Every finding on record at Beaver Dam Nursing & Rehab Center, Inc

Based on observation, interview, document review, and facility policy review, the facility failed to ensure staff consulted the Registered Dietician (RD) before they substituted pureed mashed potatoes for pureed tomatoes for 4 residents of 4 sampled residents (Resident (R) 15, 16, 41 and R49) ordered a pureed diet. The findings include: Review of a facility policy titled, Menus, revised 10/2017, indicated, policy statement menus were developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. The policy further specified the dietitian would review and approve all menus.Review of the facility menu for the dinner meal on 04/20/2026 indicated the following would be served: macaroni & cheese, stewed tomatoes, carrots, baked apples. Review of the facility Resident Summary Report dated 04/22/2026, revealed four residents R15, R16, R41, and R49 were ordered a puree texture diet. During a concurrent interview and dinner meal tray line observation on 04/20/2026 at 4:55 PM, the surveyor noted the Dietary Services Director (DSD) plate puree mashed potatoes on the dinner meal tray of residents ordered a puree texture diet. The DSD stated mashed potatoes were a substitution for the puree tomatoes. During an interview on 04/20/2026 at 5:09 PM, the DSD stated the dietary department stopped serving puree tomatoes because staff were unable to get the seeds in the tomatoes to a puree consistency. The DSD stated she contacted the RD prior to the dinner meal on 04/20/2026 to obtain permission to serve mashed potatoes instead of puree stewed tomatoes. During an interview on 04/21/2026 at 3:00 PM, the RD stated the menu should be followed and she was not notified that mashed potatoes would be served instead of puree stewed tomatoes. The RD stated she would expect a vegetable substitution for the stewed tomatoes that was not a starchy vegetable like mashed potatoes since the macaroni and cheese were high in carbohydrates. The RD stated tomatoes had fewer calories and more vitamin C than potatoes. The RD stated she would not expect potatoes to be served with a high carbohydrate entree like macaroni and cheese. During an interview on 04/22/2026 at 9:10 AM with the Chief Executive Officer (CEO) / Administrator and the Clinical Operations Officer (COO), the CEO / Administrator stated he expected staff to follow the menu. The COO stated she had the same expectation for staff to follow menus, spreadsheets, policies, and procedures for following the menu.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff performed a safety check before insulin was administered which resulted in 3 medication errors out of 32 opportunities, which yielded a medication error rate of 9.38% for two residents (Resident 5 and Resident 7) of eight residents observed for medication administration. The findings include: Review of a facility policy titled, Administering Medications, revised 04/2019, indicated medications were administered in a safe and timely manner, and as prescribed.Review of the Lantus SoloStar pen manufacturer information with a copyright date of 2022, indicated Step 3, Perform a Safety Test. Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after your perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin, coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. The undated Novolog pen manufacturer information indicated Get your pen ready 1. Wash and dry your hands well. 2. Remove the pen cap. 3. Look at the insulin in the pen to make sure the liquid is clear and has no color and no specks. Only use the pen if the liquid is clear, had no color and no specks in it. It's normal to see air bubbles. 4. Wipe the rubber end of the pen with an alcohol swab. 5. Remove the paper seal from the new pen needle. Carefully screw the pen needle onto the end of the pen. 6. Remove the outer needle cap and set it aside. Remove the inner needle cap and throw it away. 7. Turn the knob on the pen to dial up a dose of 2 units. 8. Hold the pen with the needle pointing straight up. Gently tap the side of the pen to get rid of any large air bubbles. You may still see some small bubbles. This is normal. 9. Push the injection button until you see 0 (zero) in the dose window. You should see a drop of liquid at the end of the needle. This means your pen is ready to use. 10. If you can't see a drop of liquid, repeat steps 7 to 9. Do this until you see a drop of medicine. 1. Review of R5's admission Record revealed the facility admitted the resident on 02/17/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of R5's Order Summary Report with active orders as of 04/22/2026, revealed an order dated 02/17/2026, for Lantus SoloStar subcutaneous solution pen-injector 100 units per milliliter inject 50 units subcutaneously one time a day for diabetes. During medication administration observation on 04/22/2026 at 6:17 AM, Licensed Practical Nurse (LPN) 4 without performing a safety test, attached a new needle to the Lantus pen, dialed it to 50 units, cleaned R5's abdominal area with an alcohol pad, then injected 50 units of Lantus insulin into the resident's abdominal area. During an interview on 04/22/2026 at 6:54 AM, LPN4 stated she never primed the insulin pens and was unsure what that meant. During an interview on 04/22/2026 at 12:19 PM, the Clinical Operations Officer stated her expectation would be for the nurse to prime the insulin pen. During a telephone interview on 04/22/2026 at 3:23 PM, the Consultant Pharmacist stated her expectation for insulin pens would be for the nurses to be consistent and prime them with the 2 units of insulin to make sure the pens did not have any air bubbles. 2. Review of R7's admission Record revealed the facility admitted the resident on 02/14/2025. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of R7's Order Summary Report with active orders as of 04/22/2026, revealed an order dated 10/03/2025, for Lantus SoloStar subcutaneous solution pen-injector 100 units per milliliter (unit/mL) inject 48 units subcutaneously one time a day for diabetes and an order dated 07/25/2025, for Novolog flex pen subcutaneous solution pen-injector 100 unit/mL inject 3 units if the resident's blood glucose level is between 151 milligrams per deciliter (mg/dL) and 200 mg/dL. During medication administration observation on 04/22/2026 at 6:32 AM, LPN4 without performing a safety test, attached a new needle to the Lantus pen, dialed it to 48 units, cleaned R7's abdominal area, and injected 48 units of Lantus into the resident's abdominal area. LPN4 then checked R7's blood glucose level and it was noted to be 170 mg/dL. LPN4 did not perform the safety test before she injected 3 units of Novolog into the resident's abdomen. During an interview on 04/22/2026 at 6:54 AM, LPN4 stated she never primed the insulin pens and was unsure what that meant. During an interview on 04/22/2026 at 12:19 PM, the Clinical Operations Officer stated her expectation would be for the nurse to prime the insulin pen. During a telephone interview on 04/22/2026 at 3:23 PM, the Consultant Pharmacist stated her expectation for insulin pens would be for the nurses to be consistent and prime them with the 2 units of insulin to make sure the pens did not have any air bubbles.

Based on observation, interview, record review, and facility policy review, the facility failed maintain infection control practices to ensure staff did not reach into their pockets with a gloved hand to retrieve medical supplies during medication administration for two of eight residents observed for medication administration (Resident (R) 5 and R7). The findings include: Review of a facility policy titled, Infection Prevention and Control Program, revised 10/2018, revealed an infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.1. Review R5's admission Record revealed the facility admitted the resident on 02/17/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of R5's Order Summary Report with active orders as of 04/22/2026, revealed an order dated 02/17/2026, for Lantus SoloStar subcutaneous solution pen-injector 100 units per milliliter inject 50 units subcutaneously one time a day for diabetes. During medication administration observation on 04/22/2026 at 6:17 AM, Licensed Practical Nurse (LPN) 4 placed her gloved left hand in the pocket of her jacket and removed a packaged disinfectant wipe to clean R5's glucometer before she placed the glucometer in the resident's bedside table. During an interview on 04/22/2026 at 6:54 AM, LPN4 stated she did not realize she put her gloved hand back in her pocket to get the disinfectant cloth. LPN4 stated it was her process to keep the disinfectant packages in her pocket. During an interview on 04/22/2026 at 12:19 PM, the Clinical Operations Officer stated she would expect the nurse to perform hand hygiene at the appropriate times. 2. Review of R7's admission Record revealed the facility admitted the resident on 02/14/2025. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia. Review of R7's Order Summary Report with active orders as of 04/22/2026, revealed an order dated 10/03/2025, for Lantus SoloStar subcutaneous solution pen-injector 100 units per milliliter (unit/mL) inject 48 units subcutaneously one time a day for diabetes and an order dated 07/25/2025, for Novolog flex pen subcutaneous solution pen-injector 100 unit/mL inject 3 units if the resident's blood glucose level is between 151 milligrams per deciliter (mg/dL) and 200 mg/dL. During medication administration observation on 04/22/2026 at 6:32 AM, LPN4 placed her gloved left hand in the pocket of her jacket and removed a packaged disinfectant wipe to clean R7's glucometer before she placed the glucometer in the resident's bedside table. During an interview on 04/22/2026 at 6:54 AM, LPN 4 stated she did not realize she put her gloved hand back in her pocket to get the disinfectant cloth. LPN4 stated it was her process to keep the disinfectant packages in her pocket. During an interview on 04/22/2026 at 12:19 PM, the Clinical Operations Officer stated she would expect the nurse to perform hand hygiene at the appropriate times.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 50 of the facility's 50 residents who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Receiving and Storage, revision dated ,d+[DATE], revealed dry foods that were stored in bins were removed from original packaging, labeled and dated (use bydate) and were rotated using a first in--first out system. Continued review revealed all foods stored in the refrigerator or freezer were covered, labeled and dated (use by date). Further review revealed refrigerated foods were labeled, dated and monitored so they are used by their use by date, frozen or discarded. Observation of the kitchen's dry storage area, on [DATE] at 9:45 AM, revealed a plastic container with multiple packages of croutons expired per facility use by date of [DATE]. Continued observation revealed six packages of strawberry glaze stored in a plastic container that were expired. Observation of shelf with canned products revealed a large can of peaches was dented and was still on the shelf. In an interview with the Dietary Services Manager (DSM), on [DATE] at 10:00 AM, she stated staff were aware to follow the first in, first out rule when receiving food items. She further stated all dented cans should be removed from the shelf and stored in a designated place to prevent usage. Observation of a walk-in refrigerator2, on [DATE] at 10:15 AM, revealed three bags of shedded lettuce, one open and covered, and two were unopened, but all had expired per the package label use by date. Further observation revealed a plastic storage bag with grated parmesan cheese that had expired. Additionally, a plastic bag containing six heads of lettuce was not covered when stored allowing air contamination. In an interview with the DSM, on [DATE] at 10:25 AM, she stated that the process was to date any food item that had been opened with the open date and a use by date. She stated she was unaware there was a manufacturers expiration date on the lettuce, but would remove them to ensure they had not been used. Continued observations of walk-in freezer1, on [DATE] at 10:35 AM, revealed a bag of Salisbury steak in a plastic bag, and a bag of breaded pork chops that were expired. In an interview with Dietary Aide1, on [DATE] at 11:15 AM, she stated worked in the facility for a year. She stated she had not usually received and stored food items, but was aware that food items should be dated when received in the facility. She further stated once those products were opened they were to be covered, and a new open date was written on the package before they had been stored in the refrigerator, freezer, or pantry. She stated if staff had not followed the facility's policy or guidelines there was a potential for food to be contaminated and could possibly make residents sick. She stated the goals was to serve residents good quality food and promote a homelike environment. In an interview with Dietary Aide2, on [DATE] at 11:40 AM, she stated that she has worked in the facility for nine years and worked in the kitchen for three years. She stated that all dietary staff were responsible for checking expiration dates on all food items. She stated staff would follow the food items expiration date first, if on the package before following the date the food was opened. She stated that if she encounters foods that have expired or were past their use-by date, she would notify the DSM and the food was thrown out. She stated she had taken required instructional courses regarding food borne illnesses. She further stated if residents were served spoiled or expired foods they could potetially become ill. In an interview with the DSM, on [DATE] at 2:09 PM, she stated after the inspection she had begun to prepare a in-service training for all dietary staff with a test for understanding on the following Monday. She stated she had begun to implement a new colored labeling system for every day of the week to prevent any confusion about dates and when to discard those food items. She stated she had also implemented a training in the following weeks to ensure all staff were trained on the proper way to store, label, and date all food items. She further stated her expectations for all staff would be to follow the facility's policy and procedure related to food safety and to utilize the training they have received. She stated moving forward she expected staff to use those guidelines to ensure residents were provided the best care and were served safe and quality food items.

Based on observation, interview, record review, and review of facility policy, the facility failed to store medications in accordance with the manufacturer's recommendations in one (1) of two (2) medication storage refrigerators and for one (1) of 13 sampled residents, (Resident (R) 38). The findings include: Review of the undated facility policy titled, Insulin Administration, revealed, the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the undated facility policy titled, Insulin Administration, revealed, the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the pharmacy reference guide titled, Medication storage and Administration Quick Reference Guide, with a revision date of April 2024, revealed a Refrigeration guideline that food products may not be stored in the refrigerator except when the food product is being treated as a medication and the resident has a prescriber's order. Further review of the Medication storage and Administration Quick Reference Guide revealed a section titled, Storage of Pens & Cartridges at room temperature (59 degrees Fahrenheit (F) - 86 degrees F) Discard after, revealed Insulin Lispro should be discarded after 28 days if held at room temperature. Review of the facility pharmacy-supplied manufacturer's recommended storage guideline undated and titled, SARS-CoV-2 Virus (COVID-19) mRNA Vaccine (All Populations Monograph) revealed the recommended storage duration for the Moderna COVID-19 vaccine thawing directions revealed after thawing, the vaccine may be stored refrigerated between 2 C to 8 C (36 F to 46 F) for up to 60 days prior to use or up to the expiration date printed on the carton, whichever comes first. Observation of administration of Lispro insulin on 05/06/25 at 6:34 AM for R38 revealed an open date of 04/01 on the Lispro insulin pen to total 36 days since opened. Observation of the medication storage refrigerator located in the Staff Development Coordinator's (SDC) office on 05/07/2025 at 10:00 AM, revealed one partial bag of oranges, one container of coffee creamer, one partial container of snack cheese, meat and crackers stored in the refrigerator that also contained an open vial of Tubersol solution for injection, single dose syringes of influenza vaccines, two unopened vials of pneumonia vaccine, and COVID19 single dose vaccines. Observation of the Staff Development Coordinator's (SDC) medication storage refrigerator on 05/07/2025 at 10:05 AM, revealed one (1) box containing six (6) Moderna COVID19 Spikevax 2024-2025 single dose syringes being stored unthawed without a thaw date noted. Review of the label on the vaccine packaging revealed a delivery date of 11/05/2024. In an interview with the Licensed Practical Nurse (LPN) 1 on 05/07/2025 at 11:00 AM, LPN1 was asked how long insulin could remain out of refrigeration after opening, the LPN1 stated, is it 30 days? The LPN1 stated she would change it out and get a new one to replace the Lispro insulin pen. In an interview with the Director of Nursing (DON) on 05/07/25 at 11:19 AM, she stated the LPN had made her aware of the insulin available for use on the North hall medication cart that was beyond the recommended 28 days. The DON stated staff had obtained a new Lispro insulin pen to replace the available Lispro insulin with the beyond use date. The DON stated that food and medications should be stored separately in separate refrigerators. The DON further stated the COVID19 Spikevax vaccine would be removed from the refrigerator and disposed of properly. In an interview with the SDC on 05/07/2025 at 11:20 AM, she stated the COVID19 Spikevax was stored in a frozen state until she removed it from the freezer on 02/20/2025 to prepare for administration. The SDC provided a calendar log for vaccine activities with the COVID19 Spikevax thaw date of 02/20/2025 noted on the calendar. After reviewing the pharmacy-supplied recommended storage guideline of 60 days after thawed then counting the number of days from 02/20/2025 to the current date of 05/07/2025 totaled 75 days. The SDC stated that more than 60 days had passed since the vaccine had been thawed. The SDC further stated food items should not be stored with medications. In an interview with the Administrator on 05/08/25 at 3:22 PM, he stated he expected staff to follow the facility policy regarding medication storage and use. He further stated a negative outcome could result, however, it is not in the scope of his practice and would consult the physician for guidance.

Based on observation, interview, and facility policy review the facility failed to establish an infection prevention and control program that addressed hand hygiene procedures to be followed by staff involved in direct resident contact for 1 of 7 sampled residents, (Resident (R)10). The findings include: Review of a facility policy titled Handwashing/Hand Hygiene, not dated, revealed that all personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Further review of the policy revealed that hand hygiene was indicated immediately before touching a resident, after touching a resident, and immediately after glove removal. Review of a facility policy titled General Dose Preparation and Medication Administration, revised 11/15/2024, revealed that prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy which includes using appropriate hand hygiene before and after direct resident contact. Review of R10's Facesheet revealed the facility admitted the resident on 01/22/2025 with diagnoses that include chronic obstructive pulmonary disease, chronic kidney disease, and morbid obesity. Review of R10's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/01/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R10 was cognitively intact. Observation of medication pass on 300 hall on 05/06/2025 at 6:51 AM revealed Registered Nurse1 (RN) applied Cahmosyn cream to resident (R) #10's buttocks. Further observation revealed RN failed to perform hand hygiene before donning and after doffing gloves and going into another resident's room. In an interview with RN1 on 05/06/2025 at 6:55 AM, he stated that he should have washed his hands before putting on the gloves and after removing the gloves. He stated that a negative outcome of not washing his hands would be the resident getting an infection or an infection spreading to other residents. In an interview with the Staff Development Infection Preventionist on 05/06/2025 at 6:57 AM, she stated a negative outcome of staff not performing hand hygiene could be an infection control issue. She stated that she expected staff to wash their hands before and after resident care. In an interview with the Director of Nursing (DON) on 05/08/2025 at 10:00 AM, she stated that she expected her staff to wash their hands before and after direct patient care and medication administration. She stated that it was an infection control issue for both staff and the residents. The DON stated that all staff at the facility get infection control training on hire and yearly with their continuing education. In an interview with the Administrator on 05/08/2025 at 3:22 PM, he stated that his expectation for his staff regarding handwashing while giving direct patient care would be to wash their hands between residents and tasks. He stated that possible negative outcomes of staff not washing their hands when providing direct patient care are possible infection control issues like spreading bacteria and viruses between residents.

Based on observation and interview, it was determined the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for the lunch meal served on 03/19/2024. The findings include: Review of the facility's policy titled, Food Temperatures, not dated, revealed foods would be served at proper temperatures to ensure food safety and palatability. Continued review revealed that acceptable serving temperatures for meat entrees were to be greater than 140 degrees Fahrenheit but preferred between 140 and 165 degrees Fahrenheit . Review of the posted menu for the noon meal on 03/19/2024, revealed the following items: baked glazed ham, broccoli and cheese, frosted chocolate cake, and cornbread. Observation of lunch service on 03/19/2024 at 11:08 AM, revealed the following items were served: sliced glazed ham, broccoli and cheese, green beans, barbeque pulled pork, apples, baked beans, mashed potatoes, gravy, ground ham, pureed ham, fortified mashed potatoes and pureed apples. Continued observation following serving of dining room, temperature checks were completed from the steam table and revealed the following: baked glazed ham temperature was at 116 degrees Fahrenheit (F). The alternative meat selection, pulled barbecue chicken was at 126 degrees F. These were below the preferred temperature of 140 to 165 degrees Fahrenheit. An interview with Resident #1 on 03/19/2024 at 11:20 AM, he stated his pulled pork sandwich was cold. Further, he stated the facility's food was cold often. In an interview with the Registered Dietician on 03/21/2024 at 1:44 PM, she stated she expected food temperatures to be maintained between 135 and 140 degrees Fahrenheit while on the steam table. During an interview with Administrator on 03/21/2024 at 4:21 PM, he stated he expected the kitchen staff to follow the policy and ensure meals were served at the correct temperatures.

