, urinary incontinence, falls, pressure ulcers, and nutrition, with care plan decisions completed for these areas. However, a review of the resident's medical record showed that the care plan only addressed discharge planning, mood disorder, and activities, and did not include focus areas or interventions for the triggered care areas identified in the CAA. Interviews with the MDS Coordinator and the Administrator confirmed that the comprehensive care plan had not been completed as required, and the omission was acknowledged as an oversight by the responsible staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nurse #1 failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a history of acute respiratory failure and a tracheostomy. During the observed care, Nurse #1 set up supplies without a tracheostomy kit, donned non-sterile gloves, and removed the resident's dirty dressing. After doffing gloves, Nurse #1 did not sanitize her hands before donning new gloves and continued care, including removing and replacing the inner cannula, all without using sterile technique or performing hand hygiene between glove changes. Handwashing was only performed at the end of the procedure. The resident's care plan and physician orders required tracheostomy care with attention to infection prevention. Interviews with Nurse #1 revealed she was aware of the missed hand hygiene but was not aware that sterile gloves were required for tracheostomy care. The Infection Preventionist/ADON and DON both stated their expectations for proper infection control practices, including hand hygiene and sterile technique, but were not aware of the specific deficiencies observed during this incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 27 opportunities, resulting in an 18.52% error rate. The deficiency involved a resident with a percutaneous endoscopic gastrostomy (PEG) tube, who had specific physician orders for medication administration. The orders required each medication to be dissolved separately in water, administered individually, and flushed with water between each medication, with a final flush at the end. During observation, the Unit Manager combined all prescribed medications into a single mixture, crushed and mixed them together, and administered them as a single solution through the PEG tube, contrary to the physician's orders. The Unit Manager admitted to not reviewing the resident's medication administration order prior to administering the medications and stated that her usual practice was to combine all medications for PEG-tube administration. The Director of Nursing confirmed that staff are expected to follow all medication orders as written. The observed practice resulted in multiple medication errors for the resident, as the administration did not comply with the specific instructions provided by the physician.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including wounds, hospice services, range of motion, and tube feeding. Resident #399 was admitted with multiple diagnoses, including a periprosthetic fracture and dementia. Despite having wounds on the right heel and great toe, the MDS assessment did not reflect these conditions. Interviews with the Nurse Practitioner (NP) and MDS Nurse revealed discrepancies between the clinical findings and the MDS documentation. The Director of Nursing (DON) and the Administrator both expressed expectations for accurate MDS coding based on the resident's clinical status. Resident #22 was admitted with diagnoses including venous insufficiency and type 2 diabetes. Although the care plan indicated palliative care, there was no documentation of hospice services in the medical record. The MDS assessment incorrectly coded hospice care, which was acknowledged as an error by the MDS Nurse. The Administrator reiterated the expectation for accurate MDS coding. Resident #11 had contractures in both knees and received physical therapy for limited range of motion. However, the MDS assessment did not reflect this condition. The Rehab Director and MDS Nurse confirmed the oversight. Resident #57, who was NPO and received nutrition via a PEG tube, was incorrectly assessed as requiring extensive assistance with eating instead of total staff assistance. The MDS Coordinator and Regional Quality Assessment & Assurance (QAA) Nurse identified the error, noting that the MDS was completed by a prn MDS staff member who no longer worked at the facility.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure group activities were planned and executed for rehabilitation residents, which was important to them. The March 2024 activity calendar showed daily activities at 11:00 AM and 2:00 PM, including an ice cream social and bingo twice a week. However, the Activities Assistant admitted that she did not have time to ask residents on the rehabilitation side if they wanted to attend activities due to the absence of the Activities Director since the beginning of March. This led to residents not being reminded or assisted to attend activities, as the Activities Assistant was also responsible for other duties, including resident admissions. Resident #37, who was moderately cognitively impaired and had a care plan indicating an interest in group bingo events, was not asked to attend activities after being readmitted to the facility. His Responsible Party (RP) stated that no staff members had come to the room to ask if he wanted to attend activities, and she had to personally