Every finding on record at Auburn Nursing and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure each resident's right to a safe, clean, comfortable and homelike environment by providing maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 8 of 22 residents' rooms, (Rooms 106, 117, 121, 124, 202, 207, 222, and 213). Observation on 08/19/2026 through 08/27/2026 revealed the listed rooms had maintenance issues which included damaged drywall, damaged baseboards, cracked flooring and mold-like substance on the bathroom wall in room [ROOM NUMBER] and Hall 100 shower room. The findings include:Review of the facility's policy titled, Homelike Environment, dated 03/2026, revealed the facility was to provide residents with a safe, clean, comfortable, and homelike environment. Further review revealed the facility staff was to provide person-centered care that emphasized the residents' comfort, independence, personal needs, and preferences. Additional policy review revealed the facility was to maximize to the extent possible, characteristics of the facility to reflect a personalized, homelike setting.1. Observation of Hall 100 Shower Room on 08/20/2026 at 10:15 AM revealed mold observed around the base. 2. Observation of room [ROOM NUMBER] on 08/25/2026 at 2:20 PM revealed the baseboards were damaged exposed to raw wood at the bathroom door. 3. Observation of room [ROOM NUMBER] on 08/20/2026 at 11:02 AM revealed a mobile free-standing air conditioning unit, in the residents' room, which had big, white, curled duct tubing running alongside the right side of the residents' bed. Per observation, the duct work tube ran to the window where it ran to the outside through a hole cut in a piece of plywood on the window. In interview on 08/24/2026 at 8:32 AM, with the resident residing in room [ROOM NUMBER], he stated the mobile air conditioning duct work draped across his floor didn't bother him. The State Survey Agency (SSA) Surveyor attempted further interview and after telling the SSA Surveyor he could not hear his tv, he stated, Get the fuck out of my room, I don't want anyone's help.In interview on 08/24/2026 at 9:32 AM, the Administrator stated the contracted company was coming to the facility on [DATE] and remove the mobile air conditioning unit because the facility's chiller had been working okay since 08/21/2026. When the State Survey Agency (SSA) Surveyor asked the Administrator why the facility was waiting that long to have the contract company come back to remove the mobile air unit, she stated the administrative staff wanted to make sure the chiller was working okay. In interview on 08/25/2026 at 10:00 AM, the current Maintenance Manager stated the temperature of the facility's chiller was at 48 degrees Fahrenheit.4. Observation of room [ROOM NUMBER] on 08/25/2026 at 2:46 PM revealed tile in the bathroom was damaged and missing in the middle of the restroom and in front of the door of the restroom. 5. Observation of room [ROOM NUMBER] on 08/26/2026 at 10:05 AM revealed the tile in the bathroom was missing and exposing the bare sub-flooring and the floor beside the resident bed B was damaged.In an interview on 08/21/2026 at 2:38 PM, the resident's family member, of the resident who resided in room [ROOM NUMBER], stated the bathroom tiles were coming up, and she was afraid her mother would trip if she went to the restroom. She stated on both sides of her mother's bed there was a hole in the tiles. The family member stated her mother was not safe in the building due to the living conditions. She stated she reported it to the staff and Administrator, but nothing had been done to fix anything in the building. In interview with R15, who resided in room [ROOM NUMBER], at the time of the family member interview, the resident stated she felt the building was old and needed repairs. 6. Observation of room [ROOM NUMBER] on 8/25/2026 at 2:00 PM revealed the grip bar that ran beside the commode, and bathtub was loose from the floor. 7. Observation of room [ROOM NUMBER] on 08/26/2026 at 10:25 AM revealed black mold on the bathroom wall on the right side of the sink.8. Observation of room [ROOM NUMBER] on 08/26/2026 at 11:06 AM revealed a sink leaking in the restroom and holes in the wall tile exposing raw wood.9. Observation of room [ROOM NUMBER] on 08/25/2026 at 3:05 PM revealed behind the bed, a baseboard had been torn from the wall exposing raw wood. In an interview with the Administrative Assistant on 08/19/2026 at 1:20 PM, she stated maintenance is still in the process of ordering more parts, like tiles and supplies to fix sinks. She stated some rooms had been fixed; however, they were in the process of working on all the rooms for damages. In an interview with the Director of Nursing (DON) on 08/20/2026 at 10:10 AM, she stated she was aware repairs were needed in several rooms throughout the building. She stated the work orders had been in for a few months, but the new Maintenance Manager had only been working at the facility for three weeks and was trying to make the repairs. She stated nursing staff notified her of issues such as damaged walls, baseboards, and mold but the work orders had already been submitted. She stated it was important to provide residents with a homelike environment. In an interview with the current Maintenance Manager on 08/21/2026 at 9:35 AM, he stated he was aware of the work orders for repairs to the floors and baseboards. He stated repairs for walls, ceilings, floors, and baseboards would be fixed as quickly as they could be; however, he had only been hired three weeks ago. (Review of the facility's work orders revealed the documents noted in progress.) He stated he could not give a date for when all the repairs would get made. The current Maintenance Manager stated, in regard to the supplies to make the repairs with, I have to go through vendors, and they ship them to me. He stated the facility used more than one vendor.In a phone interview on 08/26/2026 at 5:05 PM, with the previous Maintenance Manager he stated he was employed at the facility from November 2005 until March 2026. He stated the floors in the bathrooms and residents' rooms were in bad shape when he worked at the facility. He stated he tried to fix them the best he could but did not have a budget to be able to call and have a vendor come in to fix it properly. The previous Maintenance Manager stated the sinks were leaking and he would fix them, but they only worked for a short time before they started leaking again. He stated he spoke to the facility's owner many times about the repairs that were needed in the residents' rooms including the floors, baseboards, sinks, and mold. The previous Maintenance Manager stated, however, the facility's owners did not want to spend the money, so he would just do the repairs he was able to complete. He stated every time it rained hard, the administrative offices and some of the facility rooms near those offices flooded and had water standing in them. The previous Maintenance Manager stated water ran off the hill above the facility in the back and caused the standing water in the affected rooms. He stated after that happened those areas needed more repairs. In an interview on 08/27/2026 at 10:42 PM, the Administrator stated the repairs to the residents' rooms had not been completed because they were waiting for the parts to come in so maintenance could start repairing the flooring. She stated her expectation for her staff was to let upper management know when any of the rooms needed repairs to the floor, restroom, walls or beds. She stated she understood the building needed some repairs and they had hired a new Maintenance Manager three weeks ago so they could start on the repairs as soon as the supplies came in. She stated she would not want to live in a home with damaged walls and floors, and she knew the importance of maintaining a homelike environment for residents.

Based on observation, interviews, record review, review of the facility's investigation, and review of facility policy, the facility failed to ensure residents were free from abuse for one of 22 sampled residents (Residents (R) 18). Review of the facility's investigation revealed that on 07/15/2026 at 9:40 AM, R9 grabbed R18's face and pushed R18 away, after R18 had taken some money belonging to R9. R18 had a history of wandering into other residents' rooms and taking personal belongings. The findings include:Review of the facility policy titled, Abuse Prohibition Standard of Practice, revised 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State laws. Further, facility investigation would be prompt, comprehensive and responsive to the situation and contain founded conclusions including follow up resolution and measures to prevent repeat incidents.1. Review of R18's medical record revealed the facility admitted the resident on 07/03/2025 with diagnoses of schizophrenia, type 2 diabetes mellitus without complications, and acute and chronic respiratory failure with hypoxia.Review of R18's Annual Minimum Data Sheet (MDS) assessment, with an Assessment Date of Reference (ARD) of 08/11/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 12 out of 15 which indicates the resident is cognitively intact. Review of R18's Behavior Care Plan dated 06/03/2026, revealed Resident 18 had a history of taking things off the top of the medication cart and picking up other people's belongings. Review of the facility's investigation of the incident dated 07/20/2026, revealed Registered Nurse (RN) 1 stated she was in the hallway when R9 reentered the facility from a smoke break and approached R18, R9 pointed his finger at R18. Further stated, R18 stated Don't take my money anymore, then made contact to R18 face. RN 1 immediately approached R9 and R18 to step between them. Administration staff were immediately notified.Continued review of the facility's investigation revealed skin assessments were conducted on both R9 and R18 and there was no discoloration and/or swelling. Further stated SSD met with R9 and R18 after the incident and R9 was calm and apologized for getting upset and R18 did not recall the altercation. In addition, facility placed Velcro stop sign to R9's door, to cue R18 not to enter R9's room and provided a lock box for R9 to store personal belongings of his choice. Further review of facility investigation findings, the allegation of abuse was not substantiated by the facility.Review of the facility investigation, Registered Nurse (RN) 1 witnessed Resident 9 entering the facility from a smoke break and approached R18, pointed his finger at R 18 and stated, Don't take my money anymore, then made contact to R18 face. After the incident, Social Service Director (SSD) interviewed Resident 9 and revealed R 18 had taken his money from his room. However, after the incident, R18 continued wandering into other residents' rooms and picking up their belongings.On 07/15/2026 at 9:40 AM, R9 grabbed R18 face and pushed R18 away. Per the facility's Investigational Summary, dated 07/20/2026, completed by the facility's Administrator Assistant, revealed R18 entered R9 room during the night of 07/14/2026 to 07/15/2026 and R18 did have money in her possession, and it was returned to R9. Further, stated R9 did make contact to R 18's face. The facility interviewed R9 after the incident, and he stated R18 had been in his room and taken his money. R9 stated he put his finger in R18 face and told R18 not to go in his room anymore, then grabbed R18 face and pushed R18 away.Observations on 08/20/2026 and 08/21/2026 throughout the day, revealed R18 in her wheelchair and in the hallways approaching residents' room door entrance and with staff redirecting R18. Review of R18's Nursing Progress Note, dated 07/20/2026 at 4:53 AM, revealed Licensed Practical Nurse (LPN) 3 documented R18 behaviors persist, propelling self in and out of other rooms and common areas picking up items not belonging to and staff continue to find items that do not belong to R18.In a interview on 08/24/2026 at 10:08 AM, with Licensed Practical Nurse (LPN) 1, she stated at 3:00 AM today R18 went into room on 100 hall and staff immediately returned R18 back to her room on 200 hall. She further stated, R18 takes belongings from other residents' rooms and residents become upset with her each time. 2. Review of R9's medical record revealed the facility admitted the resident on 10/25/2024 with diagnoses of schizophrenia, unspecified, chronic kidney disease, stage 3, unspecified, and diabetes mellitus due to underlying condition without complications. Review of R9's Annual Minimum Data Sheet (MDS) assessment, dated 07/26/2026, with an Assessment Date of Reference (ARD), revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 12 out of 15 which indicated the resident was cognitively intact. In an interview on 08/21/2026 at 10:40 AM, with SSD, she stated R9 was upset on the day of the incident as evidenced by shaking and stated to SSD he was tired of R18 taking his belongings, was only trying to get R18 to look at him and was not trying to hurt R9. The SSD stated the facility purchased a lock box for R18 to secure his money. Further stated R18 entering resident rooms does escalate other residents and no additional interventions have been implemented for R18 since the incident. In an interview on 08/27/2026 at 11:12 AM, with the Assistant Director of Nursing (ADON), she stated R18 takes other resident belongings, staff redirect, and facility has placed Velcro stop signs to decrease entering rooms uninvited. She further stated it was her expectation that staff were to redirect and/or keep R18 at the nurse's station and would review with the clinical team on developing interventions that would ensure R18's safety. In an interview on 08/27/2026 at 12:15 PM, with the Administrative Assistant and Administrator, they stated all belongings/items taken by R18 had been replaced and would continue to meet with Interdisciplinary team to determine how to keep R18 safe.

Based on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for one (Resident (R) 1) of 19 sampled residents reviewed for Advance Directives. Staff found R1 unresponsive on 11/09/2025 without pulse or respiration. R1 was a Full Code status (indicating that CPR should be performed if the resident was found without vital signs); however, no lifesaving measures were attempted. On 03/04/2026 at 3:10 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.24 F678, as well as Substandard Quality of Care (SQC) at 42 CFR 483.24, Quality of Care. The IJ was determined to exist on 11/09/2025, when R1 was found without pulse or respiration and CPR was not initiated.The facility provided an acceptable IJ Removal Plan on 03/05/2026. The plan alleged the IJ was removed on 03/05/2026. A Partial Extended Survey and IJ Removal Validation was conducted on 03/06/2026. The State Survey Agency (SSA) validated the IJ was removed on 03/05/2026, as alleged. The deficient practice remained at a scope and severity of D following the removal of the immediate jeopardy. The findings include:Review of the facility's policy titled Cardiopulmonary Resuscitation, (CPR) revised 03/2019, revealed the facility would provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders, such as a Full Code, and the resident's advance directives.Review of R1's Face Sheet revealed the facility admitted the resident on 09/25/2025. R1's diagnoses included chronic obstructive pulmonary disease (COPD), unspecified dementia, chronic kidney disease, and acquired absence of the left and right legs below the knee.Review of a Physician's Order dated 09/26/2025, revealed an order for R1 to be a Full Code status.Review of the Advance Directives Comprehensive Care Plan, established on 10/02/2025, with an onset date of 10/03/2025, revealed R1 was a Full Code. Goals in place were to have health care wishes/advance directives honored. The care plan interventions in place for R1 included to communicate the resident's choice and provide CPR.Review of a Progress Note, dated 11/09/2025 at 4:30 PM (late entry), revealed that R1 ate a few bites of food around 8:00 AM. State Registered Nurse Aide (SRNA) 1 called Licensed Practical Nurse (LPN) 2 to R1's room at approximately 9:00 AM to check the resident. R1's arms were cold, but R1's legs, chest, and face were warm to touch; the resident had a good carotid pulse and good breath sounds, and when moved, R1 moaned and shuffled legs. At approximately 10:25 AM, Kentucky Medication Technician (KMA) 3 found R1 not breathing and cold to the touch, Registered Nurse (RN) 1 was called to the room and found the resident with no heart rate, no breath sounds, and cold to touch. The facility called the daughter at 10:30 AM to inform her that her mother was deceased . Per the note, the daughter stayed around the facility and asked several questions. The Progress Note failed to indicate whether CPR was administered in accordance with R1's care plan and/or physician's orders. Review of a certified Death Certificate revealed R1 expired on 11/09/2025 at 10:29 AM in the facility. During an interview on 02/25/2026 at 3:50 PM, R1's daughter stated that at approximately 10:00 AM, a staff member called and reported R1's eyes were glazed. KMA3 then called ten minutes later and reported R1 was deceased . The daughter stated that no CPR was given and upon arrival to the facility, she overheard staff talking about not knowing R1's code status and the reason no CPR was given. The daughter stated, I will never know how much time I may have had with my mother cause no CPR was given. During an interview on 02/25/2026 at 2:55 PM, SRNA1 stated she received a report from night shift that R1 was doing great and had been eating well. At approximately 8:00 AM, SRNA1 reported to LPN2 that R1 was not doing good, as evidenced by her mouth staying open and not responding verbally. SRNA1 stated she went to KMA3, who assessed R1 and reported R1 was dead. SRNA1 asked KMA3 if she needed to start CPR and KMA3 reported nothing could be done. SRNA1 stated she then asked LPN2 about R1's code status. RN1 and LPN2 reviewed files at the nurse's station and identified R1 was a Full Code. RN1 and LPN2 then went to R1's room. RN1 used the stethoscope and reported nothing could be done. RN1 asked KMA3 if she had performed CPR, and KMA3 replied that she did not know R1s code status.During interview on 02/26/2026 at 8:45AM, KMA3 reported she was approached by SRNA1, who stated R1 was not well. KMA3 stated she went to R1's room and assessed R1 to be cold and stiff to touch. KMA3 went and told staff and then returned to R1's room with LPN2 and RN1. LPN2 then returned to the nurse's station to look at the resident's code status. KMA3 reported that R1was cold, her eyes suctioned shut, and nothing could be done. KMA3 stated that, in addition to her role as a KMA in the facility, she also worked separately as a deputy coroner. KMA3 confirmed that on the day that R1 expired, she was not working as a deputy coroner, and instead, was responsible for providing care to residents of the facility. In reviewing the incident, KMA3 stated she should have gone into the medical record system to look for the resident's code status, gotten help, called an ambulance, gotten a crash cart, and then begun CPR. During an interview on 02/26/2026 at 11:45 AM, RN1 reported KMA3 came down the hallway, yelling R1 was dead. RN1 checked all pulse areas to verify R1 was dead and reported R1's elbows were stiff and limp. RN1 reported she did not know R1's code status and no one in the room performed CPR. RN1 confirmed CPR was not performed, stating, I just listened to [KMA3]. RN1 noted that KMA3, who was a deputy coroner, pronounced R1 dead. RN1 added that in the future, if a resident was a Full Code, she would perform CPR.During a telephone interview on 03/01/2026 at 1:50 PM, the Medical Director stated the facility staff did not follow the CPR protocol. The Medical Director stated the staff should have initiated CPR if R1 was a Full Code. During an interview on 03/02/2026 at 9:00 AM, LPN2 stated she was at the nurse's station charting when SRNA1 came to her on 11/09/2025 at approximately 8:00 AM and told her that R1 did not look good. LPN2 stated she entered the room to check R1's vital signs and, at that time, they were in normal limits. LPN2 stated she went back to the nurse's station and continued to chart. Ten minutes later, LPN2 again checked on R1, who seemed the same. After this, LPN2 was then summoned by KMA3 and, upon heading to R1's room, encountered RN1 who asked her to help her with R1. LPN2 stated KMA3 and RN1 (who assessed the resident) had a discussion and made the decision to withhold CPR as R1 was gone. LPN2 stated that, at the time, she relied on the decision RN1 made with KMA3. LPN2 confirmed that facility staff should have performed CPR, stating, When someone is a Full Code, CPR should be performed.During an interview on 02/27/2026 at 9:25 AM, the County Coroner stated that when working in the facility as an aide, KMA3 had no authority to prevent life saving measures from being given to a resident. The County Coroner stated that nothing that KMA3 could have said should have stopped nurses from performing CPR.During an interview on 03/02/2026 at 1:25 PM, Regional Nurse 1 stated the failure to provide CPR was because staff listened to KMA3 rather than following the code status adding, That was what lead to the facility's failure. Additional interview with Regional Nurse 1 on 03/07/2026 at 10:57 AM revealed that for residents who were a Full Code, CPR shall be initiated by the nurse while waiting for emergency procedures to arrive.During an interview on 03/02/2026 at 3:10 PM, the Interim Director of Nursing (DON) 14 stated the expectation would have been to perform CPR when a resident was a Full Code until the ambulance arrived. The Interim DON stated, As a licensed nurse, we do not make the decision to not do CPR when a resident is a Full Code.During an interview on 03/02/2026 at 1:35 PM, the Administrator stated the failure was that staff decided to not perform CPR on a Full Code resident. The Administrator stated RN1 decided to not perform CPR and may have leaned on KMA3, adding, CPR should have been given.