Based on observation, interview and review of facility policy it was determined that 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 6 of 21 sampled residents. (Resident #25, #39, #41, #47, #50 and #54) and 4 unsampled residents (Resident #64, #65 #66 and #67). The findings include: Review of the facility's policy titled, Policies and Practices - Infection Control, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Observation of the noon meal dining room service, on 03/19/2024 and 03/21/2024, revealed staff opened, touched, and placed straws in drinkware with bare hands prior to serving drinks to the residents. 1) a. A review of Resident #54's face sheet revealed the facility admitted the resident on 01/19/2024. The admission MDS dated [DATE] revealed the resident was assessed to have a BIMS score of eight, which indicated the resident had moderate cognitive impairment. An observation of SRNA #4 on 03/19/2024 at 11:15 showed her with her bare hands, placing a straw, with the covering removed, into the resident's juice. b. A review of the face sheet for Resident #25 revealed the facility admitted the resident on 02/27/2023. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview due to the resident's cognitive decline and not interviewable. Observation of Resident #25 on 03/21/2024 at 11:10 AM, in the dining room, showed State Registered Nurse Aide (SRNA) #6 used her bare hands to place a drinking straw in the resident's coffee cup. c. A review of the face sheet for Resident #39 revealed the facility admitted the resident on 05/13/2022. The Quarterly MDS dated [DATE] revealed a BIMS score of two, which indicated severe cognitive impairment. Observation of Resident #39 on 03/21/2024 at 11:12 AM in the dining room revealed SRNA #6 used her bare hands to place a straw in the resident's coffee. d. A review of Resident #41's face sheet record revealed the facility admitted the resident on 06/26/2019. The Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 11, which indicated the resident was moderately impaired. An observation of Resident #41 on 03/21/2024 at 11:13 AM revealed the Director of Rehabilitation touched the resident's straw with her bare hands. e. A review of Resident #50's face sheet revealed the facility admitted the resident on 08/14/2023. The Quarterly MDS dated [DATE] revealed the resident was assessed to have a BIMS score of three, which indicated the resident had severe cognitive impairment. An observation of Resident #50 in the dining room on 03/21/2024 at 11:14 AM, revealed SRNA #4 placed the resident's straw in the resident's drink with her bare hands. 2. The unsampled residents; #64, #65, #66, and #67 were all in the dining room on 03/21/2024 and an observation at 11:07 AM revealed SRNA #6 removed the paper covering from the residents' straws and placed them in their coffee prior to serving the residents at their table. In an interview with State Registered Nurse Aide (SRNA) #4 on 03/21/2024 at 1:50 PM, she stated she was not sure, but believed she should not have touched the straw with her bare hands. In an interview with the Director of Rehabilitation (DOR) on 03/21/2024 at 2:00 PM, she stated she was not usually in the dining room. She further stated, she now knew the proper technique. In an interview with SRNA #6 on 03/21/2024 at 2:05 PM, she stated she did not remember if she was taught the proper way of removing the paper from the drinking straws. She stated she was working at another facility when she first became an SRNA. During an interview with the Director of Nursing (DON) on 03/21/2024 at 2:08 PM, she stated she expected the paper from the straws would be removed without touching the straw with their bare hands. Further, she stated she expected all staff to follow infection control guidelines. During an interview with the Administrator on 03/21/2024 at 1:55 PM, he stated he expected all staff to follow the infection control policy as written regarding best practice when handling drinking straws.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure an accurate accounting of medications for one (1) of eight (8) sampled residents (Resident #6). Review of Resident #6's Medication Administration Record (MAR), dated 08/25/2022, revealed documentation the resident received PRN (as needed) pain medication at 5:00 AM. However, interview with Resident #6, on 11/16/2022 at 9:30 AM, revealed he/she had requested PRN pain medication, on 08/25/2022 at 7:45 AM, and was told by Certified Medication Tech (CMT) #3 that he/she could not have pain medication because it had been administered at 5:00 AM. The findings included: Review of the facility's policy titled, Administering Medications, dated April 2019, revealed medications were administered in a safe and timely manner and, as prescribed, as required, or indicated for a medication. Further review revealed the individual administering the medication, would record it in the resident's medical record. The staff recorded: the date and time the medication was administered; any complaints or symptoms for which the drug was administered; any results achieved; when those results were observed; and, the signature and title of the person administering the drug. Review of the facility's Pharmacy Services and Procedures Manual: General Dose Preparation and Medication Administration, dated 01/2022, revealed during administration, facility staff should take all measures required by the facility's policy and applicable law. These measures included to document the administration of controlled substances in accordance with applicable law. After medication administration, facility staff should document the necessary medication administration information on the appropriate forms. Record review revealed the facility admitted Resident #6, on 03/09/2018. with diagnoses that included Chronic Pain Syndrome, Idiopathic Gout, Unspecified and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 09/02/2022, revealed a Brief Interview for Mental Status' (BIMS) Score of fifteen (15) which indicated no cognitive impairment. Review of the Physician's Orders revealed an order for Norco (a narcotic analgesic) 10/325 (Hydrocodone 10 milligrams (mg)) and Acetaminophen three hundred and twenty-five (325) mg one (1) tablet. The Norco was ordered to be given by mouth three (3) times a day, as needed (PRN) for breakthrough pain. Review of Resident #6's Controlled Substance Count Record for Hydrocodone 10/325 mg, initiated on 08/19/2022, revealed two (2) doses were signed out as given by Registered Nurse (RN) #1, during the night shift on 08/25/2022. One (1) dose was documented as administered at 1:00 AM, and a second dose was given, at 5:00 AM. However, Registered Nurse (RN) #1 failed to sign on the MAR for both doses. Record review revealed there was no documentation on the back of the MAR that this medication was given; for what purpose; or, whether the doses were effective. Continued review revealed Resident #6 would normally receive a dose of Hydrocodone 10/325 mg between 8:00 AM and 9:00 AM; 1:00 PM and 2:00 PM; and, 8:00 PM and 9:00 PM each day. Review of the August 2022 Medication Administration Record (MAR), revealed there was no documented evidence that Resident #6 had received PRN pain medication on 08/25/2022. Continued review of the MAR revealed there was no documentation on the back of the MAR indicating a PRN medication had been administered. Review of the Progress Notes for Resident #6, revealed no documentation for 08/25/2022. Interview with Resident #6, on 11/16/2022 at 9:30 AM, revealed he/she took pain medication three (3) times a day. The resident stated that he/she took the medication in the morning, after lunch and at bedtime. Resident #6 stated he/she never asked for pain medication through the night because he/she needed it during the day. Resident #6 stated he/she recalled that on 08/25/2022, he/she asked Certified Medication Tech (CMT) #3 for pain medication and was told it wasn't time, as it had been documented by Registered Nurse (RN) #1, that he/she had received pain medication at 5:00 AM. However, Resident #6 stated he/she had not requested pain medication during the night and asked to speak to someone in administration. Resident #6 stated he/she spoke with the Assistant Director of Nursing (ADON) #2. The resident stated CMT #3 had given him/her Tylenol. Interview with CMT #3, on 11/21/2022 at 1:40 PM, revealed she had counted the cart with RN #1 on the morning of 08/25/2022. She stated around 7:30 AM, Resident #6 requested a PRN pain pill and when she checked the narcotic record she noticed RN #1 had signed out pain pills as being administered at 1:00 AM and 5:00 AM. CMT #3 stated that was unusual for Resident #6 and she told the resident that he/she could not have the medication as it had been given two times during the night. She stated Resident #6 became upset and said he/she had not taken any medication during the night and requested to speak with administration. Further interview with CMT #3, revealed she had made ADON #2 of Resident #6's concerns. She stated an investigation began due to the resident stating he/she had not been given pain medication at those times. CMT #3 revealed Resident #6 was given Acetaminophen (Tylenol) and it relieved his/her pain. Interview with Certified Medication Tech (CMT) #1, on 11/17/2022 at 11:00 AM, revealed RN #1, night shift nurse, had signed out scheduled routine narcotics between 5:00 AM and 6:00 AM when they were not due until 7:00 AM. CMT #1 stated she found that odd as she was not used to medications being administered for her. The CMT stated she had reported it to the Charge Nurse and ADON #2, but she could not recall the date. She stated she did not recall any changes or complaints from the residents. CMT #1 stated when administering a PRN medication, it had to be documented on the back of the MAR and a follow up completed to make sure it was effective. Interview, with Registered Nurse (RN) #1, on 11/17/2022 at 9:14 AM, revealed she had been employed at the facility for about three (3) weeks. She stated on 08/25/2022, ADON (Assistant Director of Nursing) #2 called her to the office and told her she had left blanks in the narcotic book and had her sign the narcotic sheet at that time. RN #1 stated ADON #2 never said she needed anything else, so she gave report and left the facility. She stated she texted the Administrator and resigned effective immediately because she had accepted a position at another facility. RN #1 stated that the facility had not made her aware of an investigation. She further stated, she had previously worked in acute care and was not used to signing medications out on paper. The RN stated she would sometimes forget to sign the MAR's. Interview, with the former Director of Nursing (DON), on 11/17/2022 at 8:02 PM, revealed she was aware that RN #1 was being investigated for medication administration, but she was not involved in the investigation. She stated ADON #2, and the Administrator conducted the investigation. Review of the printed text message revealed, on 08/25/2022 at 7:40 AM, revealed RN #1 texted the Administrator and resigned effective immediately. Record review revealed the Administrator responded and requested RN #1 to come to the facility that afternoon as she was under active investigation for medication administration. Continued review revealed the Administrator requested that she write a statement and let him know when she could come in to the facility. Further review revealed there was no response from RN #1. The review revealed at 11:34 AM, the Administrator sent another message asking RN #1 if she planned to participate in the investigation and that he needed to know by 5:00 PM. He informed RN #1 that the local authorities, Kentucky Board of Nursing (KBN) and the Office of Inspector General (OIG)/ State Survey Agency would be notified if she did not provide a statement. Interview with the consulting Pharmacist, on 11/21/2022 at 1:19 PM and 3:55 PM, revealed she performed comprehensive medication reviews monthly on all residents. She stated she looked at dosing, diagnoses, potential interactions, and monitoring of laboratory values. Further interview revealed she checked medication carts for expired medications, and ensured medications were dated and labeled. The Pharmacist stated she checked narcotics and ensured documentation had been completed and followed up on. She stated staff should sign the medication out on the controlled drug record as well as the MAR and write on the back of the MAR that a PRN medication had been given. Continued interview revealed a follow up on the PRN should also be documented on the back of the MAR. She stated she did a monthly quality report, and a copy was sent to the Administrator and DON and that the report was available on the pharmacy's website. Interview with Assistant Director of Nursing (ADON) #2, on 11/18/2022 at 9:04 AM, revealed she was the ADON for North Side and had been the ADON since 07/25/2022. ADON #2 stated that on 08/22/2022, the former DON made her aware of concerns with RN #1 not signing the narcotic shift change form located in the narcotic book. She stated she came in early on 08/25/2022 to provide education to RN #1. ADON #2 stated following her conversation with RN #1, CMT #3 came and got her because something was off on the narcotic count. She stated when they got to the cart, RN #1 had left the facility. ADON #2 stated RN #1 texted the Administrator and resigned effective immediately. RN #1 failed to respond to messages and calls to come to the facility for an interview. Interview with the Administrator, on 11/21/2022 at 4:18 PM, revealed he was aware that Resident #6 had requested pain medication and had stated that he/she had not received the medication. Further interview revealed RN #1 had resigned effective immediately via text on 08/25/2022. He stated he responded and also made several calls to RN #1 to come to the facility and provide a statement. However, he received no response. Continued interview revealed the facility initiated an investigation and notified the required agencies. Further interview, on 11/21/2022 at 4:18 PM, with the Administrator, revealed he had notified the local police agency of his concern that RN #1 may have taken narcotics. He stated he told the police the nurse no longer worked at the facility. The Administrator stated the police declined to investigate because the staff member no longer worked in the facility and it was not a priority for their agency. He stated he expected all staff to follow the facility's medication administration policy.

Based on interview, record review, review of the facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, revised [DATE], it was determined the facility failed to revise the Comprehensive Care Plan with interventions to treat pressure ulcers and prevent worsening of the pressure ulcers for one (1) of fourteen (14) sampled residents (Resident #1). On [DATE], Resident #1 returned from the hospital with an unstageable pressure injury to the sacrum that worsened. Record review revealed there were no revisions made to the comprehensive care plan related to Resident #1's wound or the weekly changes in the wounds condition. On [DATE], Resident #1 was transferred to the hospital for surgical debridement and diagnosed with a large Stage four (4) infected pressure ulcer. Resident #1 was admitted to Hospice Services on [DATE] and expired on [DATE]. The facility's failure to ensure residents' Comprehensive Care Plans were revised as indicated has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F 657, Care Plan Timing and Revisions at a Scope and Severity (S/S) of a J and, at 42 CFR 483.25 Quality of Care, F 686 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE] as alleged, prior to exit on [DATE], with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F657 Care Plan Timing and Revision at a S/S of a D and 42 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, dated [DATE], revealed a comprehensive, person-centered care plan should be developed to include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs were developed and implemented for each resident. The comprehensive care plan would incorporate identified problem areas. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition changed. Continued review revealed the Interdisciplinary (IDT) team must review and update the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident was readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required MDS assessment. Closed record review revealed the facility admitted Resident #1, on [DATE], with the following diagnoses: Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus with Unspecified Complications, and Cerebral Infarction, Unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of five (5) which indicated severe cognitive impairment Review of the Admission MDS, Section M, dated, [DATE], and the last Quarterly MDS dated [DATE], revealed the facility assessed Resident #1 to be at risk for developing pressure ulcer/injury. Further review revealed Resident #1 had a Stage three (3) pressure ulcer. Closed record review revealed Resident #1 had an acute hospital stay [DATE] through [DATE], related to an urinary tract infection (UTI). The facility readmitted Resident #1 with an unstageable pressure injury to the sacrum that worsened and required hospitalization on [DATE]. Review of the Hospital Transfer form, dated [DATE], revealed an order to cleanse sacral wound and apply Calmoseptine, (medication used to treat and prevent minor skin irritations such as from diarrhea, burns, cuts, scrapes), cover with sacral border dressing every day. Per review of [DATE] Treatment Administration Record (TAR) this treatment was provided for Resident #1 until [DATE]. Review of a Wound Note document, dated [DATE], signed by the Wound Nurse, Advance Practice Registered Nurse (APRN) #1, revealed Resident #1 had an unstageable pressure injury to the sacrum measuring three point five by two by zero-point three (3.5 x 2.0 x 0.3) centimeters (cm). Further measurements included: on [DATE] the wound measured seven by six by zero point three (7 x 6 x 0.3) cm. Continued review revealed, on [DATE], the wound measurements were seven by eight point five by zero point six (7 x 8.5 x 0.6) cm. Record review revealed, on [DATE], the wound was noted to be larger with the appearance of infection. However, the facility did not send the resident out to the hospital until [DATE], seven (7) days after staff noted the resident's wound to be infected. Review of the Wound Notes revealed on [DATE], the resident's sacral wound measurements were ten point nine by eleven by two-point five (10.9 x 11 x 2.5) cm. APRN #1 arranged for Resident #1 to be transferred to the hospital for surgical wound debridement. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed Resident #1 had a focus for Pressure Ulcer: Impaired Skin Integrity, related to pressure wound to coccyx. The goal for Resident #1 included: Progressive signs of healing through review date of [DATE]. Interventions included: administer medications and treatments as ordered, see MAR/TAR (Medication Administration Record/Treatment Administration Records) for specifics; observe for efficacy and for adverse effects; dietary consult as needed; encourage/assist to turn and reposition approximately every two (2) hours and as needed as resident will comply; encourage turning side to side avoiding pressure to coccyx; pressure re-distribution mattress to bed, pressure relieving device for chair, skin inspection by CNA during care/bathing with a report to the nurse of any area of skin breakdown or redness. Continued review revealed there were no revisions to the care plan on [DATE] when Resident #1 returned from the hospital or with weekly changes in condition to the coccyx wound. Interview with Certified Nurse Aide (CNA) #3, on [DATE] at 4:15 PM, revealed she had worked about six (6) times over a two (2) month period and did not know how to access the Kardex (a system to let CNAs know a resident's problems/concerns and interventions) on the tablet. She stated she would ask the staff or the nurses if she needed to know something as it was easier than logging onto the computer. Interview with CNA #15, on [DATE] at 1:22 PM, revealed she could not recall much about Resident #1. She stated she provided care by word of mouth. She also stated she would ask another staff member or the nurse if needed. CNA #15 stated she was unaware of the Kardex. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 2:18 PM, revealed she had never updated a care plan and did not know who did. She stated she verbally told staff of new interventions. Interview with LPN #1, on [DATE] at 4:25 PM, revealed she had started at the facility on [DATE] and received no training on updating care plans. She further stated she had no knowledge of how to update a care plan and she assumed the Assistant Director of Nursing (ADON) and MDS Nurse made those changes. Interview with LPN #4, on [DATE] at 8:18 AM, revealed she was an agency nurse and was not familiar with the facility's care plans. She stated she knew what interventions were in place by the orders that were on the Treatment Administration Record (TAR). LPN #4 stated she did not know how the CNAs knew the care that a resident needed. Interview with Registered Nurse (RN) #1, on [DATE] at 3:36 PM, revealed the floor nurses did not update the care plans. She stated they saw a flagged Physician's Order, or they would just tell us. She further stated she did not know how the Certified Nursing Assistants (CNA) knew about following the care plan. Interview with the Registered Dietician (RD), on [DATE] at 11:07 AM, revealed she had recommended supplements for Resident #1, but she was not aware that they had not been initiated. She stated residents' diet and supplements were listed on the tray card, in the physician's orders, on the MAR and the CNA Kardex. Continued interview revealed she did not revise the care plan interventions. She stated they kept them generic, i.e . diet as ordered, supplements as ordered. The RD stated she did not put thickened liquids on the care plan. The RD stated she made the care plans person centered using generic interventions. She stated RD she used the problem area to show individual issues. Continued interview with the RD, on [DATE] at 11:03 AM, revealed Resident #1 should have been brought to weekly at-risk meeting because of the wound. She stated she did not know how the resident was missed. The RD stated the care plan should have been revised each week with worsening of the wound and interventions should have been reviewed. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 11:30 AM, revealed she had been at the facility less than a week. She stated the MDS Nurse was responsible for developing the comprehensive care plan. She stated care plans were reviewed and revised if needed in the daily Interdisciplinary Team (IDT) clinical meeting. She stated the IDT members included the MDS Coordinator, the Director of Nursing (DON), Assistant Director of Nursing (ADON's) Therapy and Social Services, if needed. Continued interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed the purpose of the care plan was to let staff know how to provide care for the residents. She stated she was unsure how the CNAs were trained on the Kardex, but would think they would need training on how to access and review it. She stated the ADON's could update the care plan, but if they did not it would be updated in the clinical meeting the next day. Continued interview with the MDS Coordinator, on [DATE] at 12:02 PM, revealed the care plan should be revised with changes in the resident's condition, with new orders, and readmissions. She stated Resident #1's care plan should have been revised when the resident was readmitted to reflect the wound and, weekly as the wound changed. She stated the IDT team should discuss interventions in place and re-evaluate when interventions were not working or needed to be changed. Further interview revealed she would expect staff to do treatments as ordered and the care plan to be revised, if they failed to do that, then she thought it would have caused the wound to worsen. Interview with Director of Nursing (DON), on [DATE] at 10:21 AM, revealed she was training as the MDS Nurse in [DATE]. She stated the care plan was developed using the admission assessment and reviewing hospital records. The DON stated once the assessment was completed then the comprehensive care plan was developed using the baseline care plan. She stated the care plan showed the care that the residents needed, but at that time there were several people working on the care plans as the MDS Nurse had just left. She stated she did not know how it got missed. Continued interview with the DON on [DATE] at 12:33 PM, revealed she could not recall talking about Resident #1 or the wound. She stated she wasn't involved with Resident #1. She stated if a resident had a wound staff would just know to keep them off it. The DON stated the nurse should let staff know of changes and when a resident may need a special turn schedule. Interview with the Administrator, on [DATE] at 2:45 PM, revealed he expected staff to update and revise the residents' plans of care. Continued interview revealed the resident's care plan needed to be reviewed and updated, because the care plan showed staff how to care for residents. 35748 The facility provided an acceptable removal plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. Review of the removal plan revealed the facility implemented the following: 1. Resident #1 was transferred to the hospital on [DATE] and discharged from the facility on [DATE]. The Interdisciplinary Team (IDT) held an ad-hoc meeting on [DATE] to discuss the root cause analysis (RCA) identifying variables that led to the process failure. The RCA was reviewed and revised later in the Ad-hoc Quality Assurance (QS) meeting with the Medical Director on [DATE]. The Root Cause Analysis revealed that the failures to follow the facility's processes related to monitoring of wound assessment, treatment and documentation was related to the transition of three (3) critical nursing leadership positions Director of Nursing (DON), Assistant Director of Nursing (ADON) and Minimum Data Set Coordinator (MDS) during the time frame identified. 2. On [DATE], the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set (MDS) Coordinator, completed skin assessments on one-hundred percent (100%) of current residents, to determine skin condition. Residents were assessed to determine if any resident was at risk for pressure. Skin assessments were compared to each resident's respective care plan to ensure all necessary and appropriate wound treatments and/or interventions were reflected. All dietician's, physicians', and nurse practitioners' recommendations were reviewed by the Clinical Nurse Consultant (CNC), DON and ADON. Care plans were revised with changes to align with orders as necessary between [DATE] and [DATE] by the MDS Coordinator. 3. An audit of all other current residents who had a pressure injury, had been audited to verify that the current treatment order corresponded with the most recent Progress Note, was completed by the CNC on [DATE] and [DATE]. Any order that was found to differ than the most recent Progress Note was clarified by the nurse responsible for wound rounds and accurately transcribed. 4. Effective [DATE], responsibility for weekly wound rounds with the Wound Care Nurse (WCN)/Nurse Practitioner (APRN) was changed to a newly assigned full-time in house WCN. The WCN would monitor turning and positioning and change of skin condition daily. The DON and ADON would monitor during WCN days off work. Findings during rounds were reviewed daily during quality assurance white board meetings. 5. Education was provided to licensed nurses, certified nurse aides (CNA), and all agency staff beginning on [DATE], by the Clinical Nurse Consultant (CNC), the Director of Nursing (DON), and Assistant Director of Nursing (ADON). Training included topics of: documentation, recognizing change of condition to skin/wounds, care plans, orders, prevention and treatment of pressure ulcers, and skin/wound assessments and notification process of any change of condition. Any staff that had not completed the education, by [DATE], would not be permitted to work until training had been completed. 6. Education was provided to the interdisciplinary team (IDT) to reinforce the need to utilize the whiteboard system to validate transcription of orders, and completion of skin and wound assessments. The IDT membership consists of DON, Administrator, ADON, Quality of Life Director, Environmental Services Director, MDS, Social Services Director Dietary Director, Admissions Director, Human Resources Director, Business Office Manager, Medical Records Director and Medical Director. The education was completed on [DATE] by the CNC. 7. On [DATE], the Administrator, DON, ADON, and CNC began one-hundred percent (100%) in-servicing of all IDT Members and nursing staff on topic of pressure ulcers. Continuing sessions of the education were provided by Administrator, DON, ADON, MDS Coordinator, Human Resources Director, Activities Director, Social Services, and CNCs on [DATE] and [DATE]. Post-tests were administered upon completion of this training with scores of 100% attained. Beginning [DATE], no clinical staff were permitted to work until education was received and post-test completed. These topics were added to clinical new hire orientation effective [DATE] and included: documentation of resident skin/wound assessments promptly; updating resident care plans when a wound was identified; declines or interventions require modification; care plans to reflect the resident's current condition or needs; transcribing physician's orders following a consultant visit/readmission; assure that care needs of residents are reflected on the Nurse Aide Kardex; ensure weekly wound observations were completed by assigned staff and validate that the skin/wound assessments were completed as scheduled; ensure care plan interventions were consistently followed; and, observe residents closely during care and report any skin changes to the nurse. 8. Beginning [DATE], the DON, ADON, MDS Coordinator, or Clinical Nurse Consultant would review fifty percent (50%) of readmissions and ten percent (10%) of new orders weekly for four weeks, then two times monthly for one month, then monthly for one month, during Clinical White Board meeting, held Monday through Friday, to validate that care plans were reviewed and updated to reflect change of condition; were reviewed and updated to reflect wound onset/decline. And continuation of monitoring through the weekends will be shared by DON, ADON, WCN or other assigned licensed staff. 9. Beginning [DATE], Progress Notes written by the APRN would be reviewed by the WCN to identify orders and accurately transcribe the orders. In her absence, the ADON, DON or CNC would complete the review. 10. Beginning [DATE], the schedule for Weekly Skin Assessments would be utilized in the Whiteboard Meeting, Monday through Friday, to validate the completion of the planned assessments by the ADON and DON. Weekends would be monitored by the DON, ADON, WCN, or other assigned licensed staff. 11. Beginning [DATE], monitoring for the completion of and accuracy of wound treatments would be accomplished through rounds by the DON, ADON, MDS or CNC, observing twenty percent (20%) of completed pressure ulcer treatments two times weekly for four weeks, then once weekly for six (6) weeks. 12. On [DATE], available QAPI team members met with Medical Director via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Interdisciplinary Team and by the Medical Director on [DATE]. The RCA was revised in an Ad-hoc QA meeting held with the Medical Director on [DATE]. The Interdisciplinary Team and Medical Director would attend QAPI meetings to review the efficacy of the above mentioned plan monthly to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, HR Director, Maintenance Director, MDS Nurse, Dietary Director, WCN and Medical Director. The State Survey Agency validated the implementation of the facility's removal plan as follows: 1. Record review revealed Resident #1 was discharged from the facility on [DATE]. Review of the facility's documentation and sign-in forms, dated [DATE] and [DATE], revealed ad-hoc meetings were held on [DATE] and [DATE], with all IDT members present, to discuss the RCA of the failures to follow the facility's processes related to wounds. Interview, on [DATE], with the Wound Care Nurse (WCN), at 2:01 PM, revealed she had attended the Ad-hoc meetings and discussed the root case analysis of the wound care and care plan concerns. She further stated QAPI meetings and Whiteboard meetings were ongoing to discuss audits and any newly identified concerns related to wounds and residents' care plans. Staff interviews, conducted on [DATE], with the Director of Nursing (DON) at 2:01 PM, the Assistant Director of Nursing (ADON) at 12:01 PM, the Medical Director at 1:25 PM, Social Services Director at 1:38 PM, the Administrator at 2:45 PM, Corporate Minimum Data Set (MDS) Nurse at 11:50 AM, MDS Coordinator at 12:30 PM, Clinical Nurse Consultant (CNC) #1 at 1:22 PM, CNC #3, and CNC #2 at 1:18 PM, revealed they had attended the Ad-hoc meetings and discussed the root case analysis of the wound care and care plan concerns. They further stated QAPI meetings and Whiteboard meetings were ongoing to discuss audits and any newly identified concerns related to wounds and residents' care plans. 2. Review of the Skin Assessment List, dated [DATE], revealed the DON, ADON, and MDS Coordinator, had completed skin observations on all current residents, with no identified concerns. Interviews on [DATE], with the DON at 2:01 PM, the ADON at 12:01 PM, and the MDS Coordinator at 12:30 PM, revealed they had completed skin assessments on all current residents on [DATE]. They further revealed there were no concerns or updates needed at this time. They stated if any skin issues had been noted they would have notified the physician for treatment orders and put appropriate interventions in place. 3. Review of the, Pressure/Non-Pressure Ulcer Audit, dated [DATE] and [DATE], revealed CNC #1 had completed a chart audit of current treatment orders to ensure the orders corresponded with the most recent Progress Notes. Further review of the document revealed no concerns were identified. Interview with CNC #1, on [DATE] at 1:22 PM, revealed she had audited the records of residents who were identified to have pressure and non-pressure wounds to ensure treatment orders matched the Progress Notes and Physician's Orders. She further stated she identified no concerns, but if she had noted any, the physician would have been notified for further orders. 4. Review of the documentation provided, revealed the newly assigned Wound Care Nurse, participated in weekly wound rounds with the Nurse Practitioner. Interview with the WCN, on [DATE] at 2:01 PM, revealed she conducted rounds with the APRN weekly to ensure any new orders were transcribed to the residents' treatment records. She further revealed she completed walking rounds daily to ensure residents' care plans were followed with interventions to include turning, repositioning, and any additional preventative measures. The WCN stated she had not identified any issues, but if she noticed any concerns she would address them immediately. 5. Review of in-service sheets and a list of licensed employees, revealed education was provided to all, licensed nurses, certified nurse aides on documentation, recognizing change of condition to skin/wounds, care plans, orders, prevention and treatment of pressure ulcers, and skin/wound assessments and notification process of any change of condition. This was completed, on [DATE], by the Clinical Nurse Consultant (CNC), the Director of Nursing (DON), and Assistant Director of Nursing (ADON). Staff interviews, on [DATE], with Certified Nurse Aide (CNA) #10 at 2:20 PM, CNA #11 at 2:41 PM, CNA #12 at 2:55 PM, CNA #13 at 3:07 PM, and CNA #14 at 3:26 PM, revealed they had received education by the DON, ADON, and CNC's, related to following care plans, documentation, alerting the nurse of any change in a residents skin or status. Staff further revealed they were given a post-test and all passed with a score of 100%. Interviews, on [DATE], with Registered Nurse (RN) #5 at 4:24 PM, RN #6 at 4:32 PM, RN #7 at 4:45 PM, and RN #8 at 4:59 PM, revealed they had received education by the DON, ADON, and CNC's. The education was related to reviewing Progress Notes to ensure any new orders were transcribed and documented, revising care plans to reflect any new changes/orders, transcribing any new orders, ensure the care plans were followed, and completing weekly assigned resident skin assessments. Interview, on [DATE], with Licensed Practical Nurse (LPN) #5 at 4:40 PM, revealed he reviewed Progress Notes to ensure any new orders were transcribed and documented, revision of care plans to reflect any new changes/orders, transcription of any new orders, ensuring the care plans were followed, and completing weekly assigned resident skin assessments. Staff interviews on [DATE], with Certified Nurse Aide (CNA) #9 at 12:59 PM, CNA #15 at 8:19 AM, CNA #16 at 8:39 AM, CNA #17 at 8:52 AM, CNA #18 at 8:59 AM, CNA #19 at 9:08 AM, and CNA #20 at 10:26 AM revealed they had received education by the DON, ADON, and CNS's. The education was related to following care plans, documentation, alerting the nurse of any change in a resident's skin or status. Staff further revealed they were given a post-test and all passed with a score of 100%. Staff interview, on [DATE], with Registered Nurse (RN) #4 at 1:46 PM, revealed she had received education by the DON, ADON, and CNC's, related to reviewing Progress Notes to ensure any new orders were transcribed and documented, revising care plans to reflect any new changes/orders, transcribing any new orders, ensuring the care plans were followed, and completing weekly assigned residents' skin assessments. Staff interviews on [DATE], with Licensed Practical Nurse (LPN) #3 at 9:20 AM, and LPN #4 at 9:42 AM, revealed they had received education by the DON, ADON, and CNC's, related to reviewing Progress Notes to ensure any new orders were transcribed and documented, revising care plans to reflect any new changes/orders, transcribing any new orders, ensuring the care plans were followed, and completing weekly assigned resident skin assessments. Staff interviews on [DATE], with Certified Medication Technician (CMT) #3 at 10:36 AM and CMT #4 at 10:14 AM, revealed they had received education by the DON, ADON, and CNC's, related to following care plans, documentation, alerting the nurse of any change in a residents skin or status. Staff further revealed they were given a post-test and all passed with a score of 100%. Staff interviews, on [DATE], with the DON at 2:01 PM, the ADON at 12:01 PM, and CNC #1 at 1:22 PM, and CNC #2 at 1:18 PM, revealed they had worked together to provide education to all licensed staff on following care plans, documentation, alerting the nurse of any change in a residents skin or status. Staff interviews further revealed they had provided the licensed nurses additional education on reviewing progress notes to ensure any new orders were transcribed and documented, revising care plans to reflect any new changes/orders, transcribing any new orders, ensuring the care plans were followed, and completing weekly assigned resident skin assessments. All staff were given a post-test, with related topics based on their discipline, with all scoring 100%. 6. Review of in-service sheets, dated [DATE], revealed the Interdisciplinary team (IDT), including the DON, Administrator, ADON, Quality of Life Director, Environmental Services Director, MDS, Social Services Director Dietary Director, Admissions Director, Human Resources Director, Business Office Manager, Medical Records Director and Medical Director, had been educated on the reinforcement of the need to utilize the Whiteboard system to validate transcription of orders, and completion of skin and wound assessments, by the CNC. Staff interview with the WCN, on [DATE] at 2:01 PM, revealed she attended the whiteboard meetings held daily. She further stated all disciplines attend, even though much of it deals with nursing. The WCN stated, each staff member regardless of discipline played a role in resident care and ensuring resident needs were met. Staff interviews conducted on [DATE], with the Director of Nursing (DON) at 2:01 PM, the Assistant Director of Nursing (ADON) at 12:01 PM, the Medical Director at 1:25 PM, Social Services Director at 1:38 PM, the Administrator at 2:45 PM, Corporate Minimum Data Set (MDS) Nurse at 11:50 AM, MDS Coordinator at 12:30 PM, Business Office Manager at 11:00 AM, and Medical Records Director at 11:06 AM, revealed they had received education by CNC #1, #2, and/or #3, on utilizing the Whiteboard system to validate transcription of orders, and the completion of skin and wound assessments completed by nursing staff. 7. Review of in-service sheets, dated [DATE], as well as Post Tests, revealed education was provided by CNCs #1, #2, and/or #3, to IDT members on the topic of documentation, care plan revisions related to identifying new wounds, changes in current wounds, interventions, transcribing new treatment orders, prevention/treatment of pressure ulcers, and ensuring skin/wound assessments were completed. Staff interviews conducted on [DATE], with the Director of Nursing (DON) at 2:01 PM, the Assistant Director of Nursing (ADON) at 12:01 PM, the Medical Director at 1:25 PM, Social Services Director at 1:38 PM, the Administrator at 2:45 PM, Corporate Minimum Data Set (MDS) Nurse at 11:50 AM, MDS Coordinator at 12:30 PM, Business Office Manager at 11:00 AM, and Medical Records Director at 11:06 AM, revealed they had received education by CNC #1, #3, and/or #3, on the topic of documentation, care plan revisions related to identifying new wounds, changes in current wounds, interventions, transcribing new treatment orders, prevention/treatment of pressure ulcers, and ensuring skin/wound assessments were completed. 8. Review of the, Whiteboard Meeting Audits/Pressure Ulcers, beginning [DATE] and ongoing, revealed the DON, ADON, MDS Coordinator, and/or CNC, had reviewed orders for readmissions and residents with new orders weekly. Further review of the audit revealed the findings were evaluated during the Clinical White Board Meetings, with no concerns identified. Staff interviews conducted on [DATE], with the Director of Nursing (DON) at 2:01 PM, the Assistant Director of Nursing (ADON) at 12:01 PM, MDS Coordinator at 12:30 PM, and CNC #1 at 1:22 PM, revealed they had all assisted with auditing the charts of readmissions and recently only had two (2) readmissions. They further stated they were reviewing new orders to ensure the accuracy of the transcription. 9. Review of the, Written Order/Treatment Administration/Progress Note Audits, dated [DATE] and ongoing, revealed the audits of Progress Notes written by the APRN, were reviewed by the WCN. Interview with the WCN, on [DATE] at 2:01 PM, revealed she completed rounds with the APRN weekly and would review all new Progress Notes to ensure any new orders were transcribed correctly. She further stated rounds with the APRN were conducted on weekdays, as well as her reviews of the Progress Notes, to ensure consistency. 10. Review of the Whiteboard Meeting audit, dated [DATE] and ongoing, revealed weekly skin assessments were reviewed for completion by the DON and ADON. Staff interviews on [DATE], with the DON at 2:01 PM, the ADON at 12:01 PM, and the MDS Coordinator at 12:30 PM, revealed they reviewed the weekly skin assessments for completion daily, and if a skin assessment had not been completed, they would ensure it was done during the current shift and follow up with the nurse assigned. Interviews further revealed that all skin assessments had been completely timely. 11. Review of the Whiteboard meeting audit/wound treatments, dated [DATE] and ongoing, revealed rounds had been done to verify completed pressure ulcer treatments had been completed, by the DON, ADON, MDS and/or CNC. Interviews, on [DATE], with the DON at 2:01 PM, the ADON at 12:01 PM, and the MDS Coordinator at 1 [TRUNCATED]