take him to the ice cream social. Interviews with the Nurse Aide and Nurse assigned to Resident #37 confirmed that they had not asked him about attending activities, assuming that someone from the Activities Department would do so. Resident #85, who had severe cognitive impairment and indicated a desire to be invited to out-of-room activities, was also not asked to attend group activities. She stated that she loved being around people but could not recall being asked to join any activities. Similarly, Resident #88, who had moderately impaired cognition and expressed interest in group activities, was not informed about or invited to participate in activities. Both residents' medical records lacked activity notes, and the Nurse Aide assigned to them could not recall if they were asked or assisted to attend group activities. The Administrator was unaware of these issues and the arrangement between the Activities Director and Activities Assistant regarding resident activity participation.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following the recertification and complaint investigation survey. This failure resulted in four repeat deficiencies being cited again during the current recertification and complaint investigation survey. The deficiencies included issues related to resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control. Specifically, a resident was treated roughly during personal care, causing her to cry, and another resident was left uncovered in bed in a soiled brief. Additionally, the facility failed to code the Minimum Data Set (MDS) assessment accurately in several areas, including wounds, hospice services, range of motion, and tube feeding for multiple residents. The facility also did not follow recommendations from the Registered Dietitian and Nurse Practitioner regarding reweighing a resident with significant weight loss and addressing subtherapeutic total protein lab results. Furthermore, the facility failed to implement their infection control policy, as observed with staff not performing hand hygiene between residents during meal delivery and assistance, and not doffing soiled gloves before exiting a resident's room to obtain incontinence care supplies. During the interview, the Administrator and the Regional QAA Nurse Consultant acknowledged the repeat deficiencies and attributed them to staff taking shortcuts, the use of agency staff, MDS staffing changes, and staff oversight despite continued efforts to re-educate staff. The Administrator stated that repeat deficiencies were reviewed during quarterly QA meetings, and re-education was provided if ongoing issues were identified. However, the continued failure to sustain an effective QAA Program was evident as the same deficiencies were cited during two federal surveys of record.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement their infection control policy when a nurse aide did not perform hand hygiene between residents during meal delivery and meal assistance. Specifically, the nurse aide was observed serving meal trays to multiple residents without sanitizing hands between each interaction, despite the presence of hand sanitizing dispensers in the hallway. The Assistant Director of Nursing (ADON) intervened and provided immediate hand hygiene education to the nurse aide, who acknowledged having received prior training on the matter. In another instance, a nurse aide failed to doff soiled gloves and perform hand hygiene before exiting a resident's room after checking for incontinence. The nurse aide was observed wearing the same soiled gloves while retrieving supplies from a clean linen closet, which is against the facility's infection control practices. The nurse aide admitted to knowing the correct procedure but did not follow it at the time. Interviews with the ADON, Director of Nursing (DON), and the Administrator confirmed that all staff had received hand hygiene education and were expected to follow the facility's infection control policies. The ADON, who is also the Infection Preventionist, stated that the staff would need re-education on proper hand hygiene and incontinence care procedures to prevent such deficiencies in the future.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to recognize the use of an abdominal binder as a physical restraint for a resident admitted with diagnoses including intracranial hemorrhage, presence of a gastrostomy tube (G-tube), and dementia. The resident's baseline care plan did not include a care plan for the use of the abdominal binder as a restraint, and there was no physician order or documented consent for its use. Staff interviews revealed that the abdominal binder was used to prevent the resident from pulling out the feeding tube, but staff were unaware that it could be considered a restraint. The binder was unfastened during care but otherwise kept in place, and the resident was unable to remove it independently. Observations and interviews with various staff members, including nurses, nurse aides, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and a Nurse Practitioner, confirmed the consistent use of the abdominal binder since the resident's admission. Despite its use for safety reasons, there was no documentation of a restraint assessment or consent in the medical record. The staff's lack of awareness regarding the classification of the abdominal binder as a restraint led to the deficiency identified in the report.