Based on interview, record review, and review of the facility's policy, the facility failed to implement the care plan related to advance directives for one (Resident (R) 1) of 19 sampled residents reviewed for care plans. R1's care plan identified the resident as a Full Code (indicating that Cardiopulmonary Resuscitation (CPR) should be performed if the resident was found without vital signs.); however, staff failed to implement the care plan, and no lifesaving measures were attempted.On [DATE], at 3:10 PM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified that the failure to implement the resident's care plan by performing CPR in accordance was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.21 (b) F656. The IJ was determined to exist on [DATE], when staff failed to implement R1's care plan and initiate CPR when the resident was found without pulse or respiration.The facility provided an acceptable IJ Removal Plan on [DATE]. The plan alleged the IJ was removed on [DATE]. A Partial Extended Survey and IJ Removal Validation was conducted on [DATE]. The State Survey Agency (SSA) validated the IJ was removed on [DATE], as alleged. The deficient practice remained at a scope and severity of D following the removal of the immediate jeopardy. The findings include:Review of the facility's policy titled Comprehensive Care Plans Standard of Practice, reviewed 04/2025, revealed the facility would provide individualized comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. The facility's Care Planning/Interdisciplinary Team, in coordination with the resident, family and/or representative, would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain.Review of R1's Face Sheet revealed the facility admitted the resident on [DATE]. R1's diagnoses included chronic obstructive pulmonary disease (COPD), unspecified dementia, chronic kidney disease, and acquired absence of the left and right legs below the knee.Review of a Physician's Order, dated [DATE], revealed an order for R1to be a Full Code status.Review of the Advanced Directives Comprehensive Care Plan established on [DATE], with an onset date of [DATE], revealed R1 was a be Full Code status. The goals were to have R1's health care wishes/advance directives honored. Interventions in place for R1 were to communicate the resident's choice and provide CPR.Review of a Progress Note dated [DATE] at 4:30 PM, (late entry) revealed that at approximately 10:25 AM, Kentucky Medication Technician (KMA) 3 found R1 not breathing and cold to touch. Registered Nurse (RN) 1 was called to the room and found R1 with no heart rate, no breath sounds, and cold to touch. The Progress Note failed to indicate whether CPR was administered in accordance with R1's care plan. Review of a certified Death Certificate revealed R1 expired in the facility on [DATE] at 10:29 AM. (Refer to F678.)Interviews with State Registered Nurse Aide (SRNA)1 on [DATE] at 2:55 PM, R1's daughter on [DATE] at 3:50 PM, KMA3 on [DATE] at 8:45 AM, RN1 on [DATE] at 11:45 AM, and Licensed Practical Nurse (LPN) 2 on [DATE] at 9:00 AM confirmed that staff failed to implement R1's care plan and provide CPR in accordance with the resident's care plan.During interview with RN1 on [DATE] at 11:45 AM, she stated that she did not know the resident's code status (however, it was listed on R1's care plan.) Further interview with RN1 revealed that staff failed to follow the care plan and perform CPR, based on directions from KMA3, who also worked (while not at the facility) as a deputy coroner.During interview on [DATE] at 8:45AM, KMA3 stated she failed to follow R1's care plan regarding her Full Code status. In reviewing the incident, KMA3 stated she should have gone into the medical record system to get the resident's code status, gotten help, called an ambulance, gotten a crash cart, and then begun CPR. Interview on [DATE] at 2:20 PM with Minimum Data Set (MDS) Coordinator 1 revealed that it was important for staff to follow care plans, including the Advance Direction portion which listed a resident's code status.During an interview on [DATE] at 9:00 AM, LPN2 confirmed that KMA3 and RN1 had a discussion and made the decision to withhold CPR as R1 was gone. LPN2 stated that staff should have followed the care plan, stating When someone is a Full Code, CPR should be performed.During a telephone interview on [DATE] at 1:50 PM, the Medical Director stated that staff should have followed the care plan. The Medical Director stated that the facility should have initiated CPR if the resident was a Full Code. During an interview on [DATE] at 9:25 AM, the County Coroner stated that while working as a KMA in the facility, KMA3 had no authority to prevent life saving measures from being given to R1. Per the Coroner, nothing that KMA 3 could have said should have stopped the nurses from doing CPR (in accordance with the resident's care plan.)During an interview on [DATE] at 1:25 PM, Regional Nurse 1 stated staff listened to KMA3, rather than following the code status as directed on the Advance Directive care plan, adding, That was what lead to the facility's failure. Additional interview with Regional Nurse 1 on [DATE] at 10:57 AM revealed that for residents who were care planned as a Full Code, CPR shall be initiated by the nurse while waiting for emergency procedures to arrive.During an interview on [DATE] at 3:10 PM, the Interim Director of Nursing (DON) 14 stated the expectation would have been for staff to follow the Advance Directive care plan and perform CPR for a resident who is a Full Code until the ambulance arrives. Interview on [DATE] at 1:35 PM with the Administrator revealed the failure was that staff decided not to do CPR on a Full Code resident in accordance with her care plan. The Administrator stated RN1 decided not to perform CPR and may have leaned on KMA3's advice, saying, CPR should have been given.

Based on interview, record review, and review of the facility's policy's, it was determined the facility failed to ensure medical records were complete, accurate, and maintained for 8 of 25 sampled residents (R3, R4, R9, R12, R15, R17, R25, R58).The findings include: Review of an undated Medical Records policy revealed appropriate medical/clinical records should be maintained for each resident. Review of an undated facility policy, titled, Charting and Documentation, revealed All services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. Per the policy, interpretation and implementation included that All observations, medications administered, services performed, etc. must be documented in the resident's clinical records. 1. Review of the admission record for R4 revealed the facility admitted the resident on 06/24/2025 with diagnoses including nondisplaced fracture of olecranon of left ulna, unspecified dementia, and visual loss. a. Review of R4's admission orders, dated 06/24/2025, revealed the resident would be weighed per facility policy, every week for four weeks. After this, physician orders called for monthly weights. Review of facility records revealed no evidence that the four weekly weights and monthly weight thereafter were obtained as ordered. Review of the 100-hall weight binder for 2025 for the months of May-August revealed R4's last name handwritten at the bottom of one page, listing a weight of 193 pounds. There was no annotation of the month or date this weight was obtained, and no other weights for the resident were recorded. b. Review of R4's Medication Administration Records (MAR) since admission revealed they were incomplete, as they failed to include either the month or year that the record represented. During an interview with the Director of Nursing (DON) on 09/12/2025 at 5:01 PM, the DON reviewed each of the four MARs completed since admission and confirmed that the records were incomplete, as there was no month or year to indicate when the listed medications were administered. Further interview with the DON revealed she had assumed the DON position a few days ago and was the Assistant Director of Nursing (ADON) prior to that. The DON stated that she was thrown in the roles and was winging it, adding that she had not had time to perform chart audits. She stated the resident's MARs should always include a month and year. The DON related that the admission nurse was responsible for putting the dates on the form, but the ADON/DON should also review the MAR either that same evening or the next morning to ensure they were accurate. She stated she expected dates to be on the MAR's when completed. She further stated without weights having a date, there was no way to know when the weight was actually obtained. The DON stated the house supervisor was the staff previously responsible for documenting weights; however, she resigned two weeks ago. Interview with the Administrator on 09/12/2025 at 5:50 PM revealed that she expected the ADON/DON to review the MARs on a monthly basis to ensure they were accurate. The Administrator stated the MAR should be dated and weights should be done per physician orders. Interview with the Administrator revealed that the failure to accurately and completely document weights as ordered could result in the resident having a significant weight change which was not caught. Further interview revealed the failure to accurately documented the MAR with the date could result in the resident receiving medications for the wrong month or even the wrong orders. 2.a. Review of the admission record for R3 revealed R3 was admitted on [DATE] with diagnoses including bipolar disorder with psychotic features, major depressive disorder, and anxiety. Review of a Level I PASARR, dated 06/06/2025, indicated R3 had a diagnosis of bipolar and had required an intensive psychiatric treatment in order to maintain or restore functioning (ex: psychiatric hospitalization, partial hospitalization/day treatment, residential treatment). Further review of the Level 1 PASARR, which was documented through the Kentucky Level of Care System (KLOCS - a system used to enter and automatically route to the appropriate personnel for determinations before admission) revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. b. Review of the admission record for R17 revealed R17 was admitted on [DATE] with diagnoses including unspecified psychosis and bipolar disorder. Review of a Level I PASARR, dated 07/21/2025, indicated R17 had diagnoses of psychosis and bipolar and required intensive psychiatric treatment in order to maintain or restore functioning. Further review of the Level 1 PASARR, which was documented through KLOCS, revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. c. Review of the admission record for R9 revealed R9 was admitted on [DATE] with diagnoses including schizoaffective disorder. Review of a Level I PASARR, dated 05/15/2024 indicated R9 had a diagnosis of schizoaffective disorder. Further review of the Level 1 PASARR, which was documented through KLOCS, revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. d. Review of the admission record for R12 revealed R12 was admitted on [DATE] with diagnoses to include unspecified psychosis, altered mental status, and cognitive communication disorder. Review of a Level I PASARR, dated 10/13/2023, indicated R12 had a diagnosis of unspecified psychosis. Further review of the Level 1 PASARR, which was documented through KLOCS, revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. e. Review of the admission record for R15 revealed R15 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia, and unspecified dementia. Review of a Level I PASARR, dated 06/22/2006, indicated R15 had diagnoses of bipolar disorder and schizophrenia. Further review of the Level 1 PASARR, which was documented through KLOCS revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. f. Review of the admission record for R25 revealed R25 was admitted on [DATE] with diagnoses to include bipolar disorder, anxiety, and major depressive disorder. Review of a Level I PASARR, dated 08/01/2025, indicated R25 had diagnoses of anxiety, depression, and bipolar disorder. Further review of the Level 1 PASARR, which was documented through KLOCS revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. During an interview with the Medical Records (MR) staff and the Administrator on 09/11/2025 at 1:34 PM, MR explained that she inputs the resident's PASARR information into KLOCS. The system would then alert Life Skills (a mental health clinic) if a Level II assessment was needed, and they would send someone accordingly. She confirmed that the determination from the Level I assessment was not printing with the packet kept in the resident's record. MR stated that the determination appeared on the system and could generate error messages and instructions; however, it did not always show whether a Level II evaluation was recommended. Further interview with MR revealed she was unsure why this occurred. During this interview, the Administrator confirmed that the Level I PASARR was completed by the facility's MR person, and then Life Skills evaluated whether the resident's Level I data resulted in a Level II assessment. However, the facility could provide no further information to show that the residents' records were complete, and included the determinations made from the Level 1 screening.