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' wounds were assessed and residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of fourteen (14) sampled residents (Resident #1). On [DATE], Resident #1 returned from the hospital with an unstageable pressure injury to the sacrum that worsened. Review of Wound Notes documentation, dated [DATE], revealed Resident #1 had an unstageable pressure injury to the sacrum measuring three point five by two by zero-point three (3.5 x 2.0 x 0.3) centimeters (cm). Record review revealed the wound continued to get larger with the appearance of infection. However, the facility failed to send the resident to the hospital until [DATE], seven (7) days after staff noted the resident's wound was infected. Review of Wound Notes revealed on [DATE], the resident's sacral wound measured ten point nine by eleven by two-point five (10.9 x 11 x 2.5) cm and had the appearance of infection. The facility transferred Resident #1 to the hospital for surgical wound debridement. Review of the Emergency Department assessment, dated [DATE], revealed the resident had a large six (6) centimeter (cm) deep crater ulcer of the sacrum. He/She had a large area of dry gangrene (death of body tissue due to lack of blood flow or a serious bacterial infection) surrounding the crater ulcer. Further review of the hospital record revealed the extent of (the resident's) wounds was such that multiple debridements were necessary for healing to occur. Resident #1 was admitted to Hospice Services on [DATE] and expired on [DATE]. The facility's failure to ensure residents' wounds were assessed and received necessary treatments and services has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on [DATE], and was determined to exist on [DATE], at 42 CFR 483.25 Quality of Care (F686) at an Scope and Severity (S/S) of a J; and at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) at the S/S of J. The facility was notified of Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE] as alleged, prior to exit on [DATE], with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F657 Care Plan Timing and Revision at a S/S of a D and 42 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Prevention of Pressure Injuries, dated ,d+[DATE], revealed the purpose of this procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors, as well as the interventions, designed to reduce or eliminate those considered modifiable. Continued review revealed a risk assessment would be completed on admission (within eight (8) hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any change in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors and prior to discharge. Conduct a comprehensive skin assessment upon admission, with each risk assessment and as indicated according to the resident's risk factors, and prior to discharge. Review of the facility's policy titled, Wound Care, dated [DATE], revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Verify the Physician's Order for the procedure and review the resident's care plan to assess for any special needs of the resident. Continued review revealed staff were to apply treatments as indicated, dress wound using clean technique and apply treatment to area as ordered. Mark tape with initials, time and date and apply to the dressing. Closed record review revealed the facility admitted Resident #1, on [DATE], with the following diagnoses: Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus with Unspecified Complications, and Cerebral Infarction, Unspecified. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of five (5) which indicated severe cognitive impairment. The facility also assessed the resident to be at risk for developing pressure ulcers/injuries. Record review revealed Resident #1 developed a facility acquired Stage two (2) pressure injury on [DATE] to the sacrum. The Stage 2 pressure injury measured one by one (11) centimeters (cm). Review of Physician's Orders revealed an order, dated [DATE], to cleanse Stage 2 to coccyx with soap and water or gauze and normal saline, apply hydrocolloid and change every three (3) days and, as needed. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed Resident #1 had a focus for Pressure Ulcer: Impaired Skin Integrity, related to pressure wound to coccyx. The goal for Resident #1 was Progressive signs of healing through review date of [DATE]. Interventions included: administer medications and treatments as ordered, see Medication Administration Record (MAR)/ Treatment Administration Record (TAR) for specifics; observe for efficacy and for adverse effects; dietary consult as needed; encourage/assist to turn and reposition approximately every two (2) hours; and as needed as resident will comply. Continued review revealed interventions: to encourage turning side to side avoiding pressure to coccyx; pressure re-distribution mattress to bed; pressure relieving device for chair; skin inspection by CNA (Certified Nurse Aide) during care/bathing with a report to the nurse of any area of skin breakdown or redness. Continued review revealed there were no revisions to the care plan on [DATE] when Resident #1 returned from the hospital or with weekly changes in condition to the coccyx wound. Record review revealed the facility failed to complete weekly skin assessments or weekly wound observations until [DATE]. The facility transferred Resident #1 to the hospital on [DATE], related to an urinary tract infection (UTI) and readmitted him/her on [DATE]. Review of the Wound Observation Tool, dated [DATE], revealed Resident #1 had an unstageable pressure ulcer to the sacrum with no measurements recorded. However, review of the Admission Progress Notes, dated [DATE], revealed Resident #1 had a Stage 2 pressure area noted to the coccyx measuring two point six by two point three (2.6 x 2.3 cm) centimeters (cm). The facility referred Resident #1 to the wound clinic. Review of the Hospital Transfer Form, dated [DATE], revealed an order to cleanse sacral wound and apply Calmoseptine (medication used to treat and prevent minor skin irritations such as from diarrhea, burns, cuts, scrapes), cover with sacral border dressing every day. Review of Resident #1's [DATE] Treatment Administration Record (TAR) revealed this treatment was provided until [DATE]. Review of Wound APRN (Advanced Practice Registered Nurse) #1's initial evaluation, dated [DATE], revealed Resident #1 had an unstageable pressure injury to the sacral region measuring three point five by two by zero point three (3.5 x 2.0 x 0.3 cm) centimeters. There was minimal drainage with one hundred percent (100%) slough (yellow, tan, white, stringy tissue) and the surrounding skin was noted as a deep tissue injury (DTI). Further review of Wound APRN #1's notes revealed wound care orders on [DATE] that included: cleanse sacrum daily with wound cleanser, pat dry, apply Medi-honey (for dry to moderately exuding wounds such as pressure ulcers) to wound, skin prep peri-wound and cover with foam gentle sacrum dressing. Other orders included for Resident #1 to be turned side to side every two (2) hours and avoid sitting in chair longer than two (2) hours. Review of APRN #1's wound assessment, dated [DATE], revealed a sacral ulcer with surrounding deep tissue injury. The previous area of deep tissue injury had started to open, and the wound was much larger. Further review revealed Resident #1 was immobile and required turning frequently. Wound measurements were recorded as seven by six by zero-point three (7 x 6 x 0.3) cm. Record review revealed minimal drainage and one hundred percent (100%) slough. Continued review of APRN #1's wound care orders dated, [DATE], revealed the facility was: to cleanse the sacrum wound daily with wound cleanser, dry well; apply Santyl (medication that removes dead tissue from wounds to help with healing; Gentamicin ointment (used to treat infections of the skin) to wound; skin prep peri-wound; cover with foam gentle sacrum dressing (an Optifoam gentle foam sacral dressing). Record review revealed an additional order for a dietary recommendation for supplements to help with wound healing. Review of the Treatment Administration Record for [DATE], revealed the wound care orders written by APRN #1, from [DATE] and [DATE], were not transcribed to the TAR. Continued review revealed the orders were not initiated as ordered and the order for Calmoseptine continued. Further, the additional orders from [DATE] were written on [DATE], eight (8) days late, but were not placed on the [DATE] TAR. Review of APRN #1's wound assessment notes, dated [DATE], revealed the sacral wound measured seven by eight point five by zero-point six (7 x 8.5 x 0.6) cm. Continued review revealed the wound was noted to be larger, with the appearance of an infection. APRN #1's wound care orders included: cleanse sacrum daily with wound cleanser dry well, apply Iodosorb (ointment that absorbs fluids, removing exudate, slough and debris and forms a gel over the wound surface) to calcium alginate then apply to wound, cover with sacral foam dressing. Review of the orders, dated [DATE], and signed by APRN #2, revealed ADON #1 transcribed a wound care order that was not what APRN #1 had ordered. The order included: cleanse sacrum daily with wound cleanser, apply Santyl mixed with Bactroban to wound, skin prep peri-wound and cover with sacral hydrocolloid. Review of Wound Notes revealed on [DATE], the resident's sacral wound measurements were observed to be ten point nine by eleven by two-point five (10.9 x 11 x 2.5) cm and was larger and with the appearance of infection. APRN #1 arranged for Resident #1 to be transferred to the hospital for surgical wound debridement. Review of the Emergency Department assessment, dated [DATE], revealed the resident had a large six (6) centimeter (cm) deep crater ulcer of the sacrum. He/She had a large area of dry gangrene (death of body tissue due to lack of blood flow or a serious bacterial infection) surrounding the crater ulcer. Review of the hospital record, dated [DATE], revealed Resident #1 was transferred to the hospital for surgical debridement of the sacral wound. Further review of the hospital record revealed the extent of (Resident #1's) wounds was such that multiple debridement's were felt to be necessary for healing to occur. The resident's family agreed upon comfort measures and to not put the resident through further surgeries or extensive treatment. Resident #1 was admitted to Hospice Services on [DATE] and expired on [DATE]. Review of Resident #1's Death/Discharge Summary, dated [DATE], revealed the discharge diagnoses included: Sepsis due to a large necrotic infected Stage four (4) sacral decubitus ulcer with associated cellulitis and necrotizing fasciitis; history of stroke with deficits including hemiparesis and aphasia and Diabetes Mellitus. Interview with Certified Nursing Assistant (CNA) #7, on [DATE] at 2:33 PM, revealed he had provided care for Resident #1 in [DATE]. He stated Resident #1 required total assistance with turning in bed. CNA #7 stated he was aware that Resident #1 had a large wound on the coccyx. The CNA stated the resident's wound care was never consistent. Further interview revealed sometimes there would not be a dressing in place covering the wound. He further stated he saw some nurses just put a dressing over the wound and not even clean the wound or pack it with gauze. CNA #7 stated the facility had so many agency nurses that it was hard to keep track. He stated he reported to ADON #1 that Resident #1's wound was getting worse and was told, We know. He stated residents were turned every two (2) hours. The CNA stated if it was different, it would be on the Kardex. Interview with CNA #2, on [DATE] at 3:22 PM, revealed she had provided care to Resident #1. She stated Resident #1 had a wound on the coccyx that she had seen while giving him/her a bath. CNA #1 stated the dressing was not in place as she recalled letting RN #2 know that a new one was needed. She stated she could not recall what the wound looked like, but she turned Resident #1 on his/her side. Interview with CNA #16, on [DATE] at 11:39 AM, revealed she sometimes saw Resident #1's coccyx wound without a dressing and recalled it was not a small wound. CNA #16 stated she would let the nurse know when she did, and the nurse would replace it. Further interview revealed she was not aware that Resident #1 was to be turned side to side. She stated if residents had dressing in place, she knew to offload the area, not from the facility, but by experience. CNA #6 stated she was not sure if turning side to side would be on the Kardex as it was a yes/no question. She stated the facility was full of agency staff at that time and the facility did no training and they received no information. The CNA stated they received a log in to the computer and that was it. Interview with LPN #1, on [DATE] at 4:25 PM, revealed she was agency staff and her first day was [DATE]. She stated in just her first week there, there was several times Resident #1 did not have a dressing in place and even had the wrong dressing in place. She stated she did not think the facility's nurses had been trained on providing care to deep wounds as the wound had depth and was not being packed. LPN #1 stated she spoke with ADON #1 and asked for the order to be clarified so it could be done correctly. She stated the order was not changed and Resident #1 went to the hospital a couple of days later. Continued interview with LPN #1, on [DATE] at 3:43 PM, revealed Resident #1 had a large wound and part of it was eschar (black leathery tissue). She stated the nurses were not packing the wound because the order did not say to, but that with a deep wound and it must be packed for the medication to get to the whole area. LPN #1 stated she was off for a few days and when she came back it was like no one had done the treatment correctly. She stated Calmoseptine had been the previous order as she saw it on the TAR, but that was not the treatment she provided. She stated she would not have used Calmoseptine on the wound as it was not indicated, as it was a paste and contained zinc and menthol. Interview with LPN #6, on [DATE] at 1:25 PM, revealed the nurses do skin assessments weekly and note any new areas. She stated the wound assessments were completed by someone else. LPN #6 stated she could not recall much about Resident #1's wound only that it was large and had an odor. She further stated she when she came to work, the wrong dressing would be in place, or the wrong treatment was being done. The LPN stated she reported her concerns to ADON #1. She revealed she was not aware that Resident #1 had an order to be turned side to side and that he/she was on his/her back a lot. LPN #6 stated she did not think Resident #1 could put himself/herself on his/her back. Interview with Registered Nurse (RN) #2, on [DATE] at 6:46 PM, revealed he provided care for Resident #1 and that he/she had a horrible wound to the sacrum. He stated treatments were not appropriate and were not being completed as ordered. RN #2 stated he would do wound care for Resident #1, be off for three (3) days and return to work and the dressing he placed three (3) days before would still be in place. The RN stated he reported to ADON #1 and the former DON, but nothing was ever done. Interview with RN #3, on [DATE] at 10:24 AM, revealed she had used Calmoseptine on Resident #1's wound as that was what was ordered. She stated she told ADON #1 that Resident #1's wound needed something else and was told APRN #1 would be looking at it. RN #3 stated she applied the Calmoseptine to some gauze and covered the wound. She stated she did not pack the wound as the order did not say to pack it. Interview with APRN #2, on [DATE] at 10:22 AM, revealed she never saw Resident #1's wound. APRN #2 stated she did not give orders for wound care as the facility had a wound nurse that came weekly. Interview with (APRN) #1, on [DATE] at 12:07 PM, revealed she did the initial evaluation on Resident #1's wound on [DATE]. She revealed Resident #1 had an unstageable pressure injury as well as deep tissue injury (DTI) to his/her sacrum. She stated she ordered a specific treatment for the area, but the facility never provided it and she was never told why. APRN #1 further stated she included in her orders that Resident #1 was to be turned side to side every two (2) hours, and to avoid sitting in a chair greater than two (2) hours and heel lift boots. Continued interview revealed Resident #1 was always on his/her back each time she came to the facility. She stated the former Director of Nursing (DON) had asked her not to write specific orders on turning residents as that was a standard of care. Further, APRN #1 stated that just turning Resident #1 would have helped prevent the wound from getting worse. She stated that over a three-week period, the resident's wound worsened drastically and on her last visit she arranged for the resident's wound to be debrided. The APRN stated she verbally told ADON #1, or the nurse making rounds with her, what her orders were, and she sent her notes the next day. She stated some nurses would write it down at the time and some would wait until she sent her notes the next day. APRN #1 stated she asked ADON #1 why her orders were not being followed and she never got a response Continued interview with Wound APRN #1, on [DATE] at 4:55 PM, revealed she absolutely believed Resident #1's wound was avoidable. She stated if staff would have performed treatments as ordered and added new interventions, the wound would not have gotten in that shape. Interview with Wound APRN #1, on [DATE] at 10:33 AM, revealed Calmoseptine was not indicated for open wounds and using it could have contributed to the wound worsening. Interview with ADON #1, on [DATE] at 7:16 PM, revealed she had been the ADON since [DATE] and she received no training for the position. She stated the floor nurses were responsible for the weekly skin assessments and she was responsible for the wound assessments. ADON #1 stated the DON had been doing the wound assessments prior to her. She stated APRN #1 came weekly for wound rounds, and she made rounds with her. ADON #1 stated she received APRN #1's orders and notes the following day. She revealed she did not know why the wound care orders from [DATE] and [DATE] were not on the TAR. The ADON stated she was unable to recall who gave the wound care order for Santyl on [DATE]. She stated, on [DATE], Resident #1's wound did look infected, with brown, yellow drainage and had a foul odor. She stated Resident #1 had the incorrect dressing in place two or three times and she was unsure who did those dressings. Interview with the former Director of Nursing (DON), on [DATE] at 5:35 PM, revealed she could not recall if she ever saw Resident #1's wound. She stated ADON #1 was responsible for doing the wound rounds with the APRN #1. She stated she had no knowledge that APRN #1's orders had not been written or initiated. Continued interview revealed she could not recall any discussion about Resident #1's wound. She stated staff know to turn residents every 2 hours and that Resident #1's order to turn side to side should have been on the care plan. Further, she stated the weekly skin and weekly wound assessments not being completed should have been caught in the clinical meeting. The former DON stated she had no answer for why Resident #1 did not have weekly skin assessments or weekly wound observations from [DATE] through [DATE]. Interview with former Administrator, on [DATE] at 3:50 PM, revealed the floor nurses would be responsible for the weekly skin assessments and the ADON's were responsible for making sure those were completed. Ultimately, the DON was to follow up and ensure the ADON's were doing what was expected of them, including updating the plan of care. He further revealed he expected the wound APRN's orders to be followed. Interview with Director of Nursing, on [DATE] at 12:33 PM, revealed she was new to the role of DON, but was training for the MDS Nurse in [DATE]. She stated she did not recall discussing Resident #1 upon returning from the hospital or thereafter with the changes in Resident #1's wound. The DON stated she did not always get to attend the clinical or at-risk meetings as she was working the floor and was training as the MDS Nurse. She stated she was not involved with Resident #1. Further, she stated she was not aware of APRN #1's orders not being written and transcribed to the TAR. She stated staff know if a resident had a wound to keep them off the area as it was standard of care to turn every 2 hours. The DON stated the nurse should let the staff know when changes occurred and that residents needed special turning schedules. 35748 The facility provided an acceptable removal plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. Review of the removal plan revealed the facility implemented the following: 1. Resident #1 was transferred to the hospital on [DATE] and discharged from the facility on [DATE]. The Interdisciplinary Team (IDT) held an ad-hoc meeting on [DATE] to discuss the root cause analysis (RCA) identifying variables that led to the process failure. The RCA was reviewed and revised later in the Ad-hoc Quality Assurance (QS) meeting with the Medical Director on [DATE]. The Root Cause Analysis revealed that the failures to follow the facility's processes related to monitoring of wound assessment, treatment and documentation was related to the transition of three (3) critical nursing leadership positions Director of Nursing (DON), Assistant Director of Nursing (ADON) and Minimum Data Set Coordinator (MDS) during the time frame identified. 2. On [DATE], the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set (MDS) Coordinator, completed skin assessments on one-hundred percent (100%) of current residents, to determine skin condition. Residents were assessed to determine if any resident was at risk for pressure. Skin assessments were compared to each resident's respective care plan to ensure all necessary and appropriate wound treatments and/or interventions were reflected. All dietician's, physicians', and nurse practitioners' recommendations were reviewed by the Clinical Nurse Consultant (CNC), DON and ADON. Care plans were revised with changes to align with orders as necessary between [DATE] and [DATE] by the MDS Coordinator. 3. An audit of all other current residents who had a pressure injury, had been audited to verify that the current treatment order corresponded with the most recent Progress Note, was completed by the CNC on [DATE] and [DATE]. Any order that was found to differ than the most recent Progress Note was clarified by the nurse responsible for wound rounds and accurately transcribed. 4. Effective [DATE], responsibility for weekly wound rounds with the Wound Care Nurse (WCN)/Nurse Practitioner (APRN) was changed to a newly assigned full-time in house WCN. The WCN would monitor turning and positioning and change of skin condition daily. The DON and ADON would monitor during WCN days off work. Findings during rounds were reviewed daily during quality assurance white board meetings. 5. Education was provided to licensed nurses, certified nurse aides (CNA), and all agency staff beginning on [DATE], by the Clinical Nurse Consultant (CNC), the Director of Nursing (DON), and Assistant Director of Nursing (ADON). Training included topics of: documentation, recognizing change of condition to skin/wounds, care plans, orders, prevention and treatment of pressure ulcers, and skin/wound assessments and notification process of any change of condition. Any staff that had not completed the education, by [DATE], would not be permitted to work until training had been completed. 6. Education was provided to the interdisciplinary team (IDT) to reinforce the need to utilize the whiteboard system to validate transcription of orders, and completion of skin and wound assessments. The IDT membership consists of DON, Administrator, ADON, Quality of Life Director, Environmental Services Director, MDS, Social Services Director Dietary Director, Admissions Director, Human Resources Director, Business Office Manager, Medical Records Director and Medical Director. The education was completed on [DATE] by the CNC. 7. On [DATE], the Administrator, DON, ADON, and CNC began one-hundred percent (100%) in-servicing of all IDT Members and nursing staff on topic of pressure ulcers. Continuing sessions of the education were provided by Administrator, DON, ADON, MDS Coordinator, Human Resources Director, Activities Director, Social Services, and CNCs on [DATE] and [DATE]. Post-tests were administered upon completion of this training with scores of 100% attained. Beginning [DATE], no clinical staff were permitted to work until education was received and post-test completed. These topics were added to clinical new hire orientation effective [DATE] and included: documentation of resident skin/wound assessments promptly; updating resident care plans when a wound was identified; declines or interventions require modification; care plans to reflect the resident's current condition or needs; transcribing physician's orders following a consultant visit/readmission; assure that care needs of residents are reflected on the Nurse Aide Kardex; ensure weekly wound observations were completed by assigned staff and validate that the skin/wound assessments were completed as scheduled; ensure care plan interventions were consistently followed; and, observe residents closely during care and report any skin changes to the nurse. 8. Beginning [DATE], the DON, ADON, MDS Coordinator, or Clinical Nurse Consultant would review fifty percent (50%) of readmissions and ten percent (10%) of new orders weekly for four weeks, then two times monthly for one month, then monthly for one month, during Clinical White Board meeting, held Monday through Friday, to validate that care plans were reviewed and updated to reflect change of condition; were reviewed and updated to reflect wound onset/decline. And continuation of monitoring through the weekends will be shared by DON, ADON, WCN or other assigned licensed staff. 9. Beginning [DATE], Progress Notes written by the APRN would be reviewed by the WCN to identify orders and accurately transcribe the orders. In her absence, the ADON, DON or CNC would complete the review. 10. Beginning [DATE], the schedule for Weekly Skin Assessments would be utilized in the Whiteboard Meeting, Monday through Friday, to validate the completion of the planned assessments by the ADON and DON. Weekends would be monitored by the DON, ADON, WCN, or other assigned licensed staff. 11. Beginning [DATE], monitoring for the completion of and accuracy of wound treatments would be accomplished through rounds by the DON, ADON, MDS or CNC, observing twenty percent (20%) of completed pressure ulcer treatments two times weekly for four weeks, then once weekly for six (6) weeks. 12. On [DATE], available QAPI team members met with Medical Director via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Interdisciplinary Team and by the Medical Director on [DATE]. The RCA was revised in an Ad-hoc QA meeting held with the Medical Director on [DATE]. The Interdisciplinary Team and Medical Director would attend QAPI meetings to review the efficacy of the above mentioned plan monthly to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, HR Director, Maintenance Director, MDS Nurse, Dietary Director, WCN and Medical Director. The State Survey Agency validated the implementation of the facility's removal plan as follows: 1. Record review revealed Resident #1 was discharged from the facility on [DATE]. Review of the facility's documentation and sign-in forms, dated [DATE] and [DATE], revealed ad-hoc meetings were held on [DATE] and [DATE], with all IDT members present, to discuss the RCA of the failures to follow the facility's processes related to wounds. Interview, on [DATE], with the Wound Care Nurse (WCN), at 2:01 PM, revealed she had attended the Ad-hoc meetings and discussed the root case analysis of the wound care and care plan concerns. She further stated QAPI meetings and Whiteboard meetings were ongoing to discuss audits and any newly identified concerns related to wounds and residents' care plans. Staff interviews, conducted on [DATE], with the Director of Nursing (DON) at 2:01 PM, the Assistant Director of Nursing (ADON) at 12:01 PM, the Medical Director at 1:25 PM, Social Services Director at 1:38 PM, the Administrator at 2:45 PM, Corporate Minimum Data Set (MDS) Nurse at 11:50 AM, MDS Coordinator at 12:30 PM, Clinical Nurse Consultant (CNC) #1 at 1:22 PM, CNC #3, and CNC #2 at 1:18 PM, revealed they had attended the Ad-hoc meetings and discussed the root case analysis of the wound care and care plan concerns. They further stated QAPI meetings and Whiteboard meetings were ongoing to discuss audits and any newly identified concerns related to wounds and residents' care plans. 2. Review of the Skin Assessment List, dated [DATE], revealed the DON, ADON, and MDS Coordinator, had completed skin observations on all current residents, with no identified concerns. Interviews on [DATE], with the DON at 2:01 PM, the ADON at 12:01 PM, and the MDS Coordinator at 12:30 PM, revealed they had completed skin assessments on all current residents on [DATE]. They further revealed there were no concerns or updates needed at this time. They stated if any skin issues had been noted they would have notified the physician for treatment orders and put appropriate interventions in place. 3. Review of the, Pressure/Non-Pressure Ulcer Audit, dated [DATE] and [DATE], revealed CNC #1 had completed a chart audit of current treatment orders to ensure the orders corresponded with the most recent Progress Notes. Further review of the document revealed no concerns were identified. Interview with CNC #1, on [DATE] at 1:22 PM, revealed she had audited the records of residents who were identified to have pressure and non-pressure wounds to