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop an individualized, person-centered comprehensive care plan for two residents. Resident #399 was admitted with severe cognitive impairment and multiple diagnoses, including a periprosthetic fracture of the left hip and chronic embolism. Despite the presence of necrotic wounds on the right great toe and an open wound on the right heel, the care plan only addressed the risk for pressure ulcers and did not include the actual wounds. The MDS Nurse used the admission nursing assessment, which did not document any skin integrity issues, to complete the care plan and did not update it even after the Nurse Practitioner identified the wounds during an acute visit. Resident #11, who had severe cognitive impairment and contractures in both knees, was recommended to use bilateral knee splints by the Physical Therapy department. However, the care plan did not include this recommendation. The MDS Nurse acknowledged the oversight, and the Director of Nursing confirmed that the care plan should have been comprehensive and included the use of bilateral knee splints.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plan for a resident receiving intravenous (IV) medication. Resident #22, who was admitted with diagnoses including diabetes and retention of urine, received Vancomycin via IV from 2/1/24 to 2/12/24. The IV catheter was removed on 2/14/24. However, the resident's care plan, last reviewed on 3/5/24, still included a focus area for receiving IV fluids via midline, despite the discontinuation of the IV antibiotics and catheter. This oversight was confirmed by the MDS Nurse during an interview on 3/14/24, who acknowledged that the care plan should have been updated. The Administrator also indicated that the care plan should accurately represent the resident's current status.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate electronic records for three residents, leading to deficiencies in medication administration, weight documentation, and treatment application. For Resident #28, the Unit Manager administered an acid reflux medication but did not document it in the Medication Administration Record (MAR). The Director of Nursing confirmed that all administered medications should be documented in the MAR. Medication Aide #1, who was expected to sign off on the medication, was unavailable for an interview. Resident #71 had a physician's order for weekly weights, but the weights were not documented in the electronic medical record for the specified period. Nurse #10 recorded the weights on a report sheet but failed to enter them into the electronic system. For Resident #198, a physician's order specified the application of a medicated cream to the buttocks, but Nurse #12 applied the cream to a different area without proper documentation. The Director of Nursing stated that all treatments should be documented in the MAR and progress notes.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide Resident #11 with a functional call light to request staff assistance for three consecutive days. Resident #11, who was admitted with moderate dementia and other conditions requiring extensive assistance, was observed on multiple occasions without a working call light. On 3/11/24, Resident #11 was found in her room with her pants and brief pulled down, stating she had used facial tissue due to a lack of toilet tissue and that her call light was not working. Despite pressing the call light, neither the wall panel light nor the light outside the room door turned on, indicating a malfunction. Nurse #6 confirmed the issue and reported it to the Maintenance Director, who acknowledged the problem and stated it was repaired on 3/13/24 after being reported on 3/12/24, although the nurse claimed to have reported it on 3/11/24. Interviews with various staff members, including Nurse Aides and the Maintenance Director, revealed that Resident #11 frequently used her call light for assistance but had been observed propelling herself into the hallway when the call light was not answered. The Maintenance Director admitted that the call light cord was burned out and replaced it, stating that call light audits were conducted monthly, with the last audit on 2/29/24. However, the malfunction was not identified until the call light was pressed and found to be non-functional. The Administrator and Regional Quality Assessment and Assurance Nurse Consultant confirmed that maintenance staff should ensure all call lights are functional for residents who use them. Despite the facility's procedures for daily room rounds and weekly call light audits, the deficiency in providing a functional call light for Resident #11 persisted for three days, impacting the resident's ability to request necessary assistance and maintain her activities of daily living.

Penalty

Inspection fine: $86,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to residents on five consecutive days during the survey. Observations revealed that the daily nurse staffing sheet was placed on the ledge of the receptionist's desk in the front lobby, which was only accessible to residents by manually opening a set of double doors. This placement made the staffing information not readily visible or accessible to residents. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the current location of the posting had been in use for a long time and acknowledged that it was not in an area easily accessible to residents.