Based on interview, record review, and facility policy review it was determined the facility failed to accurately complete the Preadmission Screening process for individuals with a mental disorder and/or individuals with intellectual disabilities for nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). The systemic failure to ensure the PASARR process is completed as required has the potential to affect all residents who must be screened using this process upon admission. The findings include: Review of a facility policy titled, Preadmission Screening and Resident Review (PASARR), created 09/2025, revealed the purpose was to determine if an individual seeking admission had a serious mental illness (SMI), intellectual disability (ID), or related conditions (RC) and determine eligibility for nursing facility placement and health related services. The protocol was to utilize the Kentucky Level of Care System (KLOCS) to submit and track applications using an online self-service portal, initiate level of care request and discharges (requests were automatically routed to the appropriate KLOCS personnel for review and completion of determinations), and send providers automatic task notifications and reminders to submit any requested information. 1. Review of the admission record for R3 revealed R3 was admitted on [DATE] with diagnoses including bipolar disorder with psychotic features, major depressive disorder, and anxiety. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2025, revealed the facility assessed R3 to have a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. The MDS indicated R3 was not evaluated by the Level II PASARR (an in-depth evaluation and determination for applicants and residents with serious mental illness or intellectual and developmental disabilities to ensure appropriate placement and services are provided). Review of a Level I PASARR, dated 06/06/2025, indicated R3 had a diagnosis of bipolar and had required an intensive psychiatric treatment in order to maintain or restore functioning (ex: psychiatric hospitalization, partial hospitalization/day treatment, residential treatment). Further review of the Level 1 PASARR, which was documented through the KLOCS (a system used to enter and automatically route to the appropriate personnel for determinations before admission) revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence R3 was referred for a Level II PASARR. 2. Review of the admission record for R17 revealed R17 was admitted on [DATE] with diagnoses including unspecified psychosis and bipolar disorder. Review of an admission MDS with an ARD of 08/03/2025, revealed the facility assessed R17 to have a BIMS score of 15/15, indicating the resident was cognitively intact. The MDS indicated R17 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 07/21/2025, indicated R17 had diagnoses of psychosis and bipolar and required intensive psychiatric treatment in order to maintain or restore functioning. Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R17 was referred for a Level II PASARR. 3. Review of the admission record for R9 revealed R9 was admitted on [DATE] with diagnoses including schizoaffective disorder. Review of an admission MDS with an ARD of 05/28/2024 revealed the facility assessed R9 to have a BIMS score of 3/15, indicating the resident was severely cognitively impaired. The MDS indicated R9 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 05/15/2024 indicated R9 had a diagnosis of schizoaffective disorder. Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R9 was referred for a Level II PASARR. 4. Review of the admission record for R12 revealed R12 was admitted on [DATE] with diagnoses including unspecified psychosis, altered mental status, and cognitive communication disorder. Review of an admission MDS with an ARD of 10/26/2023 revealed the facility assessed R12 to have a BIMS score of 11/15, indicating the resident had moderate cognitive impairment. The MDS indicated R12 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 10/13/2023, indicated R12 had a diagnosis of unspecified psychosis. Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnosis, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R12 was referred for a Level II PASARR. 5. Review of the admission record for R15 revealed R15 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia, and unspecified dementia. Review of an MDS with an ARD of 08/11/2025 revealed the facility assessed R15 to have a BIMS score of 12/15, indicating the resident had moderate cognitive impairment. The MDS indicated R15 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 06/22/2006, indicated R15 had diagnoses of bipolar disorder and schizophrenia. Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R15 was referred for a Level II PASARR. 6. Review of the admission record for R25 revealed R25 was admitted on [DATE] with diagnoses including bipolar disorder, anxiety, and major depressive disorder. Review of an admission MDS with an ARD of 08/14/2025 revealed the facility assessed R25 to have a BIMS score of 15/15, indicating the resident was cognitively intact. The MDS indicated R25 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 08/01/2025, indicated R25 had diagnoses of anxiety, depression, and bipolar disorder. Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R25 was referred for a Level II PASARR. 7. Review of the admission record for R8 revealed R8 was admitted to the facility on [DATE], with diagnoses that included severe bipolar disorder with psychotic features, age related physical debility, and generalized anxiety disorder.Review of R8's admission MDS, with an ARD of 07/27/2025, revealed the resident had a BIMS score of 3/15, indicating R8 had severe cognitive impairment. The MDS indicated R8 was not evaluated by Level II PASARR. Review of a Level I PASARR, dated 07/14/2025 indicated R8 had diagnoses of bipolar disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). Further review of the Level 1 PASARR, which was documented through the KLOCS, revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R8 was referred for a Level II PASARR. 8. Review of the admission record for R 33 indicated R33 was admitted to the facility on [DATE], with diagnoses that included dementia, bipolar disorder, and anxiety disorder.Review of R33's Annual MDS, with an ARD of 09/09/2025, revealed the resident had a BIMS score of 3/15, indicating R33 had severe cognitive impairment.Review of a Level I PASARR, dated 07/14/2025 indicated R33 had diagnoses of bipolar disorder, and anxiety disorder, Further review of the Level 1 PASARR, which was documented through the KLOCS revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R33 was referred for a Level II PASARR. 9. Review of the admission record for R42 indicated R42 was admitted to the facility on [DATE], with diagnoses that included Human Immunodeficiency Virus (HIV), dementia, and delirium. Review of R 42's Annual MDS, with an ARD of 09/12/2025, revealed the resident had a BIMS score of 8/15, indicating R33 had moderate cognitive impairment.Review of a Level I PASARR, dated 02/15/2025 indicated R33 had diagnoses of HIV dementia, and anxiety disorder. Further review of the Level 1 PASARR, which was documented through the KLOCS revealed that although it listed the resident's diagnoses, it did not include any information to indicate whether a Level II assessment was needed or not, or if the appropriate referrals were made. There was no documented evidence that R42 was referred for a Level II PASARR. During an interview with Medical Records (MR) and the Administrator on 09/11/25 at 1:34 PM, MR explained that she inputs the resident's information into KLOCS before admission. The system then alerts Life Skills (a mental health clinic) if a Level II assessment was needed, and they would send someone accordingly. She confirmed that the determination from the Level I screening was not printing with the packet kept in the resident's record. MR stated that the determination appeared on the system and could generate error messages and instructions, but it did not always show whether a Level II was recommended. She was unsure why this occurred. The Administrator stated that the Level I PASARR was completed by the facility's medical records person, and then Life Skills evaluated whether the resident's Level I resulted in a Level II assessment. She understood that serious mental health conditions should trigger Level II but most of their residents did not. She also mentioned that if a resident transferred from another facility, they did not reassess the resident for Level I, even if the resident had a serious mental health diagnosis. During a second interview with MR on 09/11/2025 at 2:58 PM, she stated she had been in this role for one and one-half years. She stated she was trained on PASARRs by the previous MR employee, who was also fairly new to entering information into KLOCS. She stated the only other training she had received was zoom training, and she had received no other formal training related to regulations or PASARRs. During an interview with the Administrator on 09/11/2025 at 3:32 PM, she presented a copy of the facility policy for PASARR with a created date of 09/2025. She stated they had merged with a new company two weeks ago and that was what was provided to her. She stated she did not know if the policy was newly created or if it was based on regulations.During an interview on 09/12/2025 at 2:11 PM with the Director of Crisis for Life Skills (a mental health clinic), she stated she was also responsible to oversee PASARRs. She stated the resident's information should be entered into KLOCS prior to an admission to the facility. The Director explained that their office would then receive the information electronically and if the resident had a diagnosis and two psychiatric hospitalizations within the past two years, they would trigger for a Level II PASARR to be completed. She stated their office would then go to that resident and do an evaluation. The Director stated she did not think a diagnosis alone would trigger for a Level II evaluation to be done. She stated the facility should also review the Level I and if they found that the resident should have triggered but did not, the facility should re-do the Level I and resubmit into KLOCS, which would then prompt Life Skills to come to the facility to evaluate the resident.During an interview with the Social Services Director (SSD) on 09/12/2025 at 3:54 PM, she stated she provides MR with the information she had obtained during the referral process so she could enter the accurate information. Further interview revealed she was not responsible for entering information into KLOCS for the PASARRs. During an interview with the Director of Nursing (DON) on 09/12/2025 at 5:01 PM, she stated she did not know anything about a PASARR or even what it was, saying that it was basically a foreign language to her. During a second interview with the Administrator on 09/12/2025 at 5:50 PM, she stated MR was responsible for entering accurate information into KLOCS. She stated MR was trained prior to assuming this role by the former MR employee. She stated Level I PASARRs were done prior to admission, then entered into KLOCS. She stated it should then trigger to Life Skills if a Level II PASARR was required. The Administrator stated not every mental health diagnosis would trigger for a Level II evaluation. She stated MR was responsible to ensure the appropriate referrals were made. She stated she was not aware of an issue with the way they were submitting their PASARRs. The Administrator added that she should have been reviewing the PASARRs to ensure they were correct and did not require a Level II. She stated residents could potentially have a negative effect from the failure to complete the PASARR process as required.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life. The QAPI program failed to identify concerns regarding the Preadmission Screening and Resident Review (PASARR) process, affecting nine (Resident (R)3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine sampled residents reviewed for this mandatory screening. In addition, the QAPI program failed to identify issues for four (R6, R8, R22, R33) of four sampled residents reviewed for advance directives, who were not given the opportunity to formulate advance directives, or for whom the process was not accurately completed, with all required documentation. The failure to ensure that the QAPI program systematically reviewed care areas, identified outliers and problems, and implemented action to correct these areas has the potential to affect all 56 residents in the facility. The findings include: Review of a facility policy titled, QAPI Process Standard of Practice, dated 08/2022, revealed the facility QAPI would serve to:1. Ensure consistent and accurate functioning of care delivery systems, incorporating current and evidenced based practice standards as applicable.2. Prevent deviation from care processes to the extent possible.3. Identify issues and concerns with facility systems, as well as identifying opportunities for improvement; and4. Develop and implement plans to correct and/or improve identified areas. 1. Record review revealed a total of 20 out of 25 sampled residents triggered in the Internet Quality Improvement and Evaluation System (IQIES) for not having a Level II Preadmission Screening and Resident Review (PASARR) completed. Further review revealed nine (R3, R8, R9, R12, R15, R17, R25, R33, and R42) of nine residents reviewed for PASARR were not assessed for a Level II PASARR to determine the need for true mental health care and services. (Refer to F645). In an interview with the Social Services Director (SSD) on 09/12/2025 at 3:55 PM, she stated that they stated they do not discuss PASARRs in QAPI meetings. During an interview with the Director of Nursing (DON) on 09/12/2025 at 5:01 PM, she stated she did not know anything about a PASARR, describing it as basically a foreign language to her. The DON, who was a member of the QAPI committee, stated she had not even heard about a PASARR until this recertification survey. She stated the QAPI committee meets monthly, and she attends QAPI meetings. Per the DON, the committee decides what they are working on by departments, with each department presenting what is in their QAPI. Further interview with the DON revealed that she was not sure if PASARRs were reviewed or even discussed in QAPI. The DON stated that the former administrator may have mentioned the subject; however, since it was not directly related to her position, she did not take it all in because she has a lot on her plate.During an interview with the Administrator on 09/12/2025 at 5:50 PM, she stated she was also a Regional [NAME] President. The Administrator, who was a member of the QAPI committee, stated she should have been reviewing Level I PASARR's to ensure they were accurately completed, and ensure that each resident did not need a Level II PASARR. Further interview revealed she thought the PASARRs were being done correctly and was not aware of an issue prior to surveyor identification. 2. Record review and interview related to advance directive forms, for four (R6, R8, R22, and R33) of four residents reviewed for advance directives, revealed the facility failed to ensure that advance directives were complete and accurate, and/or that each resident was afforded the opportunity to formulate an advance directive. (Refer to F578.) Interview with the DON on 09/12/2025 at 5:02PM revealed that Medical Records' duties include performing chart audits to ensure the presence of all required documents. In an interview with the Administrator on 09/12/2025 at 5:53 PM, she stated her expectation was for staff to maintain the advanced directives for the residents. The Administrator also stated that Medical Records does a chart review monthly and audits the records for accuracy. Interview with the Medical Records staff on 09/11/2025 at 2:58 PM confirmed that she does perform chart audits; however, further interview revealed she did not identify the issues regarding advance directive documentation for these residents.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food items were not dated or labeled at the time of storage. Opened food was not covered and/or sealed to prevent contamination. Food in the dry storage area was not free from the potential for contamination, as it was stored in bins on a top shelf approximately 8 inches from the ceiling/sprinkler heads. The failure to ensure food was stored, sealed, and/or dated after opening had the potential to affect 56 of the 56 facility's residents who consumed food from the kitchen.The findings include:Review of an undated facility policy. titled Food Storage, revealed food storage areas should be maintained in a clean, safe, and sanitary manner. Interpretation and implementation of the policy included that food services staff would store all foods or food items not requiring refrigeration, at least 18 inches from sprinkler heads. In addition, the policy noted that prepared food stored in the refrigerator until service should be dated with an expiration date and tightly sealed with plastic wrap, foil, or a lid.Review of an undated facility policy, titled Refrigerators and Freezers, revealed the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and would observe food expiration guidelines. Interpretation and implementation of the policy revealed that all food should be appropriately dated to ensure proper rotation by expiration dates. Per the policy, supervisors would be responsible for ensuring food items were not expired or past perish dates.Observation of Refrigerator 3 revealed an opened package of bacon on the top shelf that was not labeled, dated, or sealed; an opened bag of shredded cheese that was not labeled, dated or sealed; and an opened jar of grape jelly that was not dated. In addition, the refrigerator contained a package of liver loaf with an open date of 08/17/2025 and a discard date of 08/24/2025. Observation of the dry storage room on 09/09/2025 at 10:25 AM revealed a jar of apple cider vinegar that was opened but not dated. Further observation in this area revealed six totes containing dry cereal were stored on a top shelf, 8-inches from the ceiling and sprinkler heads.During an interview with the Kitchen Manager (KM) on 09/09/2025 at 10:40 AM, she stated all food items should be labeled. The KM indicated that the various food items identified during the kitchen tour should be discarded since they were not labeled. Further interview with the KM revealed that the totes should be stored 18 inches from the ceiling and sprinklers. The KM stated that she had previously asked administration for more shelving units in the dry storage area; however, she had not yet received them.During an additional interview with the KM on 09/12/2025 at 9:50 AM, she stated the expectation was that whoever opened an item, would then date and seal the item. The KM added that that meat should be stored on the bottom shelf of the refrigerator to prevent contamination to other foods. She stated she was aware that totes in the dry storage room were too close to the sprinklers and ceiling. The KM added that she had asked for more shelves; however, they had not been provided. During an interview with the Director of Nursing on 09/12/2025 at 5:01 PM, she stated she expected items in the kitchen to be sealed, labeled, and dated to prevent contamination to other items. During an interview with the Interim Administrator/Regional [NAME] President of Region 6 on 09/12/2025 at 5:50 PM, she stated she expected food in the kitchen to be labeled, dated, and sealed so the residents in the facility were not served expired or contaminated foods. Further interview with the Interim Administrator/Regional [NAME] Presidents of Region 6 revealed that she was not aware of the issue with the storage totes in the dry storage room and confirmed that they should not be stored so close to the ceiling/sprinkler heads.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure expired drugs/biologicals were not available for resident use. Two different expired influenza vaccines were stored in one of the facility's two medication refrigeratorsThe findings include: Review of a facility policy, titled Medication Administration Standard of Practice, revised 04/01/2025, revealed that medications that were expired or beyond the usage date should not be administered.Review of a facility policy titled, Label/Store Drugs and Biologicals Standard of Practice, reviewed 10/01/2020, revealed Drugs and biologicals must be labeled in accordance with currently accepted professional principles and include the expiration date when applicable. The policy further stated that expired and or discontinued medication shall be removed for the medication storage area for timely return to the pharmacy and or documented destruction.Observation of one of the facility's two medication storage refrigerators, on 09/10/2025 at 1:00 PM, revealed two separate expired influenza vaccinations stored in the refrigerator. a. Afluria 2024-2025 MDV Vaccine, lot#P100712359, with an expiration date of 06/30/2025. b. Fluzone 2024-2025 High-Dose, a box of 10 single dose prefilled syringes 0/5mL each syringe, lot #UT8425CA, with an expiration date of 06/30/2025.In an interview with Licensed Practical Nurse (LPN) 1 on 09/10/2025 at 1:10 PM, LPN1 stated she was not certain what the requirements were for medication storage, as administration (the Director of Nursing (DON)) was responsible for the task. LPN1 stated that if medications were outdated, staff were to give them to the administrative staff so they could dispose of them.In an interview with Certified Medication Aide (CMA) 1 on 09/10/2025 at 1:31 PM, she stated if she found any expired medications she was to notify the nurse or the Assistant Director of Nursing (ADON) and let them know. Additionally, she stated if she found any expired medications on the medication cart, she was to pull them and take them to the house supervisor for her to dispose of them.Interview with the DON, on 09/12/2025 at 5:02 PM, revealed that in the past (under a previous owner), the pharmacy company which serviced the facility would come in and check that medications were not expired. The DON stated that in the future she would like the DON and the nursing staff to check medications routinely but indicated that this was dependent on if they could get enough staff to do so. Further interview with the DON revealed that potential negative outcomes included a resident receiving an expired vaccination.In an interview with the Administrator on 09/12/2025 at 5:53 PM, she stated she expected the medications to be stored properly.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, and comfortable homelike environment for five (Resident (R) 10, R22, R35, R53, and R57) of five residents reviewed for the environment. The residents, who all resided on one of the three halls in the facility, had missing or broken floor tiles in their rooms and/or expressed concern with housekeeping and maintenance.The findings include:Review of a facility policy titled, Resident Rights, reviewed 04/01/2025, revealed, The resident has the right to a safe, clean, comfortable, and homelike environment.Review of a facility policy titled, Homelike Environment Standard of Practice, reviewed 10/01/2020, revealed The purpose of this policy is that residents are provided with a safe, clean, comfortable, and homelike environment. 1. Review of R10's Facesheet revealed R10 admitted to the facility on [DATE]. Per R10's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2025, the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating R10 had intact cognition.Observation on 09/11/2025 at 09:57 AM revealed broken floor tiles near the bathroom door in R10's and R35's room. An interview was conducted with R10 on 09/11/2025 at 9:59 AM. R10 stated during the interview that housekeeping is kind of shabby on the weekends. She stated that until recently there were times when they went without their rooms being cleaned at all daily; however, that has recently changed. R10 stated the floor tiles by the bathroom have been that way since she moved in the facility. She stated concerns about the building were expressed at a recent resident council meeting. R10 added that she saw staff trying hard to do what they could; however, the facility just does not have enough staff here to control or manage some things that need tending to. 2. Observation on 09/10/2025 at 11:40 AM revealed missing and broken tiles on the floor of R 57's room between the resident's bed and the air conditioning unit.3, Observation on 09/11/2025 at 10:06 AM revealed missing and broken floor tiles in R 53's room between the resident's bed and air conditioning unit that was covered with an area rug. 4, Observation on 09/11/2025 at 10:09 AM revealed broken floor tiles in R22's room near the door. In an interview with Housekeeper (HK) 1 on 09/11/2025 at 10:09 AM, she stated she has been employed at facility for three months. HK 1 confirmed R53 had missing flooring tiles, stating that is why he had a rug over that area. HK1 noted that this end of the facility had the most problems with the flooring because it was the oldest part of the building. She stated the facility was aware of the problem, and when the new owners took over and bought the facility, they stated that they had plans to replace all the flooring in the near future. In an interview with the facility Maintenance Director on 09/12/2025 at 2:36 PM, he stated he had been employed as maintenance for the past two years. He stated it was hard to get replacement tiles for the floor, and they were in the process of getting new tiles. The Maintenance Director stated he would have started with the resident rooms first if it were up to him to make that decision; however, the owners decided they wanted to replace the tiles in the hall first, before doing the resident rooms. He added that the process was started with the previous owners and expressed the hope that once new ownership gets to take over, it will get done quickly. In an interview with the Administrator on 09/12/2025 at 5:53 PM, she stated she expects her facility to be clean. She added that she, herself, had physically replaced floor tiles in resident rooms in the past as needed. The Administrator stated the corporate office had mentioned that previous owners started replacing the tile in the hallways and were next to move to the resident rooms; however, they were then bought out. Per the Administrator, the new owners told her that they are going to continue with that plan. Further interview with the Administrator revealed that the residents know they are trying to fix it and that the staff knows they are supposed to report any broken or missing tiles to maintenance so that they can be repaired.