Based on observation, interview, record review and review of the facility's medication administration policy, it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #3) was free of significant medication errors. Review of Resident #3's April, May, and June 2022, Medication Administration Records (MAR) revealed the facility failed to administer a total of ninety-eight (98) doses of physician ordered medications. The findings include: Review of the facility's policy titled, Administering Medications, dated April 2019, revealed medications were administered in a safe and timely manner and as prescribed. Only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so. If a drug was withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. The individual administering the medication would initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. Medication errors were documented, reported and reviewed by the QAPI (Quality Assurance (QA) and Performance Improvement) Committee to improve process changes and, or the need for additional staff training. Record review revealed the facility admitted Resident #3, on 07/14/2021, with diagnoses that included: Parkinson's Disease, Cerebral Infarction, and Unspecified Dementia without Behavioral Disturbance. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 03/30/2022, revealed a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Review of Physician's Orders for April, May and June 2022, revealed Resident #3 had the following medications ordered: Calcium (calcium supplement) 600 milligrams (mg) by mouth every day; Carbidopa 25 mg-Levodopa 100 mg by mouth once daily; (anti-Parkinson's); Eliquis 5 mg by mouth two times a day (blood thinner); Magnesium Oxide 400 mg by mouth two times a day (mineral supplement); Memantine 10 mg by mouth two times a day (memory); Methenamine Hippurate 1 gram (GM) by mouth every bedtime (anti-infective); Nuplazid 34 mg by mouth once a day (antipsychotic); Pantroprazole 40 mg by mouth once a day (proton pump inhibitor); Alendronate Sodium 70 mg one time weekly (prevents bone loss); Carbidopa 25 mg-Levodopa 100 mg, 1/2 tab by mouth four (4) times a day; Docusate Sodium 100 mg by mouth two times a day (stool softener); Montelukast Sodium 10 mg by mouth every bedtime (anti-inflammatory); Myrbetriq 25 mg by mouth daily (bladder relaxant); Quetiapine 50 mg by mouth every bedtime (antipsychotic); Potassium Chloride 10 milliequivalents (meq) by mouth two (2) times a day (electrolyte); Vitamin b-12 1000 micrograms (mcg) by mouth every day (vitamin supplement); Synthroid 200 mcg by mouth every day (thyroid hormone); Probiotic Supplement, by mouth every day; Furosemide 40 mg by mouth every other day (diuretic); and Quetiapine 25 mg by mouth two times a day at 7 AM and 12 PM (antipsychotic). Review of Resident #3's April 2022 Medication Administration Record (MAR) revealed the MAR had forty-nine (49) blanks which indicated staff had not documented if Resident #3 received physician ordered medications. The following medications were not initialed on the MAR as administered: one (1) dose of Calcium 600 milligrams (mg) every day; Carbidopa 25 mg-Levodopa 100 mg once daily; Eliquis 5 mg, two times a day; Magnesium Oxide 400 mg, two times a day; Memantine 10 mg, two times a day; Methenamine Hippurate 1 gram (GM), every bedtime; Nuplazid 34 mg, once a day; Pantroprazole 40 mg, once a day and Alendronate Sodium 70 mg, one time weekly. Further review of Resident #3's April MAR revealed the following medications had not been documented as been administered for two (2) doses; Carbidopa 25 mg-Levodopa 100 mg, 1/2 tab by mouth four (4) times a day; Docusate Sodium 100 mg, two times a day; Montelukast Sodium 10 mg, every bedtime; and Myrbetriq 25 mg, once daily; Quetiapine 50 mg, every bedtime. Additionally, Potassium Chloride 10 milliequivalents (meq) two (2) times a day and Vitamin B-12, 1000 micrograms (mcg), every day had not been initialed as given for three (3) doses. Continued review revealed; Synthroid 200 mcg every day, four (4) doses were missed; Probiotic Supplement, (no dosage) every day, with five (5) doses missed; Furosemide 40 mg every other day, with five (5) doses missed and Quetiapine 25 mg, two times a day at 7 AM and 12 PM, with 10 doses not administered. Review of Resident #3's May 2022 MAR revealed thirty-six (36) blanks that included: one (1) dose of Linzess 145 micrograms (mcg) by mouth every day and Nuplazid 34 mg by mouth every day; two (2) doses of Vitamin B-12 1000 mcg by mouth every day; and three (3) doses of Quetiapine Fumarate 25 mg by mouth twice daily. Further review revealed seven (7) missed doses of Dicyclomine 10 mg by mouth every day; Furosemide 40 mg by mouth every other day; and fifteen (15) doses of Chlordiazepoxide-Clindinium 5 mg/2.5 mg by mouth every bedtime. Review of the June 2022 MAR revealed thirteen (13) blanks, indicating Resident #3 had not received, as ordered by the physician, one (1) dose of Furosemide 40 mg by mouth every other day; Methenamine Hippurate GM by mouth every bedtime; two (2) doses of Quetiapine Fumarate 25 mg by mouth twice daily; four (4) doses of Magnesium Oxide 400 mg by mouth twice daily and five (5) doses of Chlordiazepoxide-Clindinium 5 mg/2.5 mg by mouth every bedtime. Review of the Progress Note (Late Entry), dated 05/18/2022, created on 05/26/2022 and signed by ADON (Assisted Director of Nursing) #1, revealed the Administrator, Regional Nurse, Interim Director of Nursing, Assistant Director of Nursing met with Resident #3's daughter regarding concerns about the medications that were not administered. Record review indicated Resident #3 had missed seventeen (17) days of Librax (medication used to treat stomach/intestinal disorders). This medication required prior authorization and had not been submitted correctly. Additionally, it was also noted that a new medication order received, on 05/09/2022, was not transcribed to the MAR until 05/16/2022. The facility re-educated staff and implemented a Medication Administration Record Audit. The State Survey Agency (SSA) requested Medication Error reports on three (3) occasions. However, the facility did not present any reports. The Administrator stated he could not locate any medication error incident reports. Observation of Certified Medication Tech (CMT) #20, on 06/23/2022 at 9:50 AM, revealed she reviewed the MAR and removed medication from the cart. CMT #20 opened the medications at the cart and placed the medications in a cup. CMT #20 then signed the medications on the MAR, before she administered them. Interview with Certified Medication Tech (CMT) #20, on 06/23/2022 at 9:50 AM, when asked if she was supposed to sign the MAR prior to administering medications, she stated she did not know. CMT #20 stated that was how she was trained to do it. The CMT stated a blank on the MAR meant a resident may not have taken the medication. She stated when a resident refused a medication you circled your initials and wrote on the back of the MAR. CMT #20 stated she could not recall not administering or signing out Resident #3's medication. Interview with CMT #18, on 06/24/2022 at 11:51 AM, revealed signing the MAR meant the resident had taken the medication. She stated the MAR was signed after the resident took the medication. CMT #18 stated if a medication was not available or the resident refused, she would circle her initials and document on the back of the MAR. Interview with CMT #16, on 06/28/2022 at 3:48 PM, revealed she would let the nurse know if medications were not available and the pharmacy would be called. She stated some staff may not be used to paper MARS and would forget to sign them. CMT #16 stated she was aware of an issue with a medication that was not administered for two (2) weeks (Resident #3's Librax in May). She stated ADON #1 took care of it. CMT #16 stated she did not recall any other mediations not being given. She stated she circled the MAR, but failed to write on the back as she was supposed to. Interview with CMT #17, on 06/28/2022 at 3:30 PM, revealed Resident #3 had been almost two (2) weeks without a medication (Librax). She stated she was told the pharmacy was aware and ADON #1 had submitted a prior authorization for the medication. CMT #17 stated she let the nurses know when medications were not available. She stated she called the pharmacy to check on medications. CMT #17 stated Resident #3 had increased nausea when his/her Librax was omitted. Interview with Assistant Director of Nursing (ADON) #1, on 07/05/2022 at 7:16 PM, revealed Resident #3 missed almost two (2) weeks of the prescribed medication, Librax before CMT #9 let her know. She stated she notified the pharmacy, and was informed the medication required prior authorization (PA). ADON #1 stated she let the former DON know as she was off the next day, but it was not addressed. Further interview revealed she knew Resident #3 had missed several medications as the daughter had requested a copy of the MARs. She stated a meeting was held with the daughter and administrative staff. She stated she stressed to the nurses and CMT's if it was not documented it was not given. ADON #1 stated she did not do medication error reports as she did not know she was supposed to do them. She stated everyone expected her to know how to do things, but she didn't. Continued interview revealed ADON #1 stated she did not notify the physician of the ninety-eight (98) medications that were not documented as being administered. Interview with the former (Director of Nursing) DON, on 07/05/2022 at 5:35 PM, revealed incident reports should be completed with medication errors which included omitted medications. She stated the ADONs completed the incident reports. The DON stated she was unsure if ADON #1 knew she was responsible to complete the reports. Interview with the current DON, on 07/21/2022 at 12:33 PM, revealed she had no knowledge of Resident #3 not receiving medications. She stated she was not aware of any education or MAR audits being conducted. The DON stated omitted medications were considered a medication error and incident reports should have been completed. She stated ADON #1 may not have been aware of that since she was kind of thrown into the ADON position. Interview with the Regional Resource Nurse, on 07/21/2022 at 2:55 PM, revealed she was present for the meeting held in May 2022 with Resident #3's daughter about missing medications. She stated there was a delay in the PA being submitted as ADON #1 did not know how to submit it. Continued interview revealed the ADON had provided education to the staff, but apparently there was no documentation related to the training. Interview with the Administrator, on 07/13/2022 at 2:45 PM, revealed he expected nurses and CMT's to follow Physician's Orders and administer medications as ordered. He stated medication errors would require an incident report to be completed, physician notification and maybe alert charting. He stated he was unable to locate any education provided to staff or MAR audits that had been initiated or completed related to Resident #3's missed medications.

Based on observation, interview, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, it was determined the facility failed to establish and maintain an infection prevention and control (ICP) program designed to provide a safe, sanitary, and comfortable environment to help prevent and control the development and transmission of communicable diseases, including Coronavirus Disease (COVID-19) for one (1) of fourteen (14) sampled residents (Resident #8). Observation on the 400 Hall, on 06/22/2022 at 9:50 AM, revealed no indication that Resident #8, who was readmitted from the hospital, was on transmission based precautions (TBP). Observation on the 400 Hall, on 06/23/2022 at 8:45 AM, revealed Resident #8 had been placed on TBP. However, observation revealed the resident was outside smoking with a staff member. Upon entry to the facility on [DATE], the facility failed to screen the State Survey Agency Surveyor for COVID-19. The findings include: Review of the facility's policy titled, Visitation Guidance, dated November 18, 2021, revealed it was the policy of the facility to provide safe opportunities for residents to receive visitation from outside persons, while maintaining core principles of COVID-19 infection prevention. The following were also required: Screening of all who entered the facility for signs and symptoms of COVID-19; temperature checks; questions about and observations of signs and symptoms; hand hygiene and face covering or mask. Review of the facility's policy titled, Management of Residents with Confirmed, Suspected and Higher Risk Exposure to COVID-19, Managing Admissions and Readmissions, not up to date with COVID-19 vaccinations, dated 03/25/2022, revealed newly admitted or readmitted residents, who were not up to date with COVID-19 vaccinations, would be placed in a fourteen (14) day quarantine on a dedicated unit. The residents would be placed in Transmission Based Precautions (TBP) - Enhanced Droplet Precautions, as well, as any other precautions indicated by other diagnoses. Continued review revealed the facility would follow current guidance by the Centers for Disease Control (CDC) and Prevention and the Centers for Medicare and Medicaid Services (CMS) when implementing Transmission Based Precautions for residents, determining measures and duration of restrictions to prevent avoidable transmission of COVID-19 among residents and health care personnel (HCP). Observation revealed a screening Kiosk and signage posted that stated the facility followed the CDC's guidelines and all visitors must be screened upon entrance. However, upon entry to the facility on [DATE], the facility failed to screen the State Survey Agency Surveyor. Further observation revealed there was no log book for visitors who did not use the Kiosk. Observation on the 400 Hall, on 06/22/2022 at 9:50 AM, revealed no indication that Resident #8 was on transmission based precautions (TBP). There was no signage on the door and the door was open. Resident #8 had an employee (Maintenance Assistant) sitting on the bed next to him/her. Further observation revealed the employee had on a face mask and no other Personal Protective Equipment (PPE). Interview, with the Maintenance Assistant, on 06/23/2022 at 9:15 AM, revealed he was not aware that Resident #8 was on isolation precautions. Further interview revealed Resident #8 did not have signage on the door, on 06/22/2022, when he visited with him/her. Observation on the 400 Hall, on 06/23/2022 at 8:45 AM, revealed Resident #8 had signage on the door indicating contact/droplet precautions were required when entering the room. However, observation revealed Resident #8 was not present. The resident was outside smoking. Continued observation revealed a staff member returned Resident #8 to his/her room. Interview with Certified Medication Tech (CMT) #17, on 06/24/2022 at 9:43 AM, revealed staff and visitors used the Kiosk for screening. She stated the Kiosk had questions for staff to complete; and staff obtained and recorded their own temperatures. Review of Resident #8's medical record revealed the facility admitted Resident #8 on 01/26/2022, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Atrial Fibrillation. Continued review revealed Resident #8 returned to the facility, on 06/21/2022, following a brief hospital stay. Resident #8 had not received the COVID-19 vaccine. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 06/15/2022, revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated no cognitive impairment. Observation on the 400 Hall, on 06/22/2022 at 9:50 AM, revealed no indication that Resident #8, who was readmitted from the hospital was on transmission based precautions. Further observation, on 06/23/2022 at 8:45 AM, revealed Resident #8 had signage on the door indicating contact/droplet precautions were required when entering the room. Interview with Resident #8, on 06/23/2022 at 9:08 AM, revealed the nurse had informed him/her that he/she had to be in isolation for fourteen (14) days because of not being vaccinated for COVID-19 upon returning from a hospital stay. Interview with Housekeeping staff, on 06/23/2022 at 9:18 AM, revealed she was not aware Resident #8's room was an isolation room until that day. She stated she would need to have a gown and gloves on when entering the room. Interview with Certified Nursing Assistant (CNA) #4, on 06/23/2022 at 9:25 AM, revealed Resident #8 was not in isolation until today. She stated she had not worn additional Personal Protective Equipment (PPE) when in Resident #8's room on 06/22/2022. Interview with Licensed Practical Nurse (LPN) #1, on 06/23/2022 at 10:43 AM, revealed the communication could be better. She stated, You never know who is on isolation or why, and staff were not aware of residents that had not received COVID vaccines and there was no way to find out anything. She further stated, all staff and visitors use the Kiosk to screen when entering the facility. Additionally, LPN #1 stated new visitors should be screened by staff upon entering the facility. Interview with the Assistant Director of Nursing (ADON) #2/Infection Preventionist (IP), on 06/24/2022 at 12:36 PM, revealed all visitors and staff were required to be screened at the door. She stated whoever let visitors in the facility should screen them at the Kiosk and obtain a temperature. ADON #2 stated residents who were readmitted from the hospital and were unvaccinated should be placed in isolation. She stated it was the Admission Nurse's responsibility to ensure signs were in place. The ADON stated if no barrier was placed in front of the door, then the resident's door should be closed.

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined the facility failed to ensure medications were not misappropriated for one (1) of three (3) sampled residents (Resident #1). On 04/14/2020, the north nurse notified the Director of Nursing (DON) and Administrator that they were unable to obtain [MEDICATION(S)] 7.5/325 milligrams (mg) tablets for Resident #1, because the pharmacy stated they had sent them to the facility on [DATE]. Further investigation revealed a card of forty-five (45) [MEDICATION(S)] 7.5/325 milligrams (mg) tablets was missing. During the facility investigation, Certified Medication Technician (CMT) #4 admitted she had taken the medication. The findings include: Review of the facility policy titled, Abuse Prevention Program, dated December 2016, revealed our residents have the right to be free from abuse, neglect, misappropriation of residents property and exploitation. Record review revealed the facility admitted Resident #1 on 11/14/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated 09/07/2020, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. Review of Resident #1's February 2020 Physician Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)]-Acetaminophen tablet 7.5-325 mg , one (1) tablet by mouth three (3) times a day not to exceed 4 grams (GM)/24 hours. Interview with Resident #1 on 08/04/2020 at 11:20 AM, revealed he/she always got his/her medications on time, and never recalled a time he/she never was without his/her medications. Review of the facility final investigation dated 04/21/2020, revealed on 04/14/2020 at approximately 9:45 AM , the north nurse notified the Director of Nursing (DON) and Administrator that they were unable to reorder Resident #1's narcotic pain medication, because the pharmacy stated they had sent them on 04/03/2020. Deliveries from the pharmacy typically occur between 6:00-8:00 PM. It was discovered a card of forty-five (45) [MEDICATION(S)] 7.5/325 milligrams (mg) tablets of Resident #1's was missing. An investigation was immediately initiated, and local law enforcement was notified on 04/14/2020. During the facility investigation CMT #4 admitted she had taken the medication. Interview with CMT #1 on 08/04/2020 at 12:05 PM, revealed she was the one who signed for the card of narcotics (45 tablets) when the pharmacy delivered them for Resident #1 on 04/03/2020. She stated she did not open the bag to verify what medications were actually in the bag and took the bag over and handed it to the CMT who was working on the north hall. She revealed she works the south hall, and just happened to be at the door when the pharmacy came to delivery the medication. She further revealed once she handed the bag of medication to the CMT who worked the north hall she went back to working her hall. She stated she did not know there was a problem with the medication, until the DON and Administrator started asking her questions about the missing medication. Interview on 08/04/2020 at 1:29 PM, with CMT #2, revealed on 04/14/2020 at 9:40 AM, she made her nurse aware she had given Resident #1 his/her last [MEDICATION(S)]-Acetaminophen and that she needed to call the pharmacy to inquire about the resident's medication. She stated, she had given the last pill and there was no card in the narcotic box to give the next dose. Interview with Licensed Practical Nurse (LPN) #1 on 08/04/2020 at 1:47 PM, revealed, she was made aware of the missing medication on 04/14/2020 by CMT #2 who works the north hall with her. She stated CMT #2 had just administered the resident's last dose of medication that was available in the card, and that the re-order sticker had already been pulled and that she could not locate another card of medication to give the resident's next dose that would be due around noon time. LPN #1 revealed she called the pharmacy and they stated the medication had already been sent out on 04/03/2020. She stated her and CMT #2 went back to the narcotic book and there was no narcotic sign out sheet in the book, nor could they locate the pink copy of the manifest sheet that comes with the medication that is always put in the medication room. She revealed at that point she realized there was a problem, and notified the Director of Nursing (DON). She stated the Resident did not miss any medication as the medication was in the facility's Emergency Drug Kit (EDK), and she called the pharmacy to get the special code to get the medication out of the EDK box. Attempts to interview CMT #4 (alleged perpetrator)on 08/04/2020 at 2:15 PM, 3:39 PM and on 08/05/2020 at 7:11 AM, and 3:22 PM were unsuccessful. Interview with the DON on 08/04/2020 at 2:36 PM, revealed she first became aware on 04/14/2020, when LPN #1 came to her with a concern regarding Resident #1's missing medication. She stated she also called the pharmacy to verify the medication had been delivered and they once again indicated the medication had been delivered on 04/03/2020. The Pharmacy also sent us a copy of the manifest to validate that the medication had been delivered and signed for when it was delivered. She stated once she obtained the manifest and saw who signed off for the medications when they were delivered, they started interviewing staff. She revealed the manifest was signed off by CMT #1, on 04/03/2020 and CMT#1 said she had signed off for the medications when the pharmacy delivered them, and she took them to the CMT who was working on the South hall, and then went back to her hall. She further revealed CMT #1 wrote a statement, and was suspended, and given a drug screening which she passed, on 04/14/2020. In addition, law enforcement, Office of Inspector General (OIG) and Department of Community Based Services (DCBS) was notified on 04/14/2020. Interview on 08/05/2020 at 8:58 AM, with law Enforcement, revealed the facility contacted his agency, and he went out to the facility on [DATE] to inquire about the situation, and has been in contact with the facility on several different occasions regarding the matter. He stated CMT #4 confessed to taking the medications. He revealed law enforcement was finished with their investigation and CMT #4 was charged and it was going through court system currently. Interview with the Administrator on 08/04/2020 at 3:40 PM, revealed she became aware of the missing medication on 04/14/2020, when the DON, made her aware. She stated at that time she had them check every medication cart in the building just in case it was placed on the wrong medication cart. She revealed after pharmacy sent the manifest for the medication, the facility was able to pin point who actually signed for the medications to be delivered into the building, and at that point is when the interviews started to take place. She stated Law enforcement, Office of Inspector General (OIG) and Department of Community Based Services (DCBS) were notified on 04/14/2020. She further revealed the facility covered the cost of the missing medication for the resident and substantiated the incident actually occurred as CMT #4 came into the facility on [DATE] and confessed to taking the medication for a family member. She stated CMT #4 asked, what she could do to fix the matter and make things right, and she was told this was very serious and the facility was obligated by law to report her to law enforcement, and to the nursing board as well. CMT #4 was escorted out of the building. She revealed the facility has implemented new measures to ensure this does not happen again. *** The facility implemented the following actions to correct the deficient practice: 1. A new policy was implemented on 04/15/2020 that now requires there to be two (2) licensed staff to sign-in narcotics. 2. All licensed staff who administer medication were educated on the new policy on 04/15/2020. 3. The pharmacy requisitions/narcotic audit sheets were immediately audited starting on 04/14/2020 through 04/15/2020 with no concerns identified. Audits continued daily for (2) weeks, then twice a week for (2) weeks, and are still ongoing. 4. A new policy was reviewed in Quality Assurance (QA) meeting, with the Medical Director on 04/15/2020. 5. All interviewable residents on the North Hall were interviewed by the SSW on 04/15/2020, to ensure receiving their pain medications. 6. All non-interviewable residents had a pain assessment completed on 04/15/20. 7. Abuse and Resident Rights post test education was completed on 04/16/2020. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of the Controlled Medication and Controlled Record Count Procedure, revealed, it was last revised on 04/15/2020. 2. Review of Record of Inservice entitled, Narcotics Received from Pharmacy, dated 04/15/2020, revealed all licensed staff who administered medication received education. Interviews on 08/04/2020 with CMT #2 at 1:29 PM, LPN #1 at 1:47 PM, Registered Nurse (RN) #1 at 2:48 PM, LPN #3 at 3:05 PM, CMT #3 at 3:16 PM, and on 08/05/2020 with RN #1 at 9:16 AM, and RN #3 at 9:36 AM, revealed education was provided related to the new process when receiving narcotics from the pharmacy, which requires two (2) signatures. 3. Review of sixteen (16) residents narcotic manifest sheets revealed they had been audited on 04/14/2020, and review of audit sheet tool from dates 04/15/2020 through 07/30/2020, revealed narcotic manifest sheets had been audited. Interview with the Director of Nursing on 08/04/2020 at 12:36 PM, revealed the pharmacy requisitions/narcotic audit sheets were immediately audited on 04/14/2020 through 04/15/2020 with no concerns identified. The audits continued daily for two (2) weeks, then twice a week for (2) weeks, and it is still on going. 4. Interview with the Medical Director on 08/06/2020 at 11:11 AM, revealed the narcotic misappropriation concern was discussed with him on 04/14/2020. He stated they also discussed the new process with receiving narcotics from the pharmacy in an emergency QA meeting on 04/15/2020 and the staff now have two licensed staff signatures when receiving any narcotics into the building. 5. Interview with the Social Worker on 08/04/2020 at 4:19 PM, revealed she interviewed all the interviewable residents on the North hall, to ensure they received their pain medication with no concerns identified. 6. Review of pain assessment's for non-interviewable residents revealed they were completed on 04/15/2020 with no concerns identified. 7. Review of Record of Inservice entitled,Abuse and Resident Rights Education, dated 04/16/2020, revealed staff received education on 04/16/2020. Interviews on 08/04/2020 with CMT #2 at 1:29 PM, LPN #1 at 1:47 PM, RN #1 at 2:48 PM, LPN #3 at 3:05 PM, CMT #3 at 3:16 PM, and on 08/05/2020 with RN #1 at 9:16 AM, and RN #3 at 9:36 AM, revealed education had been provided related to Abuse, Neglect, Resident Rights as well as misappropriation of property. Interview with the Director of Nursing on 08/04/2020 at 12:36 PM, revealed all staff that pass medication have been educated on Abuse and Resident Rights related to misappropriation, as well as the new narcotic process. She stated the staff's understanding of the education will be monitored once a month at their staff meetings with a quiz.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to revise the comprehensive care plans for two (2) of three (3) sampled residents (Resident #1 and Resident #2). The facility identified Resident #1 and Resident #2 had significant weight loss; however, the facility failed to revise the resident's care plans to include goal and specific interventions to address the residents' identified weight loss. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Interdisciplinary Team (IDT) must review and update the care plan when there has been a significant change in the resident's condition and when the resident has been readmitted to the facility from a hospital stay. Record review revealed the facility admitted Resident #1, on 08/06/16, with [DIAGNOSES REDACTED]. Further review revealed the resident was hospitalized from [DATE] through 04/18/2020. Review of Resident #1's Significant Change Minimum Data Set (MDS) assessment, dated 04/26/2020, revealed the resident had been identified as having significant weight loss and he/she was not on a physician prescribed weight-loss regimen. Review of Resident #1's Comprehensive Care Plan for Nutritional Problem, History of Obesity related to Spinal Cord Injury/[MEDICAL CONDITION]; recent decreased intakes and significant weight loss, not dated, revealed a goal for the resident to maintain adequate nutrition status as evidenced by maintaining weight within gain/loss of five (5) pounds of 223 pounds. Further review of the care plan revealed interventions to monitor/record/report to Medical Doctor (MD) s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, and significant weight loss of three (3) pounds in one (1) week, greater than five percent (5%) in one (1) month, greater than seven.five percent (7.5%) in three (3) months, or greater than ten (10) percent in six (6) months. Review of Resident's #1's Weight Record revealed the resident was weighed 223 pounds on 03/19/2020, and hospital records revealed a weight of 164.1 pounds on 04/18/2020 (after dieuresed: hospitalized [DATE]-04/18/2020); and the facility Weight Record revealed the resident weighed 162.2 pounds on 05/11/2020. However, further review of the Care Plan for Nutritional Problem revealed there were no revisions to the care plan goal to address the resident's weight loss and new weight of 162.1 pounds and not specific interventions to address the resident's identified weight loss. 2. Record review revealed the facility readmitted Resident #2 from the hospital, on 04/24/2020, with [DIAGNOSES REDACTED]. Further review revealed the resident was hospitalized from [DATE] through 04/24/2020. Review of Significant Change (MDS) assessment, dated 05/01/2020, revealed the resident was not identified as having weight loss in the last month and was not on a physician prescribed weight-loss regimen. Review of Resident #2's Comprehensive Care Plan for Nutritional Problem, Obesity as Evidenced by Basic Metabolic Index (BMI) of 36.9, not dated, revealed goal to maintain adequate nutritional status, target date 07/14/2020. Further review of the care plan revealed interventions to provide and serve diet as ordered, monitor intake and record every meal, provide and serve supplements as ordered, and weigh per MD (medical doctor) orders prn (as needed). Review of Resident #2's Weight Record revealed the resident weighed 248.4 pounds on 03/30/2020 and 213.8 pounds on 05/15/2020. The facility identified a significant weight loss of 13.9 percent; however, further review of the Care Plan for Nutritional problems revealed there was no specific interventions to address the resident's identified weight loss. Interview with the Registered Dietician, on 05/27/202 at 4:07 PM, revealed recommendations and care interventions should be reflected on resident's care plan. Interview with the Director of Nursing (DON), on 06/03/2020 at 1:59 PM, revealed staff is expected to review and revise care plans which is ongoing to reflect changes residents' condition.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure two (2) of three (3) sampled resident's weights were obtained on readmission (Resident #1 and #2). The facility failed to obtain Resident #1's and #2's weight on readmission from the hospital; per facility policy. The residents were admitted to the COVID Unit and there was no scale located on the unit to obtain weights. Resident #1 was readmitted on [DATE] and his/her weight was not obtained until 05/11/2020. Resident #2 was readmitted on [DATE], and his/her weight was not obtained until 05/15/2020 at which time he/she was identified to have a 13.9 percent weight loss. The findings include: Review of the facility's policy titled, Weight Assessment and Intervention, dated September 2008, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will strive to measure resident weights on admission and weekly for 2 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 1. Record review revealed the facility admitted Resident #1, on 08/06/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review of the MDS, Section K-Swallowing/Nutritional Status, K0300, did not indicate the resident had been identified as having weight loss and he/she was not on a physician prescribed weight-loss regimen. Review of Resident #1's Comprehensive Care Plan for Nutritional Problem History of Obesity related to Spinal Cord Injury/[MEDICAL CONDITION]; recent decreased intakes and significant weight loss, not dated, revealed a goal for the resident to maintain adequate nutrition status as evidenced by maintaining weight within gain/loss of five (5) pounds of two-hundred twenty three (223)pounds, no signs/symptoms (s/sx) of dehydration, target date 08/21/2020. Further review of the care plan revealed interventions to monitor/record/report to Medical Doctor (MD) s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, and significant weight loss of three (3) pounds in one (1) week, greater than five percent (5%) in one (1) month, greater than seven.five percent (7.5%) in three (3) months, or greater than ten (10) percent in six (6) months. Review of Resident #1's Weight Record revealed the resident weighed 223 pounds at the facility on 03/19/2020 and review of hospital records revealed the resident was hospitalized for [REDACTED]. The resident was readmitted back to the facility on [DATE]; however, there was no documented evidence on the weight record that Resident #1's weight was obtained on readmission and/or a monthly weight was obtained. Further review of the Weight Record revealed the resident's weight was not obtained by the facility until 05/11/2020 (52 days after last weight) and the resident weighed 162.2 pounds. The facility called the Registered Dietician(RD) and she recommended Med Pass 2.0 (to equal 540 calories and 22 grams of protein a day). Interview with the RD, on 05/27/2020 at 4:07 PM, revealed the resident was transferred to the hospital where the resident remained until 04/18/2020. The RD stated during that time the resident was dieuresed with an significant amount of fluid removed. RD #1 revealed Resident #1 was readmitted to the COVID (quarantine) Unit at the facility on 04/18/2020 and a readmission weight was not obtained. Interview with Licensed Practical Nurse (LPN) #1, on 06/02/2020 at 2:39 PM, revealed she was the nurse assigned when Resident #1 was readmitted to the facility on [DATE]. LPN #1 stated the resident had lost a significant amount of weight; however, a readmission weight was not obtained due to the quarantine (COVID) unit not having access to a scale. LPN #1 revealed there was a scale in the facility; however, it was a wheelchair scale and the resident needed a bed scale. Further interview revealed it was facility policy to obtain weights on all residents on admission, readmission, monthly, and/or as ordered by the physician. Interview with the Director of Nursing (DON), on 05/27/2020 at 12:52 PM, revealed Resident #1 weight at the facility on 03/19/2020 was 223.6 pounds. The DON stated the resident was not weighed in the facility again until 05/11/2020 because the resident was readmitted from the hospital to the COVID Unit and there was no weight scale for a wheelchair. Interview with the Administrator and DON, on 06/03/2020 at 1:59 PM, revealed Resident #1 was hospitalized [DATE] through 04/18/2020 and was dieuresed while hospitalized which attributed to a significant weight loss. The Administrator and DON stated it was identified the resident had a significant weight loss, but he/she was not weighed on readmission to assess weight. They further revealed there was not a scale on the COVID Unit to minimize possible exposure to COVID-19 although, no positive residents were identified in the facility. 2. Record review revealed the facility readmitted Resident #2 from the hospital, on 04/24/2020, with [DIAGNOSES REDACTED]. Review of Significant Change (MDS), dated [DATE], revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was rarely/never understood. Further review of the MDS, Section K-Swallowing / Nutritional Status, K0300, did not indicate the resident had been identified as having weight loss in the last month and was not on a physician prescribed weight-loss regimen. Review of Resident #2's Comprehensive Care Plan for Nutritional Problem Obesity as Evidenced by Basic Metabolic Index (BMI) of 36.9, not dated, revealed goal to maintain adequate nutritional status, target date 07/14/2020, with interventions to provide and serve diet as ordered, monitor intake and record every meal, provide and serve supplements as ordered, weigh per MD (medical doctor) orders prn (as needed). Review of Resident #2's Weight Record revealed the resident weighed 248.4 pounds on 03/30/2020. Further review of the Weight Record revealed resident weight was not obtained again until 05/15/2020 (forty-six {46} days later) at which time the resident weighed 213.8 pounds, which the facility identified as a significant weight loss of 13.9 percent. Further review of the record revealed the Physician and/or Registered Dietician was not notified of the significant weight loss until 05/28/2020 (thirteen {13} days later). Review of the Registered Dietician's (RD) Notes dated 05/28/2020, revealed a significant change in Resident #1's nutritional status with weight fluctuating; weighed 213.8 pounds on 05/15/2020, with eleven (11) percent significant weight loss in three (3) months; eighteen (18) percent in six (6) months. Resident #2 was previously on self planned weight loss program, and is currently receiving pureed diet with honey-thickened liquids. Further review of the note, revealed she recommended fortified foods with meals and magic cup supplement once a day for weight maintenance. Interview with Registered Nurse (RN) #2, on 06/04/2020 at 8:36 AM, revealed Resident #2 was hospitalized [DATE] through 04/24/2020. RN #2 stated the resident returned to the facility on [DATE]; however, a readmission weight was not obtained because he/she was readmitted to the COVID (quarantine) Unit and a scale was not available to obtain weight. RN #2 further revealed the facility had scales however, weights were not being obtained for residents quarantined. She stated the facility's policy was to obtain weights on all residents on admission, readmission, and monthly unless otherwise indicated. Interview with the Administrator and DON, on 06/03/2020 at 1:59 PM, revealed weight scale was not used on the COVID (quarantine) Unit to minimize possible exposure to COVID-19 although, no positive residents were identified in the facility. The stated no weights were obtained for residents while in quarantine until a weight device was obtained for the quarantine unit.