Based on interview, record review, and review of facility policy, the facility failed to ensure advance directives were completed and reviewed for four (Resident (R)6, R8, R22 and R33) of four sampled residents reviewed for advanced directives. R22 had missing and conflicting information regarding code status. R6, R8, and R33 did not have advance directives or evidence that they were given the opportunity to formulate or decline one. The findings include:Review of the facility's policy titled, Advance Directives Standard of Practice, revised 04/2025, revealed that on admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. Upon admission should the resident have an Advance Directive, copies will be made and placed in the resident's medical record/scanned into the electronic medical record (EMR). Further review of the policy revealed, the facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined to not have decision making capacities regarding Advance Directives and/or treatment provision. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to Advance Directives. Lastly the policy revealed any decision making will be documented in the resident's medical record and communicated to the Interdisciplinary Team (IDT).1. Review of a Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses that included amyotrophic lateral sclerosis (ALS - a neurodegenerative disease that effects the ability to walk, speak, swallow, and breathe), major depressive disorder, anxiety disorder, depression and cognitive communication deficit.Review of a facility document titled, Kentucky Emergency Medical Service (EMS) Do Not Resuscitate (DNR) Order dated [DATE], signed by the resident's Power of Attorney (POA) was found in the Advance Directive section of the resident's medical record.Review of R22's Comprehensive Care Plan, start date [DATE], revealed a choice to be a Do Not Resuscitate (DNR) status with interventions in place to obtain a written DNR order from the physician, if discharged to the hospital, send copy of the written DNR order with other orders, and review code status with each quarterly care conference and as needed.Further medical record review indicated R22's code status of DNR was printed on the Face Sheet. The record also contained an Advance Directive Acknowledgement form, which did not indicate a code status.Review of R22's Physician Order capitulation, dated [DATE], indicated a code status of Cardiopulmonary Resuscitation (CPR), rather than the DNR status which was documented in other locations. There was no evidence in the record to indicate that the resident or the responsible party had requested a code status change, or that required documentation was completed to verify that this order was the resident's current advance directive. During an interview on [DATE] at 3:55 PM, Licensed Practical Nurse (LPN)1 stated she would search the side of the medical record for the red (DNR) or green (CPR) sticker to determine R22's code status, along with looking for Advance Directive documentation in the Advance Directive tab. Further interview with LPN 1 revealed she was unclear as to what documentation she was looking for. Observation at the time of this interview revealed that R22 had a red strip, denoting DNR status, on her chart.During an interview on [DATE] at 4:07 PM, the Social Services Director (SSD) stated code status is to be reviewed every quarter during the Care Conference. The SSD retrieved an admission Packet, which contained the Kentucky (EMS) Do Not Resuscitate (DNR) Order. In addition, the SSD stated that every resident's record was to contain a Cardiopulmonary Resuscitation Consent form which must be provided at the time of admission. Review of the form revealed that it stated the following: Cardiopulmonary Resuscitation ConsentIt is my desire that I be given:______CPR (Cardiopulmonary Resuscitation)______NO CPR (No Cardiopulmonary Resuscitation)During an interview on [DATE] at 4:11 PM, the Director of Nursing (DON) searched R22's medical record under the Advance Directive tab and found the Kentucky (EMS) Do Not Resuscitate (DNR) Order and the Advance Directive Acknowledgement form. The DON was unable to locate the Cardiopulmonary Resuscitation Consent form which was referenced by the SSD.During an interview with the Administrator on [DATE] at 5:53 PM, she stated her expectation was for staff to maintain the Advanced Directives for the residents and for them to be audited as part of the medical record for accuracy. 2. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE], with diagnoses that included dementia, altered mental status, and displaced intertrochanteric fracture of the left femur, subsequent encounter.Review of R6's medical record revealed R6 did not have an advance directive on file. Further review of R6's record revealed no evidence that the facility afforded the resident the opportunity to formulate or decline the creation of an advance directive. 3. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], with diagnoses that included severe bipolar disorder with psychotic features, age related physical debility, and generalized anxiety disorder.Review of R8's medical record revealed R8 did not have an advance directive on file. Further review of R8's record revealed no evidence that the facility afforded the resident the opportunity to formulate or decline the creation of an advance directive. 4. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses that included dementia, epilepsy, and chronic obstructive pulmonary disease (COPD).Review of R33's medical record revealed R33 did not have an advance directive on file. Further review of R33's record revealed no evidence that the facility afforded the resident the opportunity to formulate or decline the creation of an advance directive.In an interview with the SSD on [DATE] at 3:55 PM, she stated she does advance directives with the residents on admission. She stated if the discharging facility sends the information ahead of time, she will use that information for the advance directive status. She stated a lot of times what they get from the hospital regarding the advance directive is not what the resident wants when they get to the facility and are interviewed. The SSD stated she will ask the resident when they get here what they would want. She stated if resident has no one to come to the care conference, she will go to that resident and ask if it is something that they want or not, The SSD stated if the resident has a state guardian, she will still talk to the resident. Further interview with the SSD revealed the potential negative outcome of not formulating an advance directive is that a resident will not get CPR that wanted it or will get it but did not want it. In an interview with the DON on [DATE] at 5:02 PM, the DON stated that to determine resident code status, she would go to the resident's chart and look for the code status paper. The DON noted that if they do not have a paper in their chart, she hopes that the physician would have that information. The DON stated that if she did not have time to go look or if resident was in an active unresponsive situation, she would go ahead and call Emergency Medical Services (EMS). Further interview with the DON revealed that a potential negative outcome is that you could give CPR to someone who does not want CPR or vice versa and subsequently break bones and hurt them unnecessarily. The DON stated Medical Records staff performed chart audits to ensure all required documents were there. In an interview with the Administrator on [DATE] at 5:53 PM, she stated Medical Records does a chart review monthly and audits them for accuracy. She stated she expected staff to maintain the advanced directives for the residents. Interview with the Medical Records staff on [DATE] at 2:58 PM confirmed that she does perform chart audits; however, further interview revealed she did not identify the issues regarding advance directive documentation for these residents.

Based on observation, interview, and review of the facility's policies, the facility failed to consistently post required staffing data. No data was posted for two of four days during the recertification survey. The failure to post required staffing data has the potential to affect any resident who wishes to know the staffing for that day.The findings include:Review of a facility policy titled Census Report, revised 01/02/2013, revealed that it addressed one required component (census) of the mandatory staffing data to be completed and posted daily. The policy stated that a daily census report was to be completed by the charge nurse on duty at midnight. The report is submitted to the Social Service Director or an Administrative designee. No further policies regarding completing and posting the required daily staffing posting were provided prior to exit.Observation during a tour of the facility on 09/09/2025 at 10:00 AM revealed that the required staffing data was not posted.Observation during a tour of the facility on 09/10/2025 at 10:05 AM revealed that the required staffing data was not posted.During an interview on 09/11/2025 at 02:22 PM, the Director of Nursing (DON) stated she had never posted a staff information sheet. The DON, who started serving as the Assistant Director of Nursing (ADON) in January and took over as DON on 09/10/2025, stated she was unaware that this was a regulation. Further interview with the DON revealed she thought the task was not done due to staffing shortages. Interview on 09/12/2025 at 11:25 AM with the Scheduler, who also served as the Staffing Coordinator, revealed that she was not aware of any regulation regarding posting the staffing sheet daily until the Administrator told her to do it on 09/11/2025 (after surveyor intervention).During an interview on 09/12/2025 at 6:13 PM with the Interim Administrator/Regional [NAME] President, she confirmed that she was aware of the regulation requiring posting of the daily staffing/census report. The Interim Administrator stated the Staffing Coordinator was supposed to have been posting the staffing sheet on a daily basis. Further interview with the Interim Administrator revealed she did not know the last time that the required staffing report was posted, nor did she know why it was not done in the past. She stated that the facility had ongoing circumstances, such as a change of owners and new administrative staff and guessed that was the reason that the forms were not completed and posted as required.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of seven sampled residents (R 7). During an observation on 04/09/2025 at 10:20 AM, Licensed Practical Nurse (LPN) 1 failed to sanitize her hands between glove changes. Further, LPN 1, failed to wear gown, mask, and eye protection while providing care to a resident on contact precautions. The findings include: Review of the facility policy titled, Infection Control, dated 08/2001 revealed the facility would provide a safe sanitary and comfortable environment. Review of the facility policy titled, Handwashing, dated 08/2001 revealed handwashing was regarded as the single most important means of preventing the spread of infections. All personnel should follow the established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. Further review of the policy revealed employees would perform appropriate ten to fifteen second handwashing procedures under the following conditions: whenever hands were obviously soiled, before handling clean or soiled dressings, gauze pads, etc, after contact with blood, body fluids, excretions, secretions, mucous membranes, or non intact skin, and after removing gloves. The use of gloves would not replace handwashing. Review of R 7s' Admission Record revealed the facility admitted the resident on 01/24/2012 with diagnoses which included: osteomyelitis, type 2 diabetes mellitus with foot ulcer, pressure ulcer of right buttock, and obesity. During an observation on 04/09/2025 at 10:40 AM, LPN 1 failed to wash her hands after removing a soiled packing strip to right buttock. She double gloved the soiled dressing and placed in trash and put on non-sterile gloves without sanitizing her hands. LPN 1 cleaned the wound with wound cleanser and dried the right buttock area with a dry gauze. She removed her gloves after cleaning and donned a third pair of gloves without sanitizing her hands. LPN 1 packed the wound with packing strips and Dakin's solution and placed a border gauze over the wound. She removed her gloves, and began to clean up the bedside table. Further LPN 1 failed to adhere to the contact isolation protocol and use the appropriate personal protective equipment such as a gown, mask, and eye protection while providing wound care. During an interview with LPN 1 on 04/10/2025 at 10:16 AM, she stated she wasn't aware the resident was on contact isolation. She stated she should have worn a gown, eye protection and mask. LPN 1 further stated she should have washed her hands between glove changes. During an interview with the Director of Nursing (DON) on 04/10/2025 at 11:13 AM, she stated she expected staff to follow the contact isolation protocol when performing close contact care with residents. She further stated she expected staff to follow the facility policies concerning handwashing with donning and doffing gloves during care. During an interview on 04/10/2025 at 11:22 AM, the Administrator stated she expected all staff to follow contact isolation guidelines and facility policies concerning handwashing.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents received treatment to prevent a urinary tract infection for one (1) of fifteen (15) sampled residents (Resident #41). Observation revealed facility staff failed to change gloves, wash their hands, and obtain clean water between dirty and clean tasks while providing indwelling urinary catheter care for Resident #41. The findings include: Review of the facility's, Catheter Care Policy, undated, revealed the policy stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Female: 9. Gently separate the labia and expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner. 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. 13. Dry area with towel. Review of an undated facility policy titled, Infection Prevention and Control Program, revealed the facility's hand hygiene protocol was for, All staff shall wash their hands .after handling contaminated objects. Review of the CDC, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings - Recommendations of the Healthcare Infection Control Practices Advisory Committee, dated 03/15/2017, from https://www.cdc.gov/hicpac/pdf/core-practices.pdf, revealed hand hygiene was to be performed, Before moving from work on a soiled body site to a clean body site on the same resident. Review of Resident #34's Admission Record revealed the facility initially admitted the resident on 01/20/2022. Continued review revealed the facility readmitted Resident #34 on 03/16/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], the facility readmitted Resident #41 from an acute care hospital on 03/16/2022. Continued review revealed the facility assessed Resident #41 as rarely/never understood, severely impaired cognitively, and incontinent of bladder and bowel with a Urinary Tract Infection ([CONDITION(S)]) in the last thirty (30) days. Further review revealed the facility had additionally assessed the resident to require extensive assistance of two (2) for toilet use and personal hygiene on readmission. Review of a physician Telephone Order, dated 04/01/2022 for Resident #41 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the order noted to leave the urinary catheter anchored if more than 300 milliliters (mls) of urine was retained in the bladder. Review of a physician Telephone Order, dated 04/11/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's Care Plan, initiated 04/01/2022, revealed the resident had an indwelling urinary catheter due to urinary retention. Further review revealed the care plan noted nursing staff were to provide Resident #41 with catheter care to include perineal care, each shift and as needed. Review of Resident #41's Infection Care Plan, dated 04/11/2022, revealed the resident required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of perineal and indwelling urinary catheter care provided for Resident #41 on 04/22/2022 at 8:36 AM, by Certified Nursing Assistant (CNA) #1 and CNA #2, revealed the CNAs washed their hands and applied gloves. Observation revealed CNA #1 obtained a pan of water and placed it on the resident's overbed table, and CNA #2 removed Resident #41's incontinence brief, and placed the brief in a trash bag. Continued observation revealed CNA #2 did not wash her hands or change her gloves before proceeding to touch Resident #41's legs to assist the resident in holding his/her legs open while CNA #1 provided the urinary catheter care. Per observation, CNA #1 provided the urinary catheter care; however, did not change gloves or change the water after cleansing Resident #41's urinary meatus (opening to the urinary tract), perineum (area between the vagina and anus), urinary catheter tubing, or the labia area (skin fold around the vagina). Further observation revealed CNA #1 obtained a new cloth to cleanse and rinse each of the areas, but failed to change gloves, and continued to utilize the same pan of water to moisten each clean cloth. Observation further revealed CNA #1 and CNA #2 applied Resident #41's clean adult brief without changing their gloves. Additionally, CNA #1 and CNA #2 removed their gloves and washed their hands after applying the resident's brief. Interview on 04/22/2022 at 9:02 AM, with CNA #1 revealed the CNA should have changed gloves after the cleansing task was done. CNA #1 stated however, she had forgotten to change her gloves. A follow up interview on 04/22/2022 at 11:16 AM, with CNA #1 revealed gloves should be changed during urinary catheter care to prevent contamination of cleansed areas. CNA #1 further stated the water used should have been changed during the urinary catheter care between cleaning Resident #41's labia and the outside area. Interview on 04/22/2022 at 9:07 AM, with CNA #2 revealed her gloves should have been changed after cleaning the urinary catheter. Further interview revealed CNA #2 confirmed she and CNA #1 had not changed their gloves during the perineal and urinary catheter care; however, they should have. Interview on 04/22/2022 at 9:11 AM, with Licensed Practical Nurse (LPN) #1 revealed staff should have changed their gloves during urinary catheter care after the area was cleansed. Interview on 04/22/2022 at 9:20 AM, with the Director of Nursing (DON) revealed staff should change their gloves during urinary catheter care when going from dirty to clean tasks. A follow up interview on 04/22/2022 at 1:41 PM, with the DON revealed staff should have changed their gloves during urinary catheter care to avoid contamination. Per the DON, the water used should have absolutely been changed during catheter care because the water would be considered contaminated. Further interview revealed the DON's expectation was for staff to change gloves and water if it was contaminated to help prevent infections for residents. Interview on 04/22/2022 at 10:12 AM, with the Administrator revealed her expectation was for staff to change gloves between dirty to clean tasks.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure one (1) of fifteen (15) sampled residents, Resident #34, received food that accommodated the resident's food preferences in his/her meals served by the facility. Interview and observation revealed the facility failed to honor Resident #34's preferences/dislikes of mashed potatoes and beans by serving those food items to the resident. The findings include: Review of the facility policy titled, Resident Food Choice, revised 12/20/2021, revealed upon admission, or within twenty-four (24) hours of admission, the Dietician or nursing staff were to identify a resident's food preferences by asking a list of questions, in reference to foods that they liked and disliked. Continued review revealed the Dietary Manager was responsible in relaying the information obtained into the resident's diet card. Per review of the policy, dietary staff members were in charge of checking residents' meal tickets before sending them out on trays to ensure all resident preferences were being followed and for accuracy. Further review revealed nursing staff were to review the accuracy of meal tickets and the meal tray before delivering the tray to the resident. In addition, policy review revealed if a resident was presented with an food item they disliked, nursing staff were to then offer the resident an alternative. Review of Resident #34's medical record revealed the facility admitted the resident on 03/23/2022, with diagnoses that included: Type II Diabetes Mellitus; [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction; Morbid Obesity; and [CONDITION(S)]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderately impaired cognition. Further review revealed the MDS noted Resident #34 required supervision and set up help for eating and had not sustained a weight loss. Review of the Daily Resident Menu, for the lunch meal on 04/19/2022, revealed the main menu food item being served was barbeque on cornbread, and the alternate protein was lemon pepper chicken. Continued review of the 04/19/2022 lunch menu revealed there were no alternative side dish choices for the meal on that date. In addition, the menu review revealed the side dishes for the main meal and the alternate meal were the same, which were noted as baked beans, mashed potatoes, and pudding. Review of Resident #34's meal tray card dated 04/19/2022 revealed, Meal note: no mashed potatoes. Special Notes: Dislikes: Mashed potatoes, deviled eggs, turnip greens, kraut, and beans. Observation on 04/19/2022 at 11:55 AM, of Resident #34 revealed the resident was seated in a wheelchair at a table in the 200 Hall dining room. Continued observation revealed Resident #34 was served a lunch meal which included barbequed meat, mashed potatoes, baked beans, cornbread, and chocolate pudding. Interview with Resident #34, during the observation, revealed on the resident's admission to the facility he/she had discussed his/her food likes and dislikes with the Dietary Manager. Per Resident #34, mashed potatoes and beans were food item dislikes discussed with the Dietary Manager, which the resident had told dietary staff he/she did not like those foods and should not been served to him/her. Further interview revealed Resident #34 stated the facility served mashed potatoes frequently to him/her, even though the resident had informed staff he/she disliked those foods. Interview on 04/19/2022 at 12:10 PM, with Certified Nursing Assistant (CNA) #1 revealed she served Resident #34's lunch meal tray to the resident in the dining room. The CNA stated all staff, including CNAs serving meal trays and the dietary staff, were responsible for ensuring residents were served their likes and preferences foods. Further interview revealed however, CNA #1 had not looked at Resident #34's meal tray card for the resident's dislikes prior to serving the tray. In addition, CNA #1 confirmed Resident #34 had been served food items from their disliked foods list. Interview on 04/19/2022 at 12:17 PM, with Dietary Employee (DE) #1 revealed she plated the food items for the lunch meal service on 04/19/2022. DE #1 stated residents' likes and dislikes related to food items should have been honored. Further interview revealed it was the line cooks and dietary aides' responsibility to serve food according to the residents' meal tray cards and to follow the residents' prescribed diet and food preferences. Interview with DE #2 on 04/19/2022 at 12:20 PM, revealed since the menu had food items on it which Resident #34 did not like, dietary staff should have offered the resident alternate food items. Additional interview with DE #2 on 04/22/2022 at 8:57 AM, revealed the cook plated the lunch menu items and placed the plate on the steam table. DE #2 stated she had been the dietary aide on the line on 04/19/2022, and she should have looked at the meal tray cards to check for residents' preferences. Per DE #2, that day had been overwhelming however, and she just missed seeing Resident #34's disliked food items. Further interview revealed DE #2's expectations were that residents' likes and dislikes for food were honored and she knew Resident #34 did not like mashed potatoes and beans. Interview on 04/22/2022 at 9:03 AM, with the Certified Dietary Manager (CDM) revealed Resident #34's food preferences had been initially reviewed with the resident on admission to the facility in order to determine his/her food likes and dislikes. The CDM stated Resident #34 had no food preference changes since his/her admission. Per interview, the CDM revealed for residents' lunch and dinner meals, a daily menu sheet which included the main meal and alternate meal, was sent to residents for them to decide what they wanted to eat. According to the CDM, when the dietary aides got the daily menu sheets back from residents, the cook wrote each resident's choices on the meal tray card. Continued interview revealed Resident #34 had chosen the main meal on 04/19/2022; however, the side food items for the main meal and the alternate meal had been the same (mashed potatoes and beans), with the protein being the only difference. According to the CDM, the alternate side dish choices should have been different from the main meal's side items. The CDM stated dietary staff should have followed up with Resident #34 after getting the menu sheet back and compared it to the resident's meal tray card in order for Resident #34's choices to have been honored. Interview revealed staff were aware Resident #34 did not like mashed potatoes and the resident had thrown those food items on the floor before when served to him/her. Additional interview with the CDM on 04/19/2022 at 12:23 PM, revealed dietary staff had been in-serviced to check residents' meal cards before sending the meals to residents to ensure the residents' preferences and diets were honored. In addition, the CDM revealed Resident #34 should not have been served mashed potatoes or beans according to the resident's disliked food items. Interview on 04/22/2022 at 9:36 AM, with the Administrator revealed dietary staff were responsible for reviewing meal tray cards to ensure accuracy of residents' meals after the meals had been plated and placed on the cart. The Administrator revealed CNAs and nurses were responsible for checking residents' meal tray cards for accuracy before placing the tray down in front of the residents. She stated she was unaware the same side dishes were being offered for the main meals and alternate meal choices on 04/19/2022. Further interview revealed her expectations were for residents' food preferences to be honored and for different alternate meal choice food items to be provided to ensure that occurred. The Administrator further stated dietary staff, after reviewing Resident #34's daily meal sheet and meal tray card, should have followed up with the resident and offered different food choices to him/her. Interview on 04/22/2022 at 1:33 PM, with the Director of Nursing (DON) revealed she expected residents to be served the foods they liked and to be offered alternate food items as necessary. Per interview, the DON stated it was not typical for the main meal and alternate meal choices to contain the same sides dishes. According to the DON, dietary and nursing were responsible for checking residents' meal tray cards to ensure accuracy.

Based on observation, interview and facility policy review it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment outside the facility related to debris on the grounds/walkways, ceiling tiles with stains, chipping paint noted on the closet doors, and exposed dry wall. The findings include: Review of the facility policy titled, Environmental Services, not dated, revealed the facility is to provide a safe, clean, comfortable, and home-like environment, allowing the resident to use his or her personal belongings to the extent possible. 1. Observation of the resident smoking area on 01/15/2020 at 2:05 PM, revealed multiple discarded cigarette butts on the sidewalk and lawn. Observation of the front entrance on 01/16/2020 at 2:52 PM, revealed a discarded water bottle, an old cigarette lighter, and multiple cigarette butts on the sidewalk and lawn area. Interview with the Housekeeping Supervisor on 01/17/2020 at 3:15 PM, revealed the residents' rooms are cleaned daily, to include wiping down doors. She stated housekeeping staff sweeps the breezeways, front side-walks, and resident smoking areas to keep the areas free of cigarette butts and debris. The Housekeeping Supervisor revealed she would ensure these areas were clean and checked more often. 2. Observations of the two-hundred hall on 01/17/2020 at 9:20 AM, revealed four (4) ceiling tiles with large dry, dark brown, stains. Continued observation of room [ROOM NUMBER] and room [ROOM NUMBER], revealed large areas of chipping paint noted on the closet doors. Further observation of room [ROOM NUMBER] revealed an area of exposed dry wall. Interview with the Maintenance Director on 11/17/2020 at 3:20 PM, revealed he is in the process of painting some rooms on the one-hundred (100) hall and making some overall improvements. He stated the facility should be clean and homelike for residents. The Maintenance Director further revealed it was the staff's responsibility to log any maintenance concerns in the maintenance binder kept on each hall. He stated he checks the binders each morning for needed repairs.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure medical records, were complete and accurately documented for one (1) unsampled resident not in the selected sampled of (17) (Resident #900). On 01/07/2020, Resident 900 was identified to be vomiting and having diarrhea; however, licensed staff failed to document the resident's change in condition, vital signs, and assessment of the resident's condition before and after administering medication for the vomiting and diarrhea. The findings include: Review of facility policy titled, Charting and Documentation, not dated, revealed all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Further review of the facility policy revealed all observations, medications administered, services performed, etc., must be documented in the resident's clinical records; and, all incidents, accidents, or changes in the resident's condition must be recorded. Review of facility policy titled, Vital Signs and Weight Protocol, not dated, revealed vital signs will be obtained following the occurrence of any incident, every shift for seventy-two (72) hours. Review of facility policy titled, PRN Medications, not dated, revealed PRN medication refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness. Further review of facility policy revealed documentation will be provided in the resident's medical record to show adequate indications for a medication's use and the diagnosed condition for which is was prescribed. When administering a PRN medication: document the time of administration and evaluate the effectiveness of the medication and document the findings. Record review revealed the facility readmitted Resident #900 on 11/18/19 with [DIAGNOSES REDACTED]. Review of Nurse's Note dated 01/07/2020 revealed a new order received from physician for [MEDICATION NAME] four (4) mg every six (6) hours PRN via [DEVICE] ([DEVICE]) for Nausea and Vomiting for ten (10) days; and, Immodium two (2) tabs first loose stool then one (1) tab after each loose stool up to eight (8) tabs in twenty-four (24) hours PRN for 10 days for diarrhea. However, further review revealed there was no documentation of the resident's assessment to indicate the resident's change in condition and the need for the medication to include vital signs; per facility policy. In addition, review of Resident #900's (MONTH) 2019 Medication Administration Record (MAR) revealed LPN #1 administered [MEDICATION NAME] 4 mg via [DEVICE] for vomiting on 01/07/2020 at 2:00 PM and Immodium 2 tabs for diarrhea on 01/07/2020 at 3:00 PM; and LPN #2 administered the medications on 01/07/2020 at 9:00 PM. However, further review of the MAR and review Nurse Notes dated 01/07/2020 and 01/08/2020, revealed there was no documentation to address the resident's assessment due to change in condition and no documentation of the resident's condition prior to administering the medication and of the effectiveness of the medications, per facility policy. Interview with LPN #1 on 01/16/2020 at 12:05 PM, revealed she failed to obtain vital signs on Resident #900 when the resident began to have symptoms of diarrhea and vomiting; and, failed to complete an evaluation of the effectiveness of the medication administered for A telephone interview with LPN #2 on 01/16/2020 at 4:30 PM, revealed she failed to assess the medication's effectiveness for Resident #900 on 01/07/2020 at 9:00 PM. Interview with Director of Nursing (DON) on 01/17/2020 at 4:30 PM, revealed she expected the nurses to document resident assessments when there was a change in condition and before and after administering PRN medications to evaluate the effectiveness of PRN medications administered.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure therapeutic diets prescribed by the attending physician were followed, and meet preference accommodation for one (1) of seventeen (17) sampled Residents (Resident #30). Meal observation on 01/15/2020 at 12:45 PM revealed a magic cup not being served as ordered during a meal service, and a chocolate shake served but listed on the tray card as dislikes The findings Include: Review of the facility policy titled, Resident Nutrition Services, dated 01/05/15, revealed each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt meal service and appropriate feeding assistance by interpretation and implementation of .1. Nursing personnel will assure that residents are served the correct food tray. 2. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to assure that the correct food tray is being served to the resident. If there in doubt, the Nurse Supervisor will check the written physician's order. 3. If an incorrect meal has been delivered, nursing staff will report it to the Food Services Manager so that a new food tray can be issues. 4. Nursing staff and a Clinical Dietitian will assess each resident's food likes, dislikes, and eating habits. They will record this information on the resident care plan. Record review revealed the facility admitted Resident #30 on 04/17/19 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 12/09/19 revealed the facility assessed Resident #30's cognition to be severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of a Change of Diet form, dated 03/22/19 revealed Resident #30 was to received a magic cup three (3) times a day (TID) with meals. Review of Resident #30 tray card revealed the resident was to receive magic cup (a dietary supplement) with meal, and no chocolate shakes. However, observation on 01/15/2020 at 11:34 AM in the 100 hall dining room revealed Resident #1's tray was passed by Registered Nurse (RN) #2 and the meal tray contained a chocolate shake and no magic cup. Interview with RN #2 on 01/15/2020 at 2:39 PM revealed Resident #30 was not allergic to chocolate but the son had told them the resident did not like chocolate. She stated the the magic cup had been ordered for weight loss. The RN further revealed she did not look at the meal card prior to delivering the tray, because she felt she knew the resident' well enough without looking at the card, but would read the whole care next time prior to delivering a tray. Interview with the Dietary Manager on 01/16/2020 at 12:30 PM revealed the mistake should have been caught by kitchen staff before delivering the tray through the kitchen window, or by the staff that delivered the tray to the resident. Interview with the Director of Nursing (DON) on 01/17/2020 at 12:40 PM revealed she expected all residents to receive what had been ordered, as well as their preferences on their meal tray.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (1) unsampled resident not in the selected sampled of seventeen (17) residents (Resident 900). Resident #900 was identified to be experiencing nausea and vomiting on 01/07/2020. Staff failed to obtain vital signs when Resident #900 was identified to have the change in condition and failed to assess the effectiveness of as needed (PRN) medication after administered; per facility policy. The findings include: Review of the facility policy titled, Change in Resident Condition or Status, NF, not dated, revealed the nurse supervisor/charge nurse would record in the resident's medical record information relative to changes in the resident medical/mental condition or status. Review of facility policy titled, Vital Signs and Weight Protocol, not dated, revealed resident's exhibiting signs/symptoms of active infection, vital signs would be obtained every shift until antibiotic therapy was completed and following the occurrence of any incident, vital signs would be obtained every shift for seventy-two (72) hours. Review of facility policy titled, PRN Medications, not dated, revealed PRN medication refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness. Further review of facility policy revealed documentation will be provided in the resident's medical record to show adequate indications for a medication's use and the diagnosed condition for which is was prescribed. When administering a PRN medication: document the time of administration and evaluate the effectiveness of the medication and document the findings. Record review revealed the facility readmitted Resident #900 on 11/18/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/13/19, revealed the facility assessed Resident #900's Brief Interview for Mental Status (BIMS) score as unrated, which indicated the resident was not interviewable. Further review of MDS revealed Resident #47 required extensive assist of two (2) for bed mobility, transfer, and toilet use. Resident #900 was not in facility or available for observation during investigation. Review of the Comprehensive Care Plan, dated 10/24/19 revealed Resident #900 required tube feeding per MD orders related to a [DIAGNOSES REDACTED]. Further review revealed orders that resident remain on nothing by mouth (NPO) status due to dysphagia and risk for Aspiration with other pertinent interventions listed below: 1. Head of bed to elevated to 30 degrees at all times. 2. Listen to lung sounds each shift and document. 3. (MONTH) suction as needed. 4. Monitor/document/report PRN (as needed) and signs and symptoms of aspiration-fever, shortness of air, tube dislodged, infection at tube site, as well at diarrhea, nausea/vomiting and dehydration. Review of Nurse's Note dated 01/07/2020 revealed new order received from physician for [MEDICATION NAME] four (4) mg every six (6) hours PRN via [DEVICE] ([DEVICE]) for Nausea and Vomiting for ten (10) days; and, Immodium two (2) tabs first loose stool then one (1) tab after each loose stool up to eight (8) tabs in twenty-four (24) hours PRN for 10 days for diarrhea. Further review revealed there was no documented evidence the nurse obtained vital signs when identified the resident's change in condition per facility policy. Review of Resident #900's (MONTH) 2019 Medication Administration Record (MAR)revealed LPN #1 administered [MEDICATION NAME] 4 mg via [DEVICE] on 01/07/2020 at 2:00 PM and Immodium two (2) tabs on 01/07/2020 at 3:00 PM; and, LPN #2 administered the medications on 01/07/2020 at 9:00 PM. However, further review of the MAR and review Nurse Notes dated 01/07/2020 and 01/08/2020, revealed there was no documented evidence the nurse performed an assessment before and after the medications were administered, per facility policy. Interview with LPN #1 on 01/16/2020 at 12:05 PM, revealed she failed to obtain vital signs on Resident #900 when the resident began to have symptoms of diarrhea and vomiting; and, failed to complete an evaluation of the effectiveness of the medication administered for Resident #900's symptoms of diarrhea and vomiting on 01/07/2020 at 2:00 PM. LPN #1 reported the vital signs and assessment should have been documented in the nurses notes and/or MAR. A telephone interview with LPN #2 on 01/16/2020 at 4:30 PM, revealed she failed to assess the medication's effectiveness for Resident #900 on 01/07/2020 at 9:00 PM. Interview with Director of Nursing (DON) on 01/17/2020 at 4:30 PM, revealed she expected the nurses to perform resident assessments before administering PRN medications and to evaluate the effectiveness of PRN medications administered. She stated she also expected the nurses to document the assessments in the Nurse's Notes and to document the administration of medications on the MAR of each resident's medical record.

Based on observation, interview and facility policy review, it was determined the facility failed to accommodate privacy for one (1) of seventeen (17) sampled residents related to staff not ensuring resident was provided privacy during care. The findings include: Review of facility policy titled, Privacy and Dignity, last revised 06/21/12, revealed it is the intent of the facility to provide each resident with a dignified existence as stipulated in the Resident Rights. Each resident will be provided privacy during bathing, grooming, peri-care, wound care and any other personal care. Privacy curtain and drapes/blinds will be pulled closed in bedrooms and shower rooms when providing wound care or personal care. Record review revealed the facility admitted Resident #1 on 04/25/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/15/2020 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Observation of Resident #1 receiving physical therapy on 01/15/2020 at 2:40 PM revealed the shade on the window to outside was open. In addition, a utility vehicle could be seen with workers on street from Resident #1's window. Interview with Physical Therapy Assistant (PTA) #1 on 01/15/2020 at approximately 2:43 PM revealed Resident #1 should not have to ask for privacy but it should be ensured during care. Observation of Resident #1's incontinent care by Certified Nursing Assistant (CNA) #8 on 01/16/20 at 2:57 revealed the blinds on window were open and Resident #1 asked staff to close the blinds during care. Interview with House Supervisor/Licensed Practical Nurse (LPN) #4 revealed Resident # 1's blinds pulled, doors shut, and privacy curtains between residents closed; residents covered during care as much as possible and staff should automatically know to close blinds during care. Additionally UM/LPN #4 stated that residents should not have to ask for these things to be done. Interview with the Director of Nursing (DON), on 01/17/2020 at approximately 5:10 PM revealed she expected privacy to be ensured for residents when personal care or therapy was being provided.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide services by qualified personnel according to the written plan of care for one (1) of three (3) sampled residents (Resident #1), related to supervision. The facility assessed and care planned Resident #1 as being at risk for elopement. Interventions included to distract the resident when he/she was wandering and exit seeking. However, on 11/23/14 Resident #1 was noted wandering throughout the building and attempting to go out an exit door. There was no documented evidence staff attempted to distract the resident, as per the resident's care plan. At approximately 1:15 PM, Resident #1 was noted outside the exit door of the 200 Wing by two (2) staff members, Certified Nursing Assistant (CNA) #3 and CNA #4. The facility's failure to ensure care and services were provided according to the resident's care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/26/14 and determined to exist on 11/23/14. The facility was notified of the Immediate Jeopardy on 11/26/14. An acceptable Allegation of Compliance (AoC) was received on 12/10/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/28/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Corrections (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, "Elopement of Patient", revised 10/27/12, revealed "An elopement care plan is developed to include preventative elopement interventions. Further review revealed all staff is informed/educated to 'at risk' residents' status and care plan interventions to reduce/prevent elopement." Record review revealed the facility admitted Resident #1 on 07/22/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/30/14, revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was not interviewable. Review of the Elopement Risk Assessment, dated 10/30/14, revealed Resident #1 was identified at risk for elopement. Review of Resident #1's Comprehensive Care Plan, dated 07/28/14, revealed the resident was considered at risk for elopement related to impaired safety awareness and [DIAGNOSES REDACTED]. Interventions included for staff to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books the resident prefers and, to intervene as appropriate. Review of the facility's Unusual Occurrence Report, dated 11/23/14, revealed Resident #1 was witnessed coming in from outside at the 200 Wing West entry. Further review revealed the Care Trak did not alarm when Resident #1 came through the door. Review of the witnesses' written statements revealed CNA #3 and CNA #4 witnessed the incident and documented the Care Trak alarm did sound once the resident was back in the building. Further review of the Report revealed it was unknown which door the resident exited. Observations of Resident #1, on 11/25/14 at 1:35 PM; and, on 11/26/14 at 10:50 AM, revealed the resident was ambulating throughout the facility at a fast pace. A Care Trak bracelet was noted to the resident's right ankle. On 11/26/14 at 11:00 AM, the resident attempted to exit the building with other residents who were going out to participate in a smoke break. The Sitter, assigned to Resident #1, redirected the resident from walking out to the breezeway with the residents that were smoking. Interview with CNA #4, on 11/25/14 at 3:40 PM, revealed on 11/23/14 (Sunday) at approximately 1:00 PM to 1:15 PM, she and CNA #3 noted Resident #1 attempting to enter the building at the 200 Wing exit door. Further interview revealed Resident #1 was escorted back into the building. Because of Resident #1's impaired cognition, the resident was not able to identify how he/she got outside the building. Interview with Medication Aide (MA) #1, on 11/25/14 at 2:55 PM, revealed she noticed Resident #1 walking throughout the facility on 11/23/14. She stated it was approximately 1:00 PM the last time she saw him/her. Further interview revealed she witnessed Resident #1 go to the exit door and stick his/her head out of the door; however, the resident turned around and left the exit door when the Care Trak alarm sounded. MA #1 was unable to identify the time of the incident. Further interview revealed she did not utilize the care plan intervention to redirect the resident. Interview with Registered Nurse (RN) #1, on 11/25/14 at 3:05 PM, revealed she was the 100 Wing Charge Nurse on 11/23/14 when Resident #1 exited the facility. RN #1 stated the last time she saw Resident #1 prior to the elopement, was at approximately 1:00 PM or 1:05 PM. She stated the resident was wandering past the Nurse's Station on the 100 Wing drinking a carton of milk. Interview with CNA #2, on 11/26/14 at 1:25 PM, revealed she was the CNA assigned to care for Resident #1 on 11/23/14 on day shift. She stated the last time she saw Resident #1 prior to the resident exiting the building, without staff knowledge, was at 11:45 AM walking in the hallway of the 100 Wing. She stated Resident #1 wanders and was considered an elopement risk. CNA #2 further revealed Resident #1 was care planned as an elopement risk and had a Care Trak bracelet. She stated if the resident attempted to leave the facility the Care Trak would go "off " unless the alarm was de-activated at the exit doors. Further interview revealed CNA #2 was serving lunch trays and did not intervene or distract Resident #1 while he/she was walking in the hallway. Interview with Assistant Director of Nursing (ADON) on 11/26/14 at 4:00 PM, revealed on 11/23/14 between approximately 1:15 P.M. to 1:30 PM, she received a call from RN #1 reporting Resident #1 was standing at the 200 Wing back door trying to get back into facility. Further interview revealed RN #1 was unsure how, when, or where Resident #1 exited the facility. The ADON stated she would expect staff to provide activity for Resident #1 when he/she was noted wandering to keep him/her focused on a task or alternate diversion, per the care plan. Interview with the Administrator, on 11/26/14 at 5:15 PM, revealed she received a call, on 11/23/14 around 1:30 PM from RN #1, informing her Resident #1 got out the building without staff's knowledge and was only witnessed attempting to get back into facility. Further interview revealed Resident #1 was not observed when the other residents were taken to the breezeway to smoke at the 1:00 PM break. The Administrator revealed during her investigation of the incident it was identified CNA #1 silenced the Care Trak alarm at the exit door while assisting residents out to the breezeway to smoke. She further stated any resident with a Care Trak bracelet could exit the facility without the alarm sounding. The Administrator stated the elopement could be prevented by staff checking all areas prior to disarming the Care Trak alarm. Further interview with the Administrator, on 11/26/14 at 6:30 PM, revealed Resident #1's care plan identified interventions to divert/distract the resident when he/she was noted wandering aimlessly. Further interview revealed her expectation was for staff to utilize interventions listed in the care plan, by providing a structured activity and intervene as appropriate, to distract the resident from wandering The facility implemented the following actions to remove the Immediate Jeopardy: 1. RN #1 completed a full body assessment, including vital signs, on Resident #1 on 11/23/14, with no injuries noted. 2. RN #1 notified the ADON, Interim Administrator, Power of Attorney (POA), and Medical Director (MD) of the elopement on 11/23/14. 3. RN #1 completed an unusual occurrence report and documented in the resident's medical record. She indicated that it was raining outside and the resident's clothes were dry on 11/23/14. 4. Resident #1 was monitored and assigned a 1:1 sitter on 11/23/14. 5. LPN #1 checked all door alarms to ensure proper functioning on 11/23/14. Further interview revealed all exit doors did not exhibit any malfunction with the Care Trak transmitter alarm system. 6. All doors and all residents wearing a Care Trak were rechecked by the Maintenance Director for proper functioning on 11/24/14. All Systems were functioning. 7. The Administrator and Quality Assurance Team consulted and involved the Medical Director in all aspects of the process; including notification of the elopement, conference calls, Quality Assurance meetings, the plan of action, the issuance of Immediate Jeopardy, and any recommendation/suggestions made by the team and Medical Director about changes to the facility's policies and system changes to remove the immediate jeopardy. 8. Resident #1's care plan was reviewed and updated on 11/24/14 by the Social Service Director. The Administrator reviewed and updated Resident #1 Elopement Risk Assessment on 11/24/14. 9. The MDS Coordinator revised Resident #1's Elopement Care Plan and interventions on 11/26/14 to include: Resident will wander safely within the environment as evidenced by no falls or injury through review date. On 11/27/14, MDS Coordinator reviewed and/or revised elopement care plan goals for ten (10) residents the facility assessed to be at risk for elopement. 10. The Social Services Director (SSD), on 11/24/14, reviewed and updated Resident #1's care plan. The SSD also updated Elopement Risk Assessments for all other residents who were assessed to be at risk for elopement 11. The House Supervisor completed an audit in Point Click Care (electronic medical records), on 11/26/14, to ensure the ten (10) residents assessed at risk for elopement had "Wear Care Trak bracelet" included in their tasks on a daily basis. 12. On 11/26/14, the Administrator counseled CNA #1 for failure to monitor the residents during the smoke break. The DON counseled RN #1 for failure to supervise and keep residents who wander safe. The Corporate Compliance officer counseled the Administrator for failure to follow State and federal nursing home regulations and ensure the facility's policies were being followed. 13. On 11/26/14, the Facility Orientation form used by Department Heads to orient new staff was updated by the Administrator to include information regarding the following: Elopement, Care Trak, Care Plans, and Smoking Policy. 14. On 11/27/14, the Maintenance Director and ADON, inserviced all licensed staff on how to check exit doors for proper functioning using the Care Trak transmitter and documenting on the Care Trak Monitor log. 15. On 11/25/14, in-service training was initiated on the Elopement and Care Trak policy by the House Supervisor, MDS Coordinator, and ADON to educate on the facility's policy revisions and system changes. 16. On 11/26/14, the Administrator, DON, ADON updated the Elopement, Care Trak, Care Plan, and system changes were made to the Smoking Policy. 17. The Housekeeping Supervisor in-serviced housekeeping staff on 11/26/14 on placing the dirty linen cart in a different location. 18. On 11/25/14, Quality Assurance form N-24 titled, "Elopement" was reviewed and revised by Administrator to include the question, "Has Care Trak been added to the task in Point Click Care". 19. On 11/27/14, Quality Assurance form N-19 titled, "Care Plans", was reviewed by the Administrator and completed by the MDS Coordinator. 20. On 11/26/14 through 11/27/14, all staff was in-serviced on the system changes made to the revised Elopement, Care Trak, and Smoking Policy to include: Department Heads, Licensed Nurses, Certified Medication Aides, CNAs, Environmental Services, Activity Director, and Activity Assistant, Dietary Manager, Social Services Director, Office Manager, Medical Records, and all PRN staff. The in-service was conducted by the House Supervisor, ADON, Maintenance Director, and MDS Coordinator. Staff in-serviced on the following system changes: The Charge Nurse assigns (2) staff members to take the residents out to smoke. The additional staff member's responsibility is to watch each resident exit and re-enter the building safely. The weekend Charge Nurse is responsible for checking and documenting that Care Trak doors are functioning properly. All newly hired staff will receive orientation on the revised Facility Orientation Form. The dirty linen carts are not to block the view of the 200 Wing Hall door from the smoking area. 21. The Maintenance Director and ADON, on 11/27/14, demonstrated and re-inserviced all licensed staff on how to check the exit doors for proper functioning using the Care Trak transmitter and how to document on the Care Trak Monitoring Sheets. 22. The Quality Assurance form N-24, "Elopement", will be completed weekly for all residents assessed to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per the CQI schedule by the Social Services Director. 23. Quality Assurance form N-19 titled, "Care Plans", will be completed weekly for all residents to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per the CQI schedule by the MDS Coordinator. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #1's chart, on 12/10/14 at 4:45 PM, revealed on 11/23/14 at 1:15 PM, a full body assessment including vital signs were completed by RN #1. 2. Interview with ADON, on 12/12/14 at 9:45 AM, revealed she received a call from RN #1, on 11/23/14 at approximately 1:15 to 1:30 PM, informing her of Resident #1 elopement. Interview with Interim Administrator on 12/12/14 at 10:00 AM, revealed on 11/23/14 at 1:30 PM, she received a call from RN #1 informing her of Resident #1 elopement. Interview with Resident #1 POA/husband, on 11/26/14 at 1:45 PM, revealed on Sunday 11/23/14 at 2:00 PM he received a call from RN #1 informing him Resident #1 got outside the facility without staff knowledge. Interview with Resident #1's Primary Care Physician (PCP) and the facility's Medical Director, on 11/26/14 at 2:00 PM, revealed she was notified on 11/23/14 of Resident #1's elopement. 3. Review of the facility's investigation revealed RN #1 completed an unusual occurrence report, on 11/23/14, regarding Resident #1's elopement and documented the incident in the resident's medical record. 4. Review of Resident #1's chart and staff assignment sheet revealed Resident #1 was assigned a 1:1 sitter, on 11/23/14 and continued with a 1:1 sitter. 5. Interview with LPN #1, on 12/11/14 at 3:20 PM, revealed on 11/23/14 she checked the Care Trak exit doors for proper functioning after the elopement incident without any malfunction of the doors noted. 6. Interview with the Maintenance Director, on 12/11/14 at 12:50 PM, revealed on 11/24/14 he checked all the exit doors and residents wearing a Care Trak device for proper functioning. He revealed all systems functioned properly. 7. Interview with the Medical Director, on 12/12/14 at 11:20 AM, revealed the QA Committee meets every third Wednesday of the month and as necessary. She stated she was aware of the facility's policy and system changes related to Elopement, Care Trak, Smoking, Care Plans, and Immediate Jeopardy cited on 11/26/14. 8. Review of Resident #1's elopement care plan revealed a revision dated 11/24/14 by Social Services Director (SSD). Interview with SSD, on 12/11/14 at 1:45 AM, revealed she updated Resident #1's elopement care plan 11/24/14 following the elopement on 11/23/14 with the following interventions: 1:1 sitter with the sitter to remain with resident. Review of Resident #1's Elopement Risk Assessment revealed it was updated on 11/24/14 by the Administrator. Interview with the Administrator, on 12/12/14 at 10:00 AM, revealed she reviewed and updated Resident #1 Elopement Risk Assessment on 11/24/14. 9. Interview with the MDS Coordinator, on 12/11/14 at 8:55 AM, revealed she revised Resident #1's Elopement Care Plan and interventions on 11/26/14 to include: "Resident will wander safely within the environment as evidenced by no falls or injury through review date". Further interview revealed she revised ten (10) residents' care plan goals that had been assessed as at risk for elopement. Review of the ten (10) residents that have Care Trak transmitters, their elopement care plans were reviewed, on 12/11/14, with a new intervention added "Wander Alert" with Care Trak device number added to Resident #1's elopement care plan. 10. Review of the Elopement Risk Assessments of the remaining residents assessed as elopement risk revealed SSD updated elopement risk assessments on 11/24/14. 11. Interview with the House Supervisor, on 12/12/14 at 9:30 AM, revealed an audit in Point Click Care (electronic medical record) was conducted 11/26/14 to ensure that current residents assessed to be at risk for elopement had "wear a Care Trak bracelet" included to the daily task. 12. Interview with CNA #1, on 12/11/14 at 2:30 PM, revealed she was counseled by the Administrator regarding elopement and failure to monitor residents during smoke break. Further interview revealed she was in-serviced regarding policy/system changes to include: elopement, Care Trak, smoking policy, and new location of linen storage. CNA #1 was able to identify changes to policies/system. Interview with RN #1 on 12/11/14 at 12:00 PM, revealed she was counseled by the DON regarding failure to ensure safety of residents that wander. Interview with the Administrator, on 12/12/14 at 10:00 AM, revealed she was counseled by the Corporate Compliance Officer for failure to follow State and federal nursing home regulations and failure to ensure facility policies were being followed. All counseling was verified through documentation on 11/26/14. 13. Review of the Facility Orientation form that Department Heads use to orient new staff, last revised 11/26/14, verified it included information on the following: elopement, Care Trak, care plans, and smoking policy. 14. Review of the in-service training log, dated 11/26/14, revealed all staff was re-inserviced to include: proper functioning of the Care Trak transmitter and documentation on the Care Trak Monitoring sheets. In-service training was conducted by the ADON, Housekeeping Supervisor, MDS Coordinator, and Maintenance Director with 100% staff participation. Interview with CNA #1, on 12/11/14 at 2:30 PM, revealed she would float between all shifts and units. Further interview revealed she was re-educated, on 11/26/14, on policy revisions and changes to include: Smoke Break; (2 staff members are assigned to supervise residents who smoke rather than one (1) staff. First staff member is to gather "smoker notebook" to identify all residents that are allowed to smoke in breezeway. The staff member with the notebook will verify all residents listed in the notebook are the only residents to be in the breezeway at the designated smoking times. The second staff member will assist in getting residents with smoking privileges to the breezeway and re-activate the Care Trak alarm system at breezeway exit door. She also stated the facility designed a notebook updated with pictures of each resident that smoked. The notebook was to be utilized at each designated smoke break. CNA #1 also stated she was in-serviced on elopement, Care Trak, and location change of the dirty linen storage cart. She revealed the new location of dirty linen cart storage allows staff to see the entire breezeway area when residents were smoking. CNA #1 further revealed that Care Trak alarm will not be silenced while residents exit the building to smoke. Further interview revealed the second staff member is to re-activate the Care Trak alarm after residents participating in smoke break are in breezeway. Interview with LPN #1, on 12/11/14 at 3:20 PM, revealed her normal work shift is 3 PM-11 PM. She revealed she received in-service training on 11/26/14 conducted by the ADON, House Supervisor regarding policy changes on elopement, Care Trak, smoke breaks and care plans. Interview with LPN #2, on 12/12/14 at 8:30 AM, revealed her normal work shift is 11 PM-7 AM as a Charge Nurse. Further interview revealed she received in-service training on 11/26/14 regarding policy changes implemented to include: elopement, Care Trak, care plans, smoke break and location change of dirty linen storage 15. Interview with the Administrator on 11/26/14 at 5:15 PM revealed training was initiated on 11/25/14 on the Elopement policy and Care Trak policy by House Supervisor, MDS Coordinator, and ADON to discuss policy revisions and system changes. Review of the in-service training record and sign in sheet verified. Interview with the MDS Coordinator, on 12/11/14 at 8:55 AM, revealed she received in-service training on 11/27/14 in group setting with the Department Heads. Further interview revealed in-service training was conducted by the Administrator on topics to include: Care Trak, Elopement, Care Plan policy revisions. She revealed she was in-serviced on the following revisions: Care Trak, residents with Care Trak alarms have been added to the smoke book for staff to identify all residents to be in the breezeway at designated smoke breaks. The Charge Nurse on weekends and holidays will check to ensure the proper function of Care Trak alarm at exit doors and document in monitor log. The DON will collect and monitor the log on Monday mornings. The Maintenance Director will continue to check the function of Care Trak alarm at the exit doors Monday through Friday and document in the monitor log. The Administrator will assign a designated person in the absence of the Maintenance Director. Interview with the ADON, on 12/12/14 at 9:40 AM, revealed she received in-service training, on 11/24/14. She revealed she received further in-service training on 11/27/14 with all Department Heads and in-service training was conducted by the Administrator. Further interview revealed in-service training consisted of policy revisions and system changes implemented regarding elopement, Care Trak, care plans, and system changes regarding smoke break. The ADON stated all residents with Care Trak transmitters, care plans were updated to include Care Trak device number and goal revised. 16. Review of the Elopement, Care Trak, Care Plan and system revealed changes were made to the facility's Smoking Policy, revision date of 11/26/14. 17. Observation on 12/11/14 revealed the dirty linen cart was moved so there was a complete view of the breezeway perimeter. 18. Review of Quality Assurance form N-24 titled, "Elopement", was revised, 11/25/14 and included, "Has Care Trak been added to the task in Point Click Care". 19. Review of Quality Assurance form N-19 titled, "Care Plans", was completed by the MDS Coordinator on 11/27/14. 20. Interview with the Administrator, on 11/26/14 at 10:00 AM, revealed on 11/26/14 and 11/27/14, all staff was re-educated. The re-education included the facility's revision of policies/system changes on elopement, Care Trak, care plans, and smoking policy revision. Each employee completed a post test to validate learning with 100% pass rate. Education was verified by viewing the in-service sign-in sheets and post test packets were reviewed on 12/11/14. 21. Interview with the Maintenance Director, on 12/11/14 at 12:50 AM, revealed he was re-educated regarding proper function of the Care Track transmitter on 11/26/14. Further interview revealed he and the ADON conducted in-service training to all staff 11/26/14 through 11/27/14. The in-service training was verified by a sign in sheet with staff members signatures beginning 11/26/14 through 11/27/14. Interview with RN #2, on 12/11/14 at 12:20 PM, revealed her normal work shift is 7 AM to 7 PM on the weekend. Further interview revealed she was in-serviced 11/26/14 by the ADON, Maintenance Director on policy revisions which included: Care Trak, charge nurse to check exit doors for proper functioning on the weekend, document on monitor log. Care Plans, all residents with Care Trak transmitter, device number added to elopement care with goal revised. Smoking policy, system revised, charge nurse to assign two (2) staff members to take residents to the breezeway for designated smoke break and staff assigned to residents who smoke are to always use the "Smoker notebook" with the residents' picture to identify residents that participate in smoke breaks. She further revealed the dirty linen cart storage location was changed to allow clear view of the breezeway perimeter. Interview with RN #1, on 12/11/14 at 12:30 PM, revealed she received in-service training on 11/26/14 regarding policy changes which include: elopement, Care Trak, care plans, smoking policy revisions. 22. Interview with the Administrator on 12/12/14 at 10:00 AM, revealed Quality Assurance form N-24, "Elopement", will be completed weekly for all residents assessed to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per CQI schedule by the SSD. 23. Interview with the Administrator on 12/12/14 at 10:00 AM, revealed Quality Assurance form N-19 titled "Care Plans" will be completed weekly for all residents assessed to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per CQI schedule by the MDS Coordinator.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 11/23/14, during the 1:00 PM smoke break, Resident #1, whom the facility assessed as an elopement risk, exited the facility without staff's knowledge. Resident #1 was observed by Certified Nursing Assistant (CNA) #3 and CNA #4, on 11/23/14 between 1:00 to 1:15 PM, attempting to enter the facility through the back door of the 200 Wing. The facility was unable to determine how the resident exited the building unsupervised. (Refer to F282) The facility's failure to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/26/14 and determined to exist on 11/23/14. The facility was notified of the Immediate Jeopardy on 11/26/14. An acceptable Allegation of Compliance (AoC) was received on 12/10/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/28/14, as alleged. The Scope and Severity was lowered to a " D " while the facility develops and implements the Plan of Corrections (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled "Elopement", last revised 10/27/12, revealed the definition of Elopement as "When a resident leaves the premises or a safe area without authorization and /or necessary supervision to do so." Further review of the Policy Interpretation and Implementation (Section 1) revealed, "Upon admission and/or readmission to the facility the resident/family/responsible party and/or the referring facility are interviewed regarding known history of wandering/elopement. If a resident is identified as a potential wanderer he/she will be issued a Care Trak bracelet, as appropriate. The elopement assessment is reviewed/revised quarterly and with any significant change of condition as well as with any actual elopement event. An Interdisciplinary Care Plan is developed to include preventive elopement interventions. All staff is informed/educated to "at risk" residents' status and care plan interventions to reduce/prevent elopement." Review of Section 4.) revealed, "The weekend Charge Nurse is responsible for documenting and checking of the Care Trak transmitters and all Care Trak door alarms to ensure the system is functioning properly. All residents at risk for elopement who smoke are identified by pictures in the smoking book. Staff members assigned to smoke breaks are responsible for reviewing the pictures in the binder, to ensure that any non-smokers have not exited the building. Any nonsmokers who are at risk for elopement will be identified as well." Review of the facility's Care Trak Policy, not dated, revealed keypads are located at all doors leading outside which are accessible to residents, with the exception of the kitchen and dining room doors. Residents who are at an optimum risk for wandering will be issued a Care Trak transmitter wrist/ankle band. The door activated must be checked immediately. The alarm is not de-activated until the premises surrounding the alarming door are searched. Transmitter batteries will be checked to make sure batteries are charged on a daily basis. Record review revealed the facility admitted Resident #1 on 07/22/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/30/14, revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was not interviewable. Review of the Elopement Risk Assessment, dated 10/30/14, revealed the facility assessed Resident #1 to be at risk for elopement. Review of the Comprehensive Care Plan, dated 07/28/14, revealed the resident was considered an elopement risk related to impaired safety awareness and [DIAGNOSES REDACTED]. Review of the facility's Unusual Occurrence Report, dated 11/23/14, revealed Resident #1 was witnessed coming in from outside at the 200 Wing West entry. Further review revealed the Care Trak was not alarming when Resident #1 reentered the building through the 200 Wing West door. CNA #3 and CNA #4 witnessed the resident come back in the facility. The CNAs stated the Care Trak alarm did sound once the resident was back in the building. However, staff was not aware which door the resident went out when he/she exited the building unsupervised. Interviews with CNA #3, on 11/26/14 at 3:25 PM; and, CNA #4, on 11/25/14 at 3:40 PM, revealed on 11/23/14 at approximately 1:00-1:15 PM, the CNAs noted Resident #1 was outside and attempting to enter the facility at the 200 Wing exit door. The CNAs stated Resident #1 was escorted back into the building. However, Resident #1 was not able to identify how he/she got outside the building. The CNAs stated they were not aware the resident had exited the building. Interview with Licensed Practical Nurse (LPN) #1, on 11/25/14 at 2:20 PM, revealed she was the Charge Nurse working the 200 Wing on 11/23/14 at the time of Resident #1's elopement. LPN #1 stated CNA #3 and CNA #4 reported to her that Resident #1 was outside the back exit door on the 200 Wing. LPN #1 revealed Resident #1 was taken to the 100 Wing and the Charge Nurse of the 100 Wing was informed of the incident. She stated she was not aware the resident had exited the building, before she was notified by the CNAs. Interview with CNA #1, on 11/25/14 at 2:35 PM, revealed she escorted the residents out to the breezeway for a smoke break, on 11/13/14 at 1:00 PM. Further interview revealed Resident #1 doesn't smoke and did not exit the building with the other residents. CNA #1 stated when she took the "smokers" out she silenced the Care Trak transmitter alarm prior to exiting the building because three (3) of the residents who smoke, have Care Trak transmitters. She stated she failed to reactivate the Care Trak alarm while the residents were in the breezeway smoking. Interview with Medication Aide (MA) #1, on 11/25/14 at 2:55 PM, revealed she noticed Resident #1 walking throughout the facility on 11/23/14. MA #1 stated the last time she saw Resident #1 was at approximately 1:00 PM. She stated she witnessed Resident #1 go to the exit door and stick his/her head out of door. However, the resident turned around and left the exit door when the Care Trak alarm sounded. MA #1 was unable to identify what time this incident occurred. She stated she was not aware the resident had exited the building. Interview with CNA #2, on 11/26/14 at 1:25 PM, revealed she was the CNA assigned to care for Resident #1 on 11/23/14 on day shift. CNA #2 stated she last saw Resident #1 at 11:45 AM walking in the hallway of the 100 Wing prior to the elopement. She stated she was not aware the resident had exited the building. She revealed Resident #1 wanders and was considered to be an elopement risk. CNA #2 stated Resident #1 was care planned as an elopement risk and had a Care Trak bracelet. She further stated if a resident attempted to leave the facility, the Care Trak would "go off" unless the alarm was deactivated at the exit doors. Interview with Registered Nurse (RN) #1, on 11/25/14 at 3:05 P.M., revealed she was the 100 Wing Charge Nurse on 11/23/14 when Resident #1 exited facility. Further interview revealed RN #1 had gone to the "breezeway" when she received an overhead page from Licensed Practical Nurse (LPN) #1. RN #1 revealed she was informed of Resident #1's elopement upon response to the page, at approximately 1:10 PM. RN #1 stated she last saw Resident #1 between 1:00-1:05 PM and was not aware the resident had exited the building until she received the page. RN #1 revealed Resident #1's Care Trak transmitter function was assessed earlier during the shift without any concerns. Interview with the Maintenance Director, on 11/26/14 at 9:50 AM, revealed he checked the function of the Care Trak alarm at the exit doors daily, Monday through Friday, and documented his findings in the monitor log. He stated he was not aware of who was responsible for checking the function of the Care Trak alarm exit doors in his absence. He stated he was not contacted to assess the function of the Care Trak alarm system exit doors on 11/23/14. Interview with Resident #1's Spouse and Power of Attorney (POA), on 11/26/14 at 1:45 PM, revealed the nurse called him/her, on 11/23/14 (could not remember time), to inform him/her Resident #1 had exited the facility. Resident #1's spouse stated the resident had a history of [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 11/26/14 at 4:00 PM revealed on 11/23/14 between 1:15 P.M. to 1:30 PM, she received a call from RN #1 reporting Resident #1 was standing at the 200 Wing back door trying to get back into the facility. The ADON stated she was unsure how, when, or where Resident #1 had exited the facility. Further interview revealed she would expect staff to provide activity or use the listed interventions identified in the care plan for Resident #1 when he/she was noted to be wandering to keep him/her focused on a task or alternate diversion. Interview with the Administrator, on 11/26/14 at 5:15 PM, revealed she received a call on 11/23/14 around 1:30 PM, from RN #1, informing her that Resident #1 had exited the building without staff's knowledge and was witnessed attempting to get back into the building. The Administrator stated Resident #1 was not seen when the residents were taken to the breezeway to smoke during the 1:00 PM break. The Administrator revealed during her investigation of the incident it was identified that CNA #1 silenced the Care Trak alarm at the exit door while assisting the residents out to the breezeway to smoke. The CNA failed to re-activate the alarm while the residents were smoking. She further stated any resident with a Care Trak bracelet could have exited the facility through that door without the alarm sounding. Interview with Administrator, on 11/26/14 at 6:30 P.M., revealed Resident #1 care plan identified interventions to divert/distract the resident when he/she was noted to be wandering aimlessly. Further interview revealed her expectation was for staff to utilize the interventions listed in the care plan to distract the resident from wandering by providing a structured activity and intervene as appropriate. The facility implemented the following actions to remove the Immediate Jeopardy: 1. RN #1 completed a full body assessment, including vital signs, on Resident #1 on 11/23/14, with no injuries noted. 2. RN #1 notified the ADON, Interim Administrator, Power of Attorney (POA), and Medical Director (MD) of the elopement on 11/23/14. 3. RN #1 completed an unusual occurrence report and documented in the resident's medical record. She indicated that it was raining outside and the resident's clothes were dry on 11/23/14. 4. Resident #1 was monitored and assigned a 1:1 sitter on 11/23/14. 5. LPN #1 checked all door alarms to ensure proper functioning on 11/23/14. Further interview revealed all exit doors did not exhibit any malfunction with the Care Trak transmitter alarm system. 6. All doors and all residents wearing a Care Trak were rechecked by the Maintenance Director for proper functioning on 11/24/14. All Systems were functioning. 7. The Administrator and Quality Assurance Team consulted and involved the Medical Director in all aspects of the process; including notification of the elopement, conference calls, Quality Assurance meetings, the plan of action, the issuance of Immediate Jeopardy, and any recommendation/suggestions made by the team and Medical Director about changes to the facility's policies and system changes to remove the immediate jeopardy. 8. Resident #1's care plan was reviewed and updated on 11/24/14 by the Social Service Director. The Administrator reviewed and updated Resident #1 Elopement Risk Assessment on 11/24/14. 9. The MDS Coordinator revised Resident #1's Elopement Care Plan and interventions on 11/26/14 to include: Resident will wander safely within the environment as evidenced by no falls or injury through review date. On 11/27/14, MDS Coordinator reviewed and/or revised elopement care plan goals for ten (10) residents the facility assessed to be at risk for elopement. 10. The Social Services Director (SSD), on 11/24/14, reviewed and updated Resident #1's care plan. The SSD also updated Elopement Risk Assessments for all other residents who were assessed to be at risk for elopement 11. The House Supervisor completed an audit in Point Click Care (electronic medical records), on 11/26/14, to ensure the ten (10) residents assessed at risk for elopement had "Wear Care Trak bracelet" included in their tasks on a daily basis. 12. On 11/26/14, the Administrator counseled CNA #1 for failure to monitor the residents during the smoke break. The DON counseled RN #1 for failure to supervise and keep residents who wander safe. The Corporate Compliance officer counseled the Administrator for failure to follow State and federal nursing home regulations and ensure the facility's policies were being followed. 13. On 11/26/14, the Facility Orientation form used by Department Heads to orient new staff was updated by the Administrator to include information regarding the following: Elopement, Care Trak, Care Plans, and Smoking Policy. 14. On 11/27/14, the Maintenance Director and ADON, inserviced all licensed staff on how to check exit doors for proper functioning using the Care Trak transmitter and documenting on the Care Trak Monitor log. 15. On 11/25/14, in-service training was initiated on the Elopement and Care Trak policy by the House Supervisor, MDS Coordinator, and ADON to educate on the facility's policy revisions and system changes. 16. On 11/26/14, the Administrator, DON, ADON updated the Elopement, Care Trak, Care Plan, and system changes were made to the Smoking Policy. 17. The Housekeeping Supervisor in-serviced housekeeping staff on 11/26/14 on placing the dirty linen cart in a different location. 18. On 11/25/14, Quality Assurance form N-24 titled, "Elopement" was reviewed and revised by Administrator to include the question, "Has Care Trak been added to the task in Point Click Care". 19. On 11/27/14, Quality Assurance form N-19 titled, "Care Plans", was reviewed by the Administrator and completed by the MDS Coordinator. 20. On 11/26/14 through 11/27/14, all staff was in-serviced on the system changes made to the revised Elopement, Care Trak, and Smoking Policy to include: Department Heads, Licensed Nurses, Certified Medication Aides, CNAs, Environmental Services, Activity Director, and Activity Assistant, Dietary Manager, Social Services Director, Office Manager, Medical Records, and all PRN staff. The in-service was conducted by the House Supervisor, ADON, Maintenance Director, and MDS Coordinator. Staff in-serviced on the following system changes: The Charge Nurse assigns (2) staff members to take the residents out to smoke. The additional staff member's responsibility is to watch each resident exit and re-enter the building safely. The weekend Charge Nurse is responsible for checking and documenting that Care Trak doors are functioning properly. All newly hired staff will receive orientation on the revised Facility Orientation Form. The dirty linen carts are not to block the view of the 200 Wing Hall door from the smoking area. 21. The Maintenance Director and ADON, on 11/27/14, demonstrated and re-inserviced all licensed staff on how to check the exit doors for proper functioning using the Care Trak transmitter and how to document on the Care Trak Monitoring Sheets. 22. The Quality Assurance form N-24, "Elopement", will be completed weekly for all residents assessed to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per the CQI schedule by the Social Services Director. 23. Quality Assurance form N-19 titled, "Care Plans", will be completed weekly for all residents to be at risk for elopement for four (4) weeks and monthly thereafter for three (3) months, then per the CQI schedule by the MDS Coordinator. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #1's chart, on 12/10/14 at 4:45 PM, revealed on 11/23/14 at 1:15 PM, a full body assessment including vital signs were completed by RN #1. 2. Interview with ADON, on 12/12/14 at 9:45 AM, revealed she received a call from RN #1, on 11/23/14 at approximately 1:15 to 1:30 PM, informing her of Resident #1 elopement. Interview with Interim Administrator on 12/12/14 at 10:00 AM, revealed on 11/23/14 at 1:30 PM, she received a call from RN #1 informing her of Resident #1 elopement. Interview with Resident #1 POA/husband, on 11/26/14 at 1:45 PM, revealed on Sunday 11/23/14 at 2:00 PM he received a call from RN #1 informing him Resident #1 got outside the facility without staff knowledge. Interview with Resident #1's Primary Care Physician (PCP) and the facility's Medical Director, on 11/26/14 at 2:00 PM, revealed she was notified on 11/23/14 of Resident #1's elopement. 3. Review of the facility's investigation revealed RN #1 completed an unusual occurrence report, on 11/23/14, regarding Resident #1's elopement and documented the incident in the resident's medical record. 4. Review of Resident #1's chart and staff assignment sheet revealed Resident #1 was assigned a 1:1 sitter, on 11/23/14 and continued with a 1:1 sitter. 5. Interview with LPN #1, on 12/11/14 at 3:20 PM, revealed on 11/23/14 she checked the Care Trak exit doors for proper functioning after the elopement incident without any malfunction of the doors noted. 6. Interview with the Maintenance Director, on 12/11/14 at 12:50 PM, revealed on 11/24/14 he checked all the exit doors and residents wearing a Care Trak device for proper functioning. He revealed all systems functioned properly. 7. Interview with the Medical Director, on 12/12/14 at 11:20 AM, revealed the QA Committee meets every third Wednesday of the month and as necessary. She stated she was aware of the facility's policy and system changes related to Elopement, Care Trak, Smoking, Care Plans, and Immediate Jeopardy cited on 11/26/14. 8. Review of Resident #1's elopement care plan revealed a revision dated 11/24/14 by Social Services Director (SSD). Interview with SSD, on 12/11/14 at 1:45 AM, revealed she updated Resident #1's elopement care plan 11/24/14 following the elopement on 11/23/14 with the following interventions: 1:1 sitter with the sitter to remain with resident. Review of Resident #1's Elopement Risk Assessment revealed it was updated on 11/24/14 by the Administrator. Interview with the Administrator, on 12/12/14 at 10:00 AM, revealed she reviewed and updated Resident #1 Elopement Risk Assessment on 11/24/14. 9. Interview with the MDS Coordinator, on 12/11/14 at 8:55 AM, revealed she revised Resident #1's Elopement Care Plan and interventions on 11/26/14 to include: "Resident will wander safely within the environment as evidenced by no falls or injury through review date". Further interview revealed she revised ten (10) residents' care plan goals that had been assessed as at risk for elopement. Review of the ten (10) residents that have Care Trak transmitters, their elopement care plans were reviewed, on 12/11/14, with a new intervention added "Wander Alert" with Care Trak device number added to Resident #1's elopement care plan. 10. Review of the Elopement Risk Assessments of the remaining residents assessed as elopement risk revealed SSD updated elopement risk assessments on 11/24/14. 11. Interview with the House Supervisor, on 12/12/14 at 9:30 AM, revealed an audit in Point Click Care (electronic medical record) was conducted 11/26/14 to ensure that current residents assessed to be at risk for elopement had "wear a Care Trak bracelet" included to the daily task. 12. Interview with CNA #1, on 12/11/14 at 2:30 PM, revealed she was counseled by the Administrator regarding elopement and failure to monitor residents during smoke break. Further interview revealed she was in-serviced regarding policy/system changes to include: elopement, Care Trak, smoking policy, and new location of linen storage. CNA #1 was able to identify changes to policies/system. Interview with RN #1 on 12/11/14 at 12:00 PM, revealed she was counseled by the DON regarding failure to ensure safety of residents that wander. Interview with the Administrator, on 12/12/14 at 10:00 AM, revealed she was counseled by the Corporate Compliance Officer for failure to follow State and federal nursing home regulations and failure to ensure facility policies were being followed. All counseling was verified through documentation on 11/26/14. 13. Review of the Facility Orientation form that Department Heads use to orient new staff, last revised 11/26/14, verified it included information on the following: elopement, Care Trak, care plans, and smoking policy. 14. Review of the in-service training log, dated 11/26/14, revealed all staff was re-inserviced to include: proper functioning of the Care Trak transmitter and documentation on the Care Trak Monitoring sheets. In-service training was conducted by the ADON, Housekeeping Supervisor, MDS Coordinator, and Maintenance Director with 100% staff participation. Interview with CNA #1, on 12/11/14 at 2:30 PM, revealed she would float between all shifts and units. Further interview revealed she was re-educated, on 11/26/14, on policy revisions and changes to include: Smoke Break; (2 staff members are assigned to supervise residents who smoke rather than one (1) staff. First staff member is to gather "smoker notebook" to identify all residents that are allowed to smoke in breezeway. The staff member with the notebook will verify all residents listed in the notebook are the only residents to be in the breezeway at the designated smoking times. The second staff member will assist in getting residents with smoking privileges to the breezeway and re-activate the Care Trak alarm system at breezeway exit door. She also stated the facility designed a notebook updated with pictures of each resident that smoked. The notebook was to be utilized at each designated smoke break. CNA #1 also stated she was in-serviced on elopement, Care Trak, and location change of the dirty linen storage cart. She revealed the new location of dirty linen cart storage allows staff to see the entire breezeway area when residents were smoking. CNA #1 further revealed that Care Trak alarm will not be silenced while residents exit the building to smoke. Further interview revealed the second staff member is to re-activate the Care Trak alarm after residents participating in smoke break are in breezeway. Interview with LPN #1, on 12/11/14 at 3:20 PM, revealed her normal work shift is 3 PM-11 PM. She revealed she received in-service training on 11/26/14 conducted by the ADON, House Supervisor regarding policy changes on elopement, Care Trak, smoke breaks and care plans. Interview with LPN #2, on 12/12/14 at 8:30 AM, revealed her normal work shift is 11 PM-7 AM as a Charge Nurse. Further interview revealed she received in-service training on 11/26/14 regarding policy changes implemented to include: elopement, Care Trak, care plans, smoke break and location change of dirty linen storage 15. Interview with the Administrator on 11/26/14 at 5:15 PM revealed training was initiated on 11/25/14, on the Elopement policy and Care Trak policy by House Supervisor, MDS Coordinator, and ADON to discuss policy revisions and system changes. Review of the in-service training record and sign in sheet verified. Interview with the MDS Coordinator, on 12/11/14 at 8:55 AM, revealed she received in-service training on 11/27/14 in group setting with the Department Heads. Further interview revealed in-service training was conducted by the Administrator on topics to include: Care Trak, Elopement, Care Plan policy revisions. She revealed she was in-serviced on the following revisions: Care Trak, residents with Care Trak alarms have been added to the smoke book for staff to identify all residents to be in the breezeway at designated smoke breaks. The Charge Nurse on weekends and holidays will check to ensure the proper function of Care Trak alarm at exit doors and document in monitor log. The DON will collect and monitor the log on Monday mornings. The Maintenance Director will continue to check the function of Care Trak alarm at the exit doors Monday through Friday and document in the monitor log. The Administrator will assign a designated person in the absence of the Maintenance Director. Interview with the ADON, on 12/12/14 at 9:40 AM, revealed she received in-service training, on 11/24/14. She revealed she received further in-service training on 11/27/14 with all Department Heads and in-service training was conducted by the Administrator. Further interview revealed in-service training consisted of policy revisions and system changes implemented regarding elopement, Care Trak, care plans, and system changes regarding smoke break. The ADON stated all residents with Care Trak transmitters, care plans were updated to include Care Trak device number and goal revised. 16. Review of the Elopement, Care Trak, Care Plan and system revealed changes were made to the facility's Smoking Policy, revision date of 11/26/14. 17. Observation on 12/11/14 revealed the dirty linen cart was moved so there was a complete view of the breezeway perimeter. NEEDS AOC INFORMATION