Based on interview, record review, review of facility policy, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure one (1) of three (3) sampled residents was free from verbal abuse (Resident #1). On 12/28/19 at approximately 5:40 AM, staff witnessed Certified Medication Technician (CMT) #1, yelling and cursing at Resident #1 on the North Hall. Staff failed to remove the resident or alleged perpetrator from the situation to protect the resident and failed to report the incident to the Director of Nursing (DON) in a timely manner. The alleged perpetrator continued resident care and did not clock out until 12/28/19 at 6:15 AM (thirty-five) minutes later. The facility's failure to ensure residents were free from verbal abuse has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 01/23/2020 and determined to exist on 12/28/19. The facility was notified of the Immediate Jeopardy on 01/23/19. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 01/29/2020, alleging the facility achieved compliance on 01/13/2020. The State Survey Agency validated the AoC and determined due to the facility conducting education post-testing on 01/13/2020, the facility was not in compliance until 01/14/2020, which was still prior to the State Survey Agency entering the building on 01/21/2020. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Abuse Prevention Program, last revised December 2016, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Further review revealed as part of the resident abuse prevention program the staff training/orientation program will include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of the facility's Abuse and Neglect training material, not dated, revealed staff are educated that all allegations must be reported immediately to the Administrator; and, if you observe/suspect or hear abuse your top priority is to protect the resident which includes the following: call for help, do not allow the perpetrator access to other residents, the accused person must immediately be accompanied from resident care area and have no resident contact, and report to supervisor to take charge of the situation and assure notification of the administrator. Review of the closed record revealed the facility admitted Resident #1 from the Personal Care Area of the facility on 12/10/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/20/19, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (00) which indicated the resident was not interviewable. Review of the facility's Initial Report to the State Survey Agency, dated 12/28/19 revealed Patient Care Aide (PCA) #1 reported that during shift change on 12/28/19 at approximately 6:15 AM, she allegedly heard CMT #1 cursing at Resident #1. Review of a Health Status Note, dated 12/27/19 at 9:19 PM, revealed Resident #1 was assisted to bed around 8:00 PM, then got up and took his/her clothes off. At approximately 8:45 PM, the resident's alarm was sounding and the resident entered the hallway naked. When State Registered Nurse Aides (SRNA's) went to check on the resident, the resident was noted to have had a bowel movement in the hallway and in another resident room that was connected to the resident's room by a bathroom. When the resident was asked what he/she was doing, the resident stated, I'm[***]ing in the hallway!. Interview with Patient Care Aide (PCA) #1, on 01/22/2020 at 11:41 AM, revealed she came in at approximately 5:40 AM on 12/28/19. PCA #1 stated when she walked to the break room to leave her drink, she heard CMT #1 tell Resident #1 to sit your [***] ing ass down. You're not getting up, you're going to sit your Mother [***] ing ass down. You have got on my [***] ing last nerve for the past four (4) [***] ing hours. She stated she did not see anything, only heard from where she was standing at the bathroom door. She revealed when she went to the two-hundred (200) hall area she discovered the verbal abuse had not been reported, so she reported it to Licensed Practical Nurse (LPN) #1 around 6:05 AM. Interview with the Laundry Aide, on 01/22/2020 at 11:07 AM, revealed she was walking down the hall to the restroom when she heard CMT #1 yelling and cursing as if she was venting. She stated Resident #1 was in front of CMT #1 in his/her wheelchair and the resident had defecated on the floor in the hallway and in another resident's room. The Laundry Aide revealed she had heard CMT #1 use foul language before and the only word she could specifically remember was the CMT calling the resident an[***] . She revealed she reported the incident on 12/28/19 around 6:40 AM to the Director of Nursing (DON) and the incident had occurred close to 6:00 AM at shift change. She stated she did not report it immediately as she had never been in that situation before. Interview with CMT #1, on 01/24/2020 at 2:06 PM, revealed Resident #1 was combative all night long. She stated the resident caused her to have bruises and tore off one of her acrylic nails. When asked if she had cursed the resident, she replied that she told the resident to sit his/her ass down and that she used a loud tone. She denied using other profane language and stated she had her hands resting on the resident's shoulders. She reported there was only one (1) aide working with her that night. She stated the first time she heard anything about the abuse allegation was when the Social Services Director and the HR Director called her on 12/28/19 and was told she was suspended while an investigation was competed. Interview with LPN #1, on 01/28/2020 at 12:36 PM, revealed she worked on 12/28/19 and had come in to work the 6:00 AM - 2:00 PM shift. She stated she was not there when the incident happened but PCA #1 reported to her how CMT #1 was talking to the resident. LPN #1 revealed she called the Social Services/Abuse Coordinator, who in turn phoned the Administrator. She stated that she had never heard CMT#1 talk to a resident like that before. She further revealed by the time she reported the allegation, CMT #1 had already left the building. Review of the facility's investigation, dated 12/28/19 revealed the facility substantiated the allegation and terminated CMT #1. Further review revealed they determined staff failed to protect the resident from further verbal abuse and failed to report the incident immediately upon discovery. Interview with the facility's Administrator, on 01/22/2020 at 12:19 PM, revealed she had received a call regarding the abuse report around 6:30 AM on 12/28/19. She stated the facility investigated the incident and determined it was substantiated and terminated CMT #1. She further revealed the CMT admitted ly used profanity which could be deemed offensive in an area that could be heard by others and this conduct does not reflect the expectations of the facility. She stated the staff members who witnessed the verbal abuse should have removed CMT #1 from the area and resident care to protect residents from verbal abuse. **The facility implemented the following actions prior to entry for the Abbreviated Survey. 1. A head-to-toe skin assessment was completed on 12/28/19 at 7:30 AM by LPN #1 with no injuries identified. An additional skin assessment was completed on 12/28/19 to begin gathering information pertinent to the investigation. 2. Social Services/Abuse Coordinator arrived at 7:30 AM on 12/28/19 followed by the Human Resources Director who arrived at the facility at 7:50 AM on 12/28/19 to begin gathering information pertinent to the investigation. 3. The facility submitted their initial report to OIG and DCBS on 12/28/19. 4. On 12/28/19, the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Disciplinary action was given by the Human Resources Director and Social Services/Abuse Coordinator. 5. The on-site investigation was initiated on 12/28/19 by Social Services/Abuse Coordinator and Human Resources Director and continued by the Administrator and DON. The alleged perpetrator, CMT #1, was interviewed and informed that she was suspended, pending results of the investigation, by the Human Resources Director and Social Services/Abuse Coordinator on 12/28/19. CMT #1 was instructed that she was not to return to the premises during the course of the investigation. From the time of entry into the facility until exiting, CMT #1 was accompanied by staff at all times. 6. Skin assessments of residents with a BIMS less than eight (8) were initiated on 12/28/19 and completed by 12/30/19 by LPN #1, Assistant Director of Nursing (ADON) #1, and ADON #2, with no abnormal findings identified. 7. Interviews of all residents with a BIMS of eight (8) or higher were completed on 12/28/19 by Social Services Director/Abuse Coordinator. No issues or concerns were reported by residents. 8. An ad hoc QA was held on 12/28/19 with the Medical Director's involvement telephonically, to develop a plan for immediate actions. On 12/28/19, the following QA members were in attendance: Administrator, DON, Social Services Director, Human Resources Director and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 9. On 12/28/19, Social Services/Abuse Coordinator notified POA of incident and that an investigation had been started. On 12/28/19, the Administrator notified the Medical Director, who is resident's attending physician, of incident. 10. Immediate education began on 12/28/19 regarding abuse identification and reporting, identifying stress and burnout and response, and resident rights with post test administered. This was conducted by the Business Office Manager/Manager on Duty for 12/28/19. Education following 12/28/19 was conducted by Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/07/2020. 11. On 12/28/19, the Administrator reviewed the facility's abuse policy and procedures for needed changes or revisions. No changes to the policy were made at that time. 12. On 12/30/19, the Social Services/Abuse Coordinator visited Resident #1 to monitor for signs and symptoms of emotional distress. Resident #1 has a BIMS of 0, but demonstrated no visible signs of emotional distress. 13. On 12/31/19, Social Services/Abuse Coordinator visited Resident #1 again to monitor for signs and symptoms of emotional distress. Resident, with BIMS of 0 as of 12/20/19, but demonstrated no visible signs of emotional distress. 14. A root cause analysis (RCA) was initiated on 01/02/2020 by the Administrator and Regional Nurse Consultant. Through the root cause analysis, it was determined that CMT #1 was frustrated by Resident #1's repetitive behavior and did not appropriately use behavior management techniques. 15. Education on use of profanity and verbal abuse with post test was initiated on 01/02/2020 by the DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/11/2020. 16. Education on management of behaviors associated with dementia, with post test was initiated on 01/02/2020 by DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/13/2020. 17. Investigation was completed by the Administrator and DON and the results of the investigation concluded that allegations of abuse were substantiated, resulting in the immediate termination of CMT #1 effective 01/02/2020. 18. An ad hoc QA was held on 01/03/2020, with the Medical Director's involvement telephonically, to discuss root cause analysis and review implementation. On 01/03/2020, the following QA members were in attendance: Administrator, DON, Dietary Manager, Business Office Manager, Social Services Director, Maintenance Director, Medical Records Clerk, Central Supply Clerk, Rehab Director, and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 19. An ad hoc QA was held on 01/06/2020 with the Medical Director's involvement telephonically, to evaluate the effectiveness of plan (Plan Do Study Act cycle), and to set forth parameters for ongoing monitoring. On 01/06/2020, the following QA members were in attendance: Administrator, DON, Central Supply Clerk and the Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 20. Beginning on 01/07/2020, the Administrator began conducting random audits to validate retention of training through a post-test covering prior education, with a sample of employees from each shift twice weekly x 2 weeks, then weekly x 2 weeks, then biweekly x 2 weeks to be completed by 03/01/2020. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Skin Care alert sheet and skin observation tool revealed Resident #1's skin assessments were completed on 12/28/19 and 12/30/19. Interview with LPN #1, on 01/29/2020 at 1:06 PM, revealed she completed Resident #1's first skin assessment with no concerns identified. Interview with RN #1, on 01/29/2020 at 1:55 PM, revealed she completed Resident #1's second skin assessment with no concerns noted. 2. Review of the investigation revealed the Social Services/Abuse Coordinator arrived at the facility on 12/28/19 at 7:30 AM and the Human Resources Director arrived on 12/28/19 at 7:50 AM to begin the onsite investigation. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM, and the Human Resources Director on 01/29/2020 at 1:11 PM, revealed they began the facility investigation on 12/28/19. 3. Review of the facility facsimile confirmation sheet revealed OIG and DCBS was notified of the allegation of verbal abuse on 12/28/19. 4. Review of the Coaching & Counseling Session sheets dated 12/28/19 revealed the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Interviews on 01/29/2020 with the Human Resources Director at 1:11 PM and the Social Services/Abuse Coordinator at 1:44 PM revealed they gave the Laundry Aide and PCA #1 disciplinary action on 12/28/19. Interviews on 01/22/2020 with the Laundry Aide at 11:07 AM and PCA #1 at 11:41 AM revealed the received disciplinary action and education related to following facility policy for immediate intervention and reporting abuse. 5. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM revealed on 12/28/19, CMT #1 was contacted by the Social Services/Abuse Coordinator and Human Resources Director and asked to return to the facility for interview. On 12/28/19 at approximately 11:00 AM, the CMT was met at the door and accompanied to the Human Resources office. The CMT was interviewed by the investigators, suspended and instructed not to return to the premises during the course of the investigation. 6. Review of skin assessment sheets dated 12/30/19 revealed skin assessments were completed on all residents with a BIMS score of below eight (8) by LPN #1, ADON #1 and ADON #2. No concerns were identified. 7. Review of interview sheets dated 12/28/19 revealed all residents with a BIMS score of eight (8) or above were interviewed about abuse/neglect with no concerns identified. 8. Review of a sign-in sheet revealed an initial Ad hoc QA meeting was held on 12/28/19 with the Medical Director's involvement via telephone. Further review revealed the meeting was attended by the Administrator, DON, ADON #1, ADON #2, Director of Dining Services, Social Services Director, Maintenance Director, Medical Records, Central Supply/staffing, Medical Director (telephonically) and the Human Resources Director. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following the meeting. 9. Review of a Communication Note in the resident's record, dated 12/28/19 at 11:39 AM, revealed the Social Services/Abuse Coordinator notified Resident #1's Power of Attorney (POA) about the alleged abuse. Interview with the Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she spoke with the POA regarding the event. Interview with the Administrator on, 01/22/2020 at 12:19 PM, she notified the Medical Director about the alleged abuse on 12/28/19. 10. Review of Inservice Sign-in sheets dated 12/28/19, 01/11/2020, and 01/13/2020, revealed 100% of staff had been educated. Interview with the Administrator, on 01/29/2020 at 1:41 PM revealed she was educated by Corporate staff and she educated the Business Office Manager/Manager on Duty, Social Services Director, Social Services Assistant, ADON #1 and ADON #2. She stated these staff assisted with education of the remaining staff. She revealed staff were required to take post-test with 100% achieved. Interviews with the Business Office Manager on 01/26/2020 with the SS Assistant at 1:33 PM, on 01/27/2020 at 11:48 AM, and on 01/29/2020 with ADON #2 at 1:17 PM and ADON #1 at 1:22 PM, revealed they were educated on Abuse and Resident Rights, Examples of Verbal Abuse, Reasons why verbal abuse happens and Tips for Behavior Management. They stated the information was used to educate the other staff. Interviews on 01/22/2020 with Laundry Aide at 11:07 AM, PCA #1 at 11:41 AM, Kentucky Medication Aide (KMA) #1 at 12:07 PM, Human Resources Director at 12:44 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with Registered Nurse (RN) #2 at 7:44 PM, State Registered Nurse Aide (SRNA) #2 at 2:11 PM, CMT/SRNA at 2:58 PM, SRNA #3 at 3:00 PM, Occupational Therapist at 3:10 PM, Dietary Manager at 3:13 PM, Laundry staff at 3:14 PM, Maintenance Man at 3:17 PM, DON at 3:20 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM( and, on 01/28/2020 with LPN #1 at 12:36 PM revealed they received education on Abuse and Resident Rights. 11. Interview with the Administrator on 01/29/2020 at 1:44 PM revealed she reviewed the abuse policy and no changes were made. 12. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM, revealed she visited Resident #1 on 12/30/19 to monitor for signs and symptoms of emotional distress. She stated the resident had a BIMS score of 0, but she observed the resident for signs of emotional distress with none identified. 13. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she assessed Resident #1 again on 12/31/2020 with no concerns identified. 14. Review of the facility's Root Cause Analysis tool, not dated revealed a Five Whys Template that addressed the problem, why did this occur, the root cause, and possible solutions. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM, Dietary Manager at 3:13 PM, and Maintenance Director at 3:17 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, ADON #2 at 1:17 PM, Social Services Director at 1:44 PM, Central Supply/Staffing person at 1:33 PM, and Human Resources Director at 1:11 PM revealed they attended the QA meeting where Root Cause Analysis was discussed. 15. Review of the facility's education packet revealed all staff was educated on the use of profanity and verbal abuse by the Business Office Manager who was the Manager on Duty on the day of the incident, the Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2 on 01/02/2020 Review of the POS [REDACTED]. Further review revealed all staff achieved a score of 100% . Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they received education about the use of profanity and verbal abuse. 16. Review of the Education material packet revealed all staff was educated on management of behaviors associated with dementia beginning on 01/02/2020 through 01/13/2020 by the Social Services Assistant, the Social Services Director, and ADON #2. Review of the POS [REDACTED]. Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they had been educated on behaviors associated with Dementia. 17. Review of the facility's investigation dated 01/02/2020 revealed the facility substantiated the allegation and terminated CMT #1 on 01/02/2020. Interview with the Administrator on 01/22/2020 at 12:19 PM revealed CMT #1 was terminated by telephone on 01/02/2020. 18. Review of Ad Hoc attendance sheet revealed an ad hoc QA meeting was held on 01/03/2020 and attended by the Administrator, DON, Director of Dining Services, the Business Office Manager, the Social Services Director, the Maintenance Director, the Medical records staff member, Central Supply / Staffing person and the Rehabilitation Manager. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following. 19. Review of the attendance sheet for the ad hoc QA meeting held on 01/06/2020 revealed the meeting was attended by the Administrator, the DON and the Central Supply/Staffing person. The Medical Director attended telephonically. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM and the Staffing/Central Supply staff at 1:33 PM revealed they attended the Ad Hoc meeting on 01/06/2020 and discussed the effectiveness of action plan and set forth parameters for ongoing monitoring. Interview with the Medical Director, on 01/23/2020 at 8:40 AM, revealed he was made aware of the verbal abuse and recommended the staff member be terminated. He also reported he has been involved with the QA and follow-ups with the Administrator. 20. Review of the auditing tool revealed random audits began on 01/07/2020 and were completed on each shift on 01/07/20, 01/09/2020, and 01/10/2020 with no concerns identified. Audits continued on 01/14/2020, 01/17/2020, 01/23/2020, 01/24/2020 and 01/29/2020, with no concerns identified. Interview with the Administrator, on 01/31/2020 at 8:47 AM, revealed staff was able to verbalize information that they had been educated on in regards to abuse when he completed the audits.

Based on interview, record review, and review of facility policy, it was determined the facility failed to have an effective system to implement their abuse policy related to the failure to report the incident immediately and protecting residents from further abuse for one (1) of three (3) sampled residents (Resident #1). Staff witnessed Certified Medication Technician (CMT) #1 verbally abuse Resident #1 on 12/28/19 at approximately 5:40 AM; however, the staff failed to report the alleged abuse immediately and failed to remove the alleged perpetrator from the area to protect residents from further abuse, per facility policy. CMT #1 continued to work and clocked out on 12/28/19 at 6:15 AM (40 minutes later). The facility's failure to implement the facility's abuse policy and procedure related to verbal abuse, reporting alleged abuse, and protecting residents from abuse has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 01/23/2020 and determined to exist on 12/28/19. The facility was notified of the Immediate Jeopardy on 01/23/19. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 01/29/2020, alleging the facility achieved compliance compliance on 01/13/2020. The State Survey Agency validated the AoC and determined due to the facility conducting education post-testing on 01/13/2020, the facility was not in compliance until 01/14/2020, which was still prior to the State Survey Agency entering the building on 01/21/2020. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Abuse Prevention Program, last revised December 2016, revealed as part of the resident abuse prevention program, the staff training/orientation program will include such topics as abuse prevention identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of the facility's Abuse and Neglect training material, not dated, revealed staff are educated that all allegations must be reported immediately to the administrator; and, if staff observe/suspect or hear abuse your top priority is to protect the resident which included to call for help, do not allow the perpetrator access to other residents, the accused person must immediately be accompanied from resident care area and have no resident contact, and report to supervisor to take charge of the situation and assure notification of the administrator. Closed record review revealed the facility admitted Resident #1 from the Personal Care Area of the facility on 12/10/19 with [DIAGNOSES REDACTED]. Review of the facility's investigation dated 12/28/19 revealed CMT #1 verbally abused Resident #1. Further review of the investigation revealed the facility substantiated the allegation and identified staff failed to report the incident immediately upon discovery and failed to protect the resident and other residents from further verbal abuse per the facility's policy. Interview with Patient Care Aide (PCA) #1, on 01/22/2020 at 11:41 AM, Laundry Aide, on 01/22/2020 at 11:07 AM revealed they witnessed CMT #1 verbally abuse Resident #1 on 12/28/19 at approximately 5:40 AM. PCA #1 and Laundry Aide stated they did not report the alleged abuse immediately per facility policy. PCA #1 stated she reported it on 12/28/19 at 6:05 AM and the Laundry Aide stated she reported at 6:40 AM. PCA #1 and the Laundry Aide also stated they did not remove CMT #1 from the work area. to ensure residents were protected from further verbal abuse, per facility policy. Interview with the Administrator, on 01/22/2020 at 12:19 PM, revealed the two (2) staff members who observed the verbal abuse failed to follow the facility's policy when they failed to report the alleged abuse immediately and failed to remove CMT #1 from the area to protect residents from further verbal abuse. **The facility implemented the following actions prior to entry for the Abbreviated Survey. 1. A head-to-toe skin assessment was completed on 12/28/19 at 7:30 AM by LPN #1 with no injuries identified. An additional skin assessment was completed on 12/28/19 to begin gathering information pertinent to the investigation. 2. Social Services/Abuse Coordinator arrived at 7:30 AM on 12/28/19 followed by the Human Resources Director who arrived at the facility at 7:50 AM on 12/28/19 to begin gathering information pertinent to the investigation. 3. The facility submitted their initial report to OIG and DCBS on 12/28/19. 4. On 12/28/19, the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Disciplinary action was given by the Human Resources Director and Social Services/Abuse Coordinator. 5. The on-site investigation was initiated on 12/28/19 by Social Services/Abuse Coordinator and Human Resources Director and continued by the Administrator and DON. The alleged perpetrator, CMT #1, was interviewed and informed that she was suspended, pending results of the investigation, by the Human Resources Director and Social Services/Abuse Coordinator on 12/28/19. CMT #1 was instructed that she was not to return to the premises during the course of the investigation. From the time of entry into the facility until exiting, CMT #1 was accompanied by staff at all times. 6. Skin assessments of residents with a BIMS less than eight (8) were initiated on 12/28/19 and completed by 12/30/19 by LPN #1, Assistant Director of Nursing (ADON) #1, and ADON #2, with no abnormal findings identified. 7. Interviews of all residents with a BIMS of eight (8) or higher were completed on 12/28/19 by Social Services Director/Abuse Coordinator. No issues or concerns were reported by residents. 8. An ad hoc QA was held on 12/28/19 with the Medical Director's involvement telephonically, to develop a plan for immediate actions. On 12/28/19, the following QA members were in attendance: Administrator, DON, Social Services Director, Human Resources Director and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 9. On 12/28/19, Social Services/Abuse Coordinator notified POA of incident and that an investigation had been started. On 12/28/19, the Administrator notified the Medical Director, who is resident's attending physician, of incident. 10. Immediate education began on 12/28/19 regarding abuse identification and reporting, identifying stress and burnout and response, and resident rights with post test administered. This was conducted by the Business Office Manager/Manager on Duty for 12/28/19. Education following 12/28/19 was conducted by Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/07/2020. 11. On 12/28/19, the Administrator reviewed the facility's abuse policy and procedures for needed changes or revisions. No changes to the policy were made at that time. 12. On 12/30/19, the Social Services/Abuse Coordinator visited Resident #1 to monitor for signs and symptoms of emotional distress. Resident #1 has a BIMS of 0, but demonstrated no visible signs of emotional distress. 13. On 12/31/19, Social Services/Abuse Coordinator visited Resident #1 again to monitor for signs and symptoms of emotional distress. Resident, with BIMS of 0 as of 12/20/19, but demonstrated no visible signs of emotional distress. 14. A root cause analysis (RCA) was initiated on 01/02/2020 by the Administrator and Regional Nurse Consultant. Through the root cause analysis, it was determined that CMT #1 was frustrated by Resident #1's repetitive behavior and did not appropriately use behavior management techniques. 15. Education on use of profanity and verbal abuse with post test was initiated on 01/02/2020 by the DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/11/2020. 16. Education on management of behaviors associated with dementia, with post test was initiated on 01/02/2020 by DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/13/2020. 17. Investigation was completed by the Administrator and DON and the results of the investigation concluded that allegations of abuse were substantiated, resulting in the immediate termination of CMT #1 effective 01/02/2020. 18. An ad hoc QA was held on 01/03/2020, with the Medical Director's involvement telephonically, to discuss root cause analysis and review implementation. On 01/03/2020, the following QA members were in attendance: Administrator, DON, Dietary Manager, Business Office Manager, Social Services Director, Maintenance Director, Medical Records Clerk, Central Supply Clerk, Rehab Director, and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 19. An ad hoc QA was held on 01/06/2020 with the Medical Director's involvement telephonically, to evaluate the effectiveness of plan (Plan Do Study Act cycle), and to set forth parameters for ongoing monitoring. On 01/06/2020, the following QA members were in attendance: Administrator, DON, Central Supply Clerk and the Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 20. Beginning on 01/07/2020, the Administrator began conducting random audits to validate retention of training through a post-test covering prior education, with a sample of employees from each shift twice weekly x 2 weeks, then weekly x 2 weeks, then biweekly x 2 weeks to be completed by 03/01/2020. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Skin Care alert sheet and skin observation tool revealed Resident #1's skin assessments were completed on 12/28/19 and 12/30/19. Interview with LPN #1, on 01/29/2020 at 1:06 PM, revealed she completed Resident #1's first skin assessment with no concerns identified. Interview with RN #1, on 01/29/2020 at 1:55 PM, revealed she completed Resident #1's second skin assessment with no concerns noted. 2. Review of the investigation revealed the Social Services/Abuse Coordinator arrived at the facility on 12/28/19 at 7:30 AM and the Human Resources Director arrived on 12/28/19 at 7:50 AM to begin the onsite investigation. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM, and the Human Resources Director on 01/29/2020 at 1:11 PM, revealed they began the facility investigation on 12/28/19. 3. Review of the facility facsimile confirmation sheet revealed OIG and DCBS was notified of the allegation of verbal abuse on 12/28/19. 4. Review of the Coaching & Counseling Session sheets dated 12/28/19 revealed the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Interviews on 01/29/2020 with the Human Resources Director at 1:11 PM and the Social Services/Abuse Coordinator at 1:44 PM revealed they gave the Laundry Aide and PCA #1 disciplinary action on 12/28/19. Interviews on 01/22/2020 with the Laundry Aide at 11:07 AM and PCA #1 at 11:41 AM revealed the received disciplinary action and education related to following facility policy for immediate intervention and reporting abuse. 5. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM revealed on 12/28/19, CMT #1 was contacted by the Social Services/Abuse Coordinator and Human Resources Director and asked to return to the facility for interview. On 12/28/19 at approximately 11:00 AM, the CMT was met at the door and accompanied to the Human Resources office. The CMT was interviewed by the investigators, suspended and instructed not to return to the premises during the course of the investigation. 6. Review of skin assessment sheets dated 12/30/19 revealed skin assessments were completed on all residents with a BIMS score of below eight (8) by LPN #1, ADON #1 and ADON #2. No concerns were identified. 7. Review of interview sheets dated 12/28/19 revealed all residents with a BIMS score of eight (8) or above were interviewed about abuse/neglect with no concerns identified. 8. Review of a sign-in sheet revealed an initial Ad hoc QA meeting was held on 12/28/19 with the Medical Director's involvement via telephone. Further review revealed the meeting was attended by the Administrator, DON, ADON #1, ADON #2, Director of Dining Services, Social Services Director, Maintenance Director, Medical Records, Central Supply/staffing, Medical Director (telephonically) and the Human Resources Director. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following the meeting. 9. Review of a Communication Note in the resident's record, dated 12/28/19 at 11:39 AM, revealed the Social Services/Abuse Coordinator notified Resident #1's Power of Attorney (POA) about the alleged abuse. Interview with the Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she spoke with the POA regarding the event. Interview with the Administrator on, 01/22/2020 at 12:19 PM, she notified the Medical Director about the alleged abuse on 12/28/19. 10. Review of Inservice Sign-in sheets dated 12/28/19, 01/11/2020, and 01/13/2020, revealed 100% of staff had been educated. Interview with the Administrator, on 01/29/2020 at 1:41 PM revealed she was educated by Corporate staff and she educated the Business Office Manager/Manager on Duty, Social Services Director, Social Services Assistant, ADON #1 and ADON #2. She stated these staff assisted with education of the remaining staff. She revealed staff were required to take post-test with 100% achieved. Interviews with the Business Office Manager on 01/26/2020 with the SS Assistant at 1:33 PM, on 01/27/2020 at 11:48 AM, and on 01/29/2020 with ADON #2 at 1:17 PM and ADON #1 at 1:22 PM, revealed they were educated on Abuse and Resident Rights, Examples of Verbal Abuse, Reasons why verbal abuse happens and Tips for Behavior Management. They stated the information was used to educate the other staff. Interviews on 01/22/2020 with Laundry Aide at 11:07 AM, PCA #1 at 11:41 AM, Kentucky Medication Aide (KMA) #1 at 12:07 PM, Human Resources Director at 12:44 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with Registered Nurse (RN) #2 at 7:44 PM, State Registered Nurse Aide (SRNA) #2 at 2:11 PM, CMT/SRNA at 2:58 PM, SRNA #3 at 3:00 PM, Occupational Therapist at 3:10 PM, Dietary Manager at 3:13 PM, Laundry staff at 3:14 PM, Maintenance Man at 3:17 PM, DON at 3:20 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM( and, on 01/28/2020 with LPN #1 at 12:36 PM revealed they received education on Abuse and Resident Rights. 11. Interview with the Administrator on 01/29/2020 at 1:44 PM revealed she reviewed the abuse policy and no changes were made. 12. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM, revealed she visited Resident #1 on 12/30/19 to monitor for signs and symptoms of emotional distress. She stated the resident had a BIMS score of 0, but she observed the resident for signs of emotional distress with none identified. 13. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she assessed Resident #1 again on 12/31/2020 with no concerns identified. 14. Review of the facility's Root Cause Analysis tool, not dated revealed a Five Whys Template that addressed the problem, why did this occur, the root cause, and possible solutions. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM, Dietary Manager at 3:13 PM, and Maintenance Director at 3:17 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, ADON #2 at 1:17 PM, Social Services Director at 1:44 PM, Central Supply/Staffing person at 1:33 PM, and Human Resources Director at 1:11 PM revealed they attended the QA meeting where Root Cause Analysis was discussed. 15. Review of the facility's education packet revealed all staff was educated on the use of profanity and verbal abuse by the Business Office Manager who was the Manager on Duty on the day of the incident, the Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2 on 01/02/2020 Review of the POS [REDACTED]. Further review revealed all staff achieved a score of 100% . Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they received education about the use of profanity and verbal abuse. 16. Review of the Education material packet revealed all staff was educated on management of behaviors associated with dementia beginning on 01/02/2020 through 01/13/2020 by the Social Services Assistant, the Social Services Director, and ADON #2. Review of the POS [REDACTED]. Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they had been educated on behaviors associated with Dementia. 17. Review of the facility's investigation dated 01/02/2020 revealed the facility substantiated the allegation and terminated CMT #1 on 01/02/2020. Interview with the Administrator on 01/22/2020 at 12:19 PM revealed CMT #1 was terminated by telephone on 01/02/2020. 18. Review of Ad Hoc attendance sheet revealed an ad hoc QA meeting was held on 01/03/2020 and attended by the Administrator, DON, Director of Dining Services, the Business Office Manager, the Social Services Director, the Maintenance Director, the Medical records staff member, Central Supply / Staffing person and the Rehabilitation Manager. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following. 19. Review of the attendance sheet for the ad hoc QA meeting held on 01/06/2020 revealed the meeting was attended by the Administrator, the DON and the Central Supply/Staffing person. The Medical Director attended telephonically. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM and the Staffing/Central Supply staff at 1:33 PM revealed they attended the Ad Hoc meeting on 01/06/2020 and discussed the effectiveness of action plan and set forth parameters for ongoing monitoring. Interview with the Medical Director, on 01/23/2020 at 8:40 AM, revealed he was made aware of the verbal abuse and recommended the staff member be terminated. He also reported he has been involved with the QA and follow-ups with the Administrator. 20. Review of the auditing tool revealed random audits began on 01/07/2020 and were completed on each shift on 01/07/20, 01/09/2020, and 01/10/2020 with no concerns identified. Audits continued on 01/14/2020, 01/17/2020, 01/23/2020, 01/24/2020 and 01/29/2020, with no concerns identified. Interview with the Administrator, on 01/31/2020 at 8:47 AM, revealed staff was able to verbalize information that they had been educated on in regards to abuse when he completed the audits.

Based on interview, record review, and review of facility policy, it was determined staff failed to have an effective system to ensure an allegation of verbal abuse was reported immediately for one (1) of three (3) sampled residents. Staff witnessed Certified Medication Technician (CMT) #1 verbally abuse Resident #1 on 12/28/19 at approximately 5:40 AM. The staff failed to report the alleged abuse immediately. The two (2) staff reported the allegation on 12/28/19 at approximately 6:05 AM and 6:40 AM respectively. The facility's failure to report verbal abuse of Resident #1 immediately has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 01/23/2020 and determined to exist on 12/28/19. The facility was notified of the Immediate Jeopardy on 01/23/19. An acceptable Credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 01/29/2020, alleging the facility achieved compliance compliance on 01/13/2020. The State Survey Agency validated the AoC and determined due to the facility conducting education post-testing on 01/13/2020, the facility was not in compliance until 01/14/2020, which was still prior to the State Survey Agency entering the building on 01/21/2020. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Abuse Prevention Program, last revised December 2016, revealed as part of the resident abuse prevention program the staff training/orientation program will include such topics as abuse prevention identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of the facility's Abuse and Neglect training material, not dated, revealed staff are educated that all allegations must be reported immediately to the administrator, and to report to supervisor to take charge of the situation and assure notification of the administrator. Closed record review revealed the facility admitted Resident #1 from the Personal Care Area of the facility on 12/10/19 with diagnoses, which included Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] of Native Coronary Artery without [MEDICAL CONDITION] Pectoris, and Repeated Falls and Difficulty in walking. Review of a facility investigation dated 12/28/19 revealed it was alleged CMT #1 verbally abused Resident #1 on 12/28/19. Further review of the investigation revealed the facility substantiated the allegation and identified staff failed to report the incident immediately upon discovery. Interview with Patient Care Aide (PCA) #1, on 01/22/2020 at 11:41 AM, revealed on 12/28/19 at approximately 5:40 AM she heard CMT #1 tell Resident #1 to sit your [***] ing ass down. The CMT continued to curse and yell at the resident. She stated after she used the restroom she went to the 200 hall and that is when she realized it had not been reported, so she reported what she witnessed to LPN #1 around 6:05 AM (twenty-five {25} minutes later). Interview with the Laundry Aide, on 01/22/2020 at 11:07 AM, revealed she heard CMT #1 yelling and cursing as if she was venting on 12/28/19 at approximately 6:00 AM. She revealed she reported the incident on 12/28/19 around 6:40 AM to the DON (forty {40} minutes later). She stated she did not report it immediately as she has never been in that situation before and she did not remove the resident or CMT #1 from the situation. Interview with LPN #1, on 01/28/2020 at 12:36 PM, revealed she worked on 12/28/19 and had come in to work the 6:00 AM-2:00 PM shift and PCA #1 reported to her how CMT #1 was talking to Resident #1. LPN #1 revealed she called the Social Services/Abuse Coordinator, who in turn phoned the Administrator. Interview with the Administrator, on 01/22/2020 at 12:19 PM, revealed she had received a call regarding the abuse report around 6:30 AM on 12/28/19. She stated the two (2) staff members who witnessed the verbal abuse failed to report immediately and have received disciplinary action. **The facility implemented the following actions prior to entry for the Abbreviated Survey. 1. A head-to-toe skin assessment was completed on 12/28/19 at 7:30 AM by LPN #1 with no injuries identified. An additional skin assessment was completed on 12/28/19 to begin gathering information pertinent to the investigation. 2. Social Services/Abuse Coordinator arrived at 7:30 AM on 12/28/19 followed by the Human Resources Director who arrived at the facility at 7:50 AM on 12/28/19 to begin gathering information pertinent to the investigation. 3. The facility submitted their initial report to OIG and DCBS on 12/28/19. 4. On 12/28/19, the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Disciplinary action was given by the Human Resources Director and Social Services/Abuse Coordinator. 5. The on-site investigation was initiated on 12/28/19 by Social Services/Abuse Coordinator and Human Resources Director and continued by the Administrator and DON. The alleged perpetrator, CMT #1, was interviewed and informed that she was suspended, pending results of the investigation, by the Human Resources Director and Social Services/Abuse Coordinator on 12/28/19. CMT #1 was instructed that she was not to return to the premises during the course of the investigation. From the time of entry into the facility until exiting, CMT #1 was accompanied by staff at all times. 6. Skin assessments of residents with a BIMS less than eight (8) were initiated on 12/28/19 and completed by 12/30/19 by LPN #1, Assistant Director of Nursing (ADON) #1, and ADON #2, with no abnormal findings identified. 7. Interviews of all residents with a BIMS of eight (8) or higher were completed on 12/28/19 by Social Services Director/Abuse Coordinator. No issues or concerns were reported by residents. 8. An ad hoc QA was held on 12/28/19 with the Medical Director's involvement telephonically, to develop a plan for immediate actions. On 12/28/19, the following QA members were in attendance: Administrator, DON, Social Services Director, Human Resources Director and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 9. On 12/28/19, Social Services/Abuse Coordinator notified POA of incident and that an investigation had been started. On 12/28/19, the Administrator notified the Medical Director, who is resident's attending physician, of incident. 10. Immediate education began on 12/28/19 regarding abuse identification and reporting, identifying stress and burnout and response, and resident rights with post test administered. This was conducted by the Business Office Manager/Manager on Duty for 12/28/19. Education following 12/28/19 was conducted by Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/07/2020. 11. On 12/28/19, the Administrator reviewed the facility's abuse policy and procedures for needed changes or revisions. No changes to the policy were made at that time. 12. On 12/30/19, the Social Services/Abuse Coordinator visited Resident #1 to monitor for signs and symptoms of emotional distress. Resident #1 has a BIMS of 0, but demonstrated no visible signs of emotional distress. 13. On 12/31/19, Social Services/Abuse Coordinator visited Resident #1 again to monitor for signs and symptoms of emotional distress. Resident, with BIMS of 0 as of 12/20/19, but demonstrated no visible signs of emotional distress. 14. A root cause analysis (RCA) was initiated on 01/02/2020 by the Administrator and Regional Nurse Consultant. Through the root cause analysis, it was determined that CMT #1 was frustrated by Resident #1's repetitive behavior and did not appropriately use behavior management techniques. 15. Education on use of profanity and verbal abuse with post test was initiated on 01/02/2020 by the DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/11/2020. 16. Education on management of behaviors associated with dementia, with post test was initiated on 01/02/2020 by DON, Social Services Assistant, Social Services Director, and ADON #2. All employees were educated prior to the beginning of their next shift worked with post-test score of 100% achieved on 01/13/2020. 17. Investigation was completed by the Administrator and DON and the results of the investigation concluded that allegations of abuse were substantiated, resulting in the immediate termination of CMT #1 effective 01/02/2020. 18. An ad hoc QA was held on 01/03/2020, with the Medical Director's involvement telephonically, to discuss root cause analysis and review implementation. On 01/03/2020, the following QA members were in attendance: Administrator, DON, Dietary Manager, Business Office Manager, Social Services Director, Maintenance Director, Medical Records Clerk, Central Supply Clerk, Rehab Director, and Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 19. An ad hoc QA was held on 01/06/2020 with the Medical Director's involvement telephonically, to evaluate the effectiveness of plan (Plan Do Study Act cycle), and to set forth parameters for ongoing monitoring. On 01/06/2020, the following QA members were in attendance: Administrator, DON, Central Supply Clerk and the Medical Director. Content of the QA committee meeting was reviewed with members not in attendance at this meeting on days immediately following. 20. Beginning on 01/07/2020, the Administrator began conducting random audits to validate retention of training through a post-test covering prior education, with a sample of employees from each shift twice weekly x 2 weeks, then weekly x 2 weeks, then biweekly x 2 weeks to be completed by 03/01/2020. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Skin Care alert sheet and skin observation tool revealed Resident #1's skin assessments were completed on 12/28/19 and 12/30/19. Interview with LPN #1, on 01/29/2020 at 1:06 PM, revealed she completed Resident #1's first skin assessment with no concerns identified. Interview with RN #1, on 01/29/2020 at 1:55 PM, revealed she completed Resident #1's second skin assessment with no concerns noted. 2. Review of the investigation revealed the Social Services/Abuse Coordinator arrived at the facility on 12/28/19 at 7:30 AM and the Human Resources Director arrived on 12/28/19 at 7:50 AM to begin the onsite investigation. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM, and the Human Resources Director on 01/29/2020 at 1:11 PM, revealed they began the facility investigation on 12/28/19. 3. Review of the facility facsimile confirmation sheet revealed OIG and DCBS was notified of the allegation of verbal abuse on 12/28/19. 4. Review of the Coaching & Counseling Session sheets dated 12/28/19 revealed the Laundry Aide and PCA #1 were given disciplinary action and one-on-one education for failing to follow facility policy related to immediate intervention and reporting of abuse. Interviews on 01/29/2020 with the Human Resources Director at 1:11 PM and the Social Services/Abuse Coordinator at 1:44 PM revealed they gave the Laundry Aide and PCA #1 disciplinary action on 12/28/19. Interviews on 01/22/2020 with the Laundry Aide at 11:07 AM and PCA #1 at 11:41 AM revealed the received disciplinary action and education related to following facility policy for immediate intervention and reporting abuse. 5. Interview with the Social Services Director/Abuse Coordinator on 01/29/2020 at 1:44 PM revealed on 12/28/19, CMT #1 was contacted by the Social Services/Abuse Coordinator and Human Resources Director and asked to return to the facility for interview. On 12/28/19 at approximately 11:00 AM, the CMT was met at the door and accompanied to the Human Resources office. The CMT was interviewed by the investigators, suspended and instructed not to return to the premises during the course of the investigation. 6. Review of skin assessment sheets dated 12/30/19 revealed skin assessments were completed on all residents with a BIMS score of below eight (8) by LPN #1, ADON #1 and ADON #2. No concerns were identified. 7. Review of interview sheets dated 12/28/19 revealed all residents with a BIMS score of eight (8) or above were interviewed about abuse/neglect with no concerns identified. 8. Review of a sign-in sheet revealed an initial Ad hoc QA meeting was held on 12/28/19 with the Medical Director's involvement via telephone. Further review revealed the meeting was attended by the Administrator, DON, ADON #1, ADON #2, Director of Dining Services, Social Services Director, Maintenance Director, Medical Records, Central Supply/staffing, Medical Director (telephonically) and the Human Resources Director. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following the meeting. 9. Review of a Communication Note in the resident's record, dated 12/28/19 at 11:39 AM, revealed the Social Services/Abuse Coordinator notified Resident #1's Power of Attorney (POA) about the alleged abuse. Interview with the Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she spoke with the POA regarding the event. Interview with the Administrator on, 01/22/2020 at 12:19 PM, she notified the Medical Director about the alleged abuse on 12/28/19. 10. Review of Inservice Sign-in sheets dated 12/28/19, 01/11/2020, and 01/13/2020, revealed 100% of staff had been educated. Interview with the Administrator, on 01/29/2020 at 1:41 PM revealed she was educated by Corporate staff and she educated the Business Office Manager/Manager on Duty, Social Services Director, Social Services Assistant, ADON #1 and ADON #2. She stated these staff assisted with education of the remaining staff. She revealed staff were required to take post-test with 100% achieved. Interviews with the Business Office Manager on 01/26/2020 with the SS Assistant at 1:33 PM, on 01/27/2020 at 11:48 AM, and on 01/29/2020 with ADON #2 at 1:17 PM and ADON #1 at 1:22 PM, revealed they were educated on Abuse and Resident Rights, Examples of Verbal Abuse, Reasons why verbal abuse happens and Tips for Behavior Management. They stated the information was used to educate the other staff. Interviews on 01/22/2020 with Laundry Aide at 11:07 AM, PCA #1 at 11:41 AM, Kentucky Medication Aide (KMA) #1 at 12:07 PM, Human Resources Director at 12:44 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with Registered Nurse (RN) #2 at 7:44 PM, State Registered Nurse Aide (SRNA) #2 at 2:11 PM, CMT/SRNA at 2:58 PM, SRNA #3 at 3:00 PM, Occupational Therapist at 3:10 PM, Dietary Manager at 3:13 PM, Laundry staff at 3:14 PM, Maintenance Man at 3:17 PM, DON at 3:20 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM( and, on 01/28/2020 with LPN #1 at 12:36 PM revealed they received education on Abuse and Resident Rights. 11. Interview with the Administrator on 01/29/2020 at 1:44 PM revealed she reviewed the abuse policy and no changes were made. 12. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM, revealed she visited Resident #1 on 12/30/19 to monitor for signs and symptoms of emotional distress. She stated the resident had a BIMS score of 0, but she observed the resident for signs of emotional distress with none identified. 13. Interview with Social Services/Abuse Coordinator, on 01/29/2020 at 1:44 PM revealed she assessed Resident #1 again on 12/31/2020 with no concerns identified. 14. Review of the facility's Root Cause Analysis tool, not dated revealed a Five Whys Template that addressed the problem, why did this occur, the root cause, and possible solutions. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM, Dietary Manager at 3:13 PM, and Maintenance Director at 3:17 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, ADON #2 at 1:17 PM, Social Services Director at 1:44 PM, Central Supply/Staffing person at 1:33 PM, and Human Resources Director at 1:11 PM revealed they attended the QA meeting where Root Cause Analysis was discussed. 15. Review of the facility's education packet revealed all staff was educated on the use of profanity and verbal abuse by the Business Office Manager who was the Manager on Duty on the day of the incident, the Social Services Director, Administrator, Social Services Assistant, ADON #1 and ADON #2 on 01/02/2020 Review of the POS [REDACTED]. Further review revealed all staff achieved a score of 100% . Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they received education about the use of profanity and verbal abuse. 16. Review of the Education material packet revealed all staff was educated on management of behaviors associated with dementia beginning on 01/02/2020 through 01/13/2020 by the Social Services Assistant, the Social Services Director, and ADON #2. Review of the POS [REDACTED]. Interviews on 01/22/2020 with SRNA #2 at 2:11 PM, Dietary Manager at 3:13 PM, Administrator at 12:19 PM, DON at 3:20 PM, SRNA #5 at 1:13 PM, Laundry Aide at 11:07 AM, RN #2 at 2:02 PM, and LPN #2 at 3:03 PM; on 01/25/2020 with RN #1 at 7:44 PM; on 01/26/2020 with SRNA #4 at 6:00 PM; on 01/28/2020 with LPN #1 at 12:36 PM; and, on 01/29/2020 with ADON #1 at 1:22 PM, Social Services Director at 1:44 PM, and Staffing/Central Supply staff at 1:33 PM revealed they had been educated on behaviors associated with Dementia. 17. Review of the facility's investigation dated 01/02/2020 revealed the facility substantiated the allegation and terminated CMT #1 on 01/02/2020. Interview with the Administrator on 01/22/2020 at 12:19 PM revealed CMT #1 was terminated by telephone on 01/02/2020. 18. Review of Ad Hoc attendance sheet revealed an ad hoc QA meeting was held on 01/03/2020 and attended by the Administrator, DON, Director of Dining Services, the Business Office Manager, the Social Services Director, the Maintenance Director, the Medical records staff member, Central Supply / Staffing person and the Rehabilitation Manager. Interview with the Administrator on, 01/22/19 at 12:19 PM, revealed members not attending the meeting had meeting content reviewed with them on days immediately following. 19. Review of the attendance sheet for the ad hoc QA meeting held on 01/06/2020 revealed the meeting was attended by the Administrator, the DON and the Central Supply/Staffing person. The Medical Director attended telephonically. Interviews on 01/22/2020 with the Administrator at 12:19 PM, DON at 3:20 PM and the Staffing/Central Supply staff at 1:33 PM revealed they attended the Ad Hoc meeting on 01/06/2020 and discussed the effectiveness of action plan and set forth parameters for ongoing monitoring. Interview with the Medical Director, on 01/23/2020 at 8:40 AM, revealed he was made aware of the verbal abuse and recommended the staff member be terminated. He also reported he has been involved with the QA and follow-ups with the Administrator. 20. Review of the auditing tool revealed random audits began on 01/07/2020 and were completed on each shift on 01/07/20, 01/09/2020, and 01/10/2020 with no concerns identified. Audits continued on 01/14/2020, 01/17/2020, 01/23/2020, 01/24/2020 and 01/29/2020, with no concerns identified. Interview with the Administrator, on 01/31/2020 at 8:47 AM, revealed staff was able to verbalize information that they had been educated on in regards to abuse when he completed the audits.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to keep resident care information confidential for one (1) of nineteen (19) sampled residents (Resident #21). Observations on 10/08/19 and 10/09/19, revealed Resident #21 had a posted sign on the wall of his/her room that faced the hallway. The sign contained care information for Activity of Daily Living (ADL) needs and was visible to other residents and visitors from the hallway. The findings include: Review of the facility's policy, Quality of Life-Dignity, last revised (MONTH) 2009, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain, and protect resident privacy. Record review revealed the facility readmitted Resident #21 on 03/29/19, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/12/19, revealed the facility assessed Resident #21's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (00), which indicated the resident was not interviewable. Observations on 10/08/19 at 10:12 AM and 10/09/19 at 1:50 PM, revealed a posted sign in Resident #21's room that had ADL care need on it. The sign was on a wall that faced the hallway and entrance door. The ADL needs of Resident #21, which could be read from the hallway, included honey thickened liquids at all times and no straws. Further observation revealed staff and other residents walked past Resident #21's room. The resident's door was open and Resident #21's ADL care needs on the sign were not covered and were readable from the hallway. Interview with Certified Nursing Assistant (CNA) #1, on 10/11/19 at 9:30 AM, revealed the sign containing resident care information could be a dignity issue and may be better placed inside the closet door or placed inside the bathroom door, out of others view. CNA #1 stated care information for Resident #21 is found on the care plan. Interview with the Director of Nursing (DON), on 10/11/19 at 2:20 PM, revealed the information posted on the sign could be a dignity issue.

Based on observation, interview, record review, review of facility policy, and review of the facility's investigation, it was determined the facility failed to revise the care plan for one (1) of three (3) sampled residents (Resident #1). On 03/07/19 between 2:00 PM to 3:00 PM, the resident attempted to exit the building, unsupervised. The licensed nurse initiated a wanderguard device (device that alarms to alert staff the resident is exiting the building); however, the facility failed to revise the Baseline Care Plan and State Registered Nurse Aide (SRNA) care plan for the wanderguard and failed to address the resident's need for increased supervision due to the resident wanting to go home. At approximately 5:30 PM to 6:00 PM, the resident exited the building without any alarms sounding and without staff's knowledge. A local citizen found Resident #1 on the far side of the road 250-350 feet from the facility. Resident #1 had fallen and sustained abrasions to his/her knees and right hand. The facility's failure to revise the care plan to ensure adequate supervision to prevent accidents caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/14/19 and determined to exist on 03/07/19. The facility was notified of the Immediate Jeopardy on 03/14/19. An acceptable Allegation of Compliance (AoC) was received on 03/20/19. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/15/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (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, Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR), revealed assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change. Review of the facility's policy titled, Safety and Supervision of Residents, last revised (MONTH) (YEAR), revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide policy. Implementing interventions to reduce accident risks and hazards shall include documenting the interventions. Closed record review revealed the facility admitted Resident #1 on 03/06/19 at 3:30 PM, with [DIAGNOSES REDACTED]. Review of a Progress Note, dated 03/07/19 at 2:53 PM and interviews on 03/13/19 with the Assistant Director of Nursing (ADON) at 10:00 AM and SRNA #1 at 10:27 AM, revealed a wanderguard bracelet was applied to the ankle of Resident #1 after he/she attempted to leave the facility through the front door. The resident was kicking and resistive to the wanderguard being applied and stated that he/she knew that was the way out and what the bracelet meant. Interview with Resident #1's Son, on 03/13/19 at 11:11 AM, revealed on 03/07/19 around 2:00 PM, he was visiting the resident and the resident was getting more agitated and upset, stating I want to go home, so he left the facility. Review of an Elopement Risk Assessment Tool, dated 03/07/19, revealed the facility assessed Resident #1 to have a score of five (5), which indicated the resident was a moderate risk for elopement due to the resident verbalizing wanting to leave the facility. Review of Resident #1's Baseline Care Plan dated 03/06/19, revealed the resident was at risk for wandering/elopement due to exit seeking with an intervention for a wanderguard bracelet with no date documented as to when the intervention was added. Further review of the care plan revealed there was no documented evidence any increased supervision or monitoring of resident was put in place per facility policy. In addition, review of the SRNA Care Plan dated (MONTH) 2019 revealed there was no documented evidence the resident was an elopement risk and had a wanderguard in place. Review of a Progress Note, documented by the ADON (Assistant Director of Nursing) dated 03/08/19 at 3:00 PM, and interviews on 03/13/19 with Licensed Practical Nurse (LPN) #2 at 11:47 AM, and LPN #1 at 4:36 PM; and, on 03/12/19 at 4:02 PM with the ADON revealed at approximately 6:00 PM-6:05 PM on 03/07/19, the Business Officer Manager (BOM) went to Resident #1's room to speak with him/her and he/she was not there. The ADON, LPN #1 and SRNA #3 began searching for Resident #1. As they were completing the search in the building, a man called the facility asking if the facility was missing someone. The caller stated he had found (Resident #1) on the side of the road, almost to a restaurant driveway. The caller had called 911 (Emergency Services). Further review of the Progress Note revealed the resident was asked about his/her wanderguard bracelet, which was not on the resident at the time. The resident stated, I threw it in the trash. I was just going home. The resident was wearing shoes, flannel pants and a green coat, which was buttoned up. Emergency Medical Services' (EMS) arrived and transported the resident to the emergency room (ER). In addition, the progress note revealed LPN #1 later found the wanderguard device in Resident #1's trash can. Review of Resident #1's emergency room Physician documentation, dated 03/07/19 at 6:45 PM, revealed the resident was diagnosed with [REDACTED]. Observation, on 03/12/19 at 12:53 PM, of the location where Resident #1 was found, revealed the area was down a hill, across the road and to the left of the facility. The road was a two (2)-lane road with moderate traffic flow and the posted speed limit was forty-five (45) miles per hour (mph) where the resident was found. In addition, review of Internet Weather Data for Thursday, 03/07/19, revealed sunset was at 5:47 PM, and the high temperature was forty-two (42) degrees Fahrenheit (F). with a low of twenty-eight (28) degrees F. Review of the facility's investigation, dated 03/07/19, revealed the facility identified the root cause was that Resident #1 knew the door code or went out when a visitor exited the building. Interview with the ADON on 03/13/19 at 10:00 AM revealed she did not update the care plan related to the wanderguard until after the resident eloped from the facility. She stated the nurse who implements the new intervention was responsible for updating the care plan. Further interview revealed she had not revised the care plan for any increased supervision by staff even though the resident had been resistive to the wanderguard being put on; had stated he/she knew that was the way out; and, he/she knew what the bracelet meant. She stated she notified the SRNA's of how the resident was acting; however, she did not complete the paperwork for the wanderguard because she had not had time. The ADON stated she felt like the resident would not attempt to leave the building again because the resident was here willfully. Interview with the Director of Nursing (DON), on 03/14/19 at 5:24 PM, revealed the care plans (Baseline and SRNA) should have been updated to include the wanderguard and checking for placement and functioning every shift. Further interview (Post Survey) with the DON, on 04/02/19 at 9:44 AM, revealed when a resident receives a wanderguard, the nurse should document the wanderguard on the care plan. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Administrator and Regional Nurse Consultant (RNC) conducted a thorough investigation of the 03/07/19 event on 03/08/19. 2. The Administrator and RNC conducted a Root Cause Analysis to identify the variables that led to the process failure on 03/08/19. 3. The RNC and MDS Coordinator conducted a 100% audit of all other residents who had a wandering transmitter present to confirm placement and working status on 03/07/19. 4. The RNC and MDS Coordinator conducted a 100% audit of all care plans of residents with high risk of elopement to ensure accuracy of the care plan and appropriateness of interventions on 03/07/19, 5. The RNC conducted a 100% audit of all SRNA Care Plans of residents at high risk for elopement to ensure accuracy of the Nurse Aide Care Plan on 03/07/19. 6. The Maintenance Assistant changed the front door code on 03/07/19; and the Medical Records Clerk educated all facility staff not to divulge the code to visitors, residents, or family members on 03/07/19. 7. The Administrator placed a new, prominent door signage on the front door alerting visitors to be mindful of who they help exit the building on 03/07/19. 8. The RNC and MDS Coordinator checked, on 03/07/19, to verify placement and function of wanderguard transmitters for all other residents who utilize them. 9. The Administrative Nurse, DON, ADON and MDS Coordinator reviewed all current residents' elopement risk evaluations to ensure that it accurately reflected the resident's status on 03/07/19. Any inaccurate evaluation had a new assessment completed at that time. 10. The Maintenance Assistant inspected all exit doors to verify functioning and alarm on 03/07/19. 11. The Administrator, DON, and Medical Records Clerk initiated education, on 03/07/19. House-wide education and in-service training was provided to all staff to include topics of elopement protocol, behaviors that might suggest high-risk elopement, use of the facility's Elopement Book, expectations surrounding responding to alarms, elopement/wandering monitoring and oversight, elopement notifications, elopement drill process, and only staff members will have access to the door codes. Licensed nurses also received education on completion of the Elopement Risk Assessment use and application. Education continued at the beginning of each shift, with oncoming staff members not previously trained. The training was provided prior to beginning work. No staff members were permitted to work prior to completing the training. The majority of employees were trained by 03/09/19 (80%) with all except PRN (as needed) staff or those staff on Medical Leave, who were trained by 03/13/19. Any employee not trained by 03/15/19 was sent a certified letter, informing them that they would not be permitted to work until education had been completed. The on-call supervisor has a list of those employees to ensure they were not called in to work prior to receiving the letter. The Administrator, DON, and Medical Records Clerk administered posttests on the above topics beginning on 03/07/19. The majority of employees were tested by 03/09/19 (80%), and all except PRN (as needed) staff or those on Medical Leave, were tested by 03/13/19. Any employee not trained and tested by 03/15/19 was sent a certified letter, informing them that they would not be permitted to work until education and the Posttest had been completed. The On-call Supervisor has a list of those employees to ensure they are not called in to work prior to receiving the letter. 12. The Administrator began unannounced elopement drills on 03/08/19 and the drills will be conducted weekly on each shift for two (2) weeks following the initial drill. After the initial monitoring elopement drills were completed on 03/08/19, ongoing monitoring will be continued with elopement drills conducted weekly on each shift x 4 weeks, then monthly on each shift x 6 months. 13. Starting on 03/08/19, each unit's 24-hour report and available push reports will be reviewed daily (M-F) in clinical meeting by the Administrator, DON, ADON's, MDS, Administrative Nurses or Regional Nurses to validate residents identified at-risk residents were appropriately monitored if wandering or exit seeking behaviors were present and required interventions initiated. The Nurse on Call will review on weekends. 14. Lastly, all audit results will be shared with the facility's Quality Assurance Performance Improvement (QAPI) team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's investigation data revealed the Administrator and the Regional Nurse Consultant (RNC) completed the investigation. Review of facsimile (fax) confirmation sheets revealed the Department of Community Based Services (DCBS) and the Office of Inspector General (OIG) received the facility's Initial Report (03/07/19), as well as the five (5) day/Final Report (03/13/19) of the self-reported incident. 2. Interview with the Administrator, on 03/21/19 at 3:29 PM revealed the Administrator and the Regional Nurse Consultant (RNC) identified variables that led to the process failure on 03/08/19 and concluded Resident #1 observed someone enter the door code or followed someone out of the facility. 3. Interview with the MDS Coordinator on 03/21/19 at 2:24 PM, and the DON on 03/21/19 at 3:11 PM, revealed together with the former ADON, they completed an audit of 100% of other residents with who utilized a wander transmitter device to confirm the placement and working status of the existing wanderguards. No concerns were identified. 4. Interview with the DON on 03/21/19 at 3:11 PM, and the MDS Coordinator, on 03/21/19 at 2:24 PM revealed the former ADON, DON and MDS Coordinator completed care plan reviews of 100% residents with wanderguards, on 03/07/19, to confirm the accuracy of the risk of elopement for each resident. 5. Interview with the DON on 03/21/19 at 3:11 PM and the MDS Coordinator, on 03/21/19 at 2:24 PM revealed the former ADON, DON and MDS Coordinator completed SRNA care plan reviews of 100% residents with wanderguards to confirm accuracy. 6. Interview with Maintenance, on 03/21/19 at 1:48 PM, revealed he changed the door codes successfully on 03/07/19, after the incident. Maintenance also reported he does not give out the door code to anyone. Interview with the Administrator on 03/21/19 at 2:15 PM, revealed the ADON no longer was employed at the facility, as she resigned over the weekend. Interviews on 03/21/19 with the Staffing Coordinator/SRNA, at 2:18 PM, MDS Nurse at 2:24 PM, SRNA #4 at 2:29 PM, SRNA #5 at 2:34 PM, SRNA #6 at 2:39 PM, Housekeeping at 2:44 PM, LPN #4 at 2:52 PM, LPN #5 at 2:58 PM, Business Office Manager (BOM) at 3:06 PM, DON at 3:11 PM and the Administrator at 3:29 PM revealed they were educated related to not giving the door code to visitors and residents. 7. Observation and interview with the Administrator, on 03/21/19 at 3:29 PM revealed she placed new door signage on the front door to alert visitors to not allow residents to exit the building on 03/07/19. 8. Interview with the MDS Coordinator on 03/12/19 at 2:24 PM, revealed after the incident on 03/07/19 with Resident #1, the Regional Nurse Consultant (RNC) and she checked all remaining residents in the facility to verify placement and functioning of the wanderguard. Observation, on 03/21/19 at 1:00 PM, with the Administrator revealed six (6) residents identified at risk for elopement had wanderguard devices in place and the wanderguards were functioning with no concerns identified. 9. Review of documentation and interviews on 03/21/19 with the Administrator at 3:29 PM, DON at 3:11 PM, and MDS Coordinator at 2:24 PM, revealed all elopement risk assessments were reviewed for all residents with no concerns noted. 10. Interviews on 03/21/19 with the Administrator at 3:29 PM, and Maintenance at 1:48 PM, revealed all doors were checked for functioning by Maintenance on 03/07/19 and were found to be in working order. 11. Interviews on 03/21/19 with the Administrator at 3:29 PM, and DON at 3:11 PM, revealed all staff, except PRN (as needed) staff or those on medical leave were educated, prior to 03/13/19, and the remaining were alerted by mail that they must be educated prior to working another shift. Staff were required to complete a post-test, results were shared with the SSA and were provided in the packet provided by the facility. Interview with the Corporate Chief Nursing Officer (CNO), on 03/13/19 at 12:50 PM, revealed all staff were educated on elopement plan; behaviors that might suggest a resident was at high risk for elopement and verbalizations that they want to leave such as hanging around a door, attempting to open doors, following behind visitors or employees that were leaving, increased agitation or aggression with attempts to redirect away from the door. Staff were educated on the location of the elopement books and the fact that they all were responsible for looking at the book on a regular basis so that they would know which residents were at risk for elopement. Staff were educated on the need to immediately respond to any alarm and if unable to determine who activated the alarm, they should immediately check outside to verify that no resident has exited the building, Staff were educated that when a resident demonstrates such behavior, he/she should have increased monitoring/oversight. Residents that demonstrate an increased risk for behaviors should have an elopement reassessment. If indicated by the elopement assessment a wanderguard should be placed and the resident should be added to the elopement book and a care plan is to be initiated. In addition, the CNO stated the facility failed to educate licensed nurse on revision of care plan so education for licensed nurses began on 03/13/19 related to care plan developement/revision, to reflect interventions, placement of wanderguard alert transmitters in a secure manner to reduce opportunities for removal, and the need for enhanced monitoring for effectiveness and resident response for twenty-four (24) hours when new alert transmitter applied. She stated this educaion would continue at the beginning of each shift for any oncoming staff not previously educated and not staff would be allowed to work until educated. Elopement drills are to be done on all shifts and staff are to complete a post test after the elopement education. Education was provided by the Administrative team to include CNO, Administrator, DON and the Medical Records Clerk. Interviews on 03/21/19 with the Staffing Coordinator/SRNA, at 2:18 PM, MDS Nurse at 2:24 PM, SRNA #4 at 2:29 PM, SRNA #5 at 2:34 PM, SRNA #6 at 2:39 PM, Housekeeping at 2:44 PM, LPN #4 at 2:52 PM, LPN #5 at 2:58 PM, Business Office Manager (BOM) at 3:06 PM, DON at 3:11 PM, and the Administrator at 3:29 PM; revealed they were educated on elopements, including what to do when a resident cannot be located, signs of a resident who may want to elope, the location of the wander book and that staff should immediately respond to alarms. 12. Review of Attendance Logs revealed unannounced elopement drills were conducted on 03/08/19 at 8:30 AM, 03/08/19 at 3:40 PM, 03/11/19 at 1:00 PM, 03/12/19 at 7:45 PM, 03/12/19 at 9:50 PM, 03/13/19 at 10:48 PM, 03/15/19 at 11:00 AM, 03/17/19 at 10:00 AM, 03/19/19 at 7:00 PM and 03/20/19 at 10:40 AM by the Administrator or designee. 13. Interview with the Administrator on 03/21/19 at 3:29 PM and 04/02/19 at 11:23 AM revealed she was the person that oversees all audits and maintains the logs for auditing the compliance and efficacy of the plan put in place. The Administrator stated the Push Reports and 24 hour reports were being reviewed daily Monday through Friday in morning meeting and the Nurse on Call reviewed them on the weekend. Interview with the Social Service/Admissions Director, on 04/02/19 at 1:31 PM, confirmed that she has been involved in the audit processes since the elopement of Resident #1. She stated this included review of the completion of the Twenty-four (24) hour push reports. Interview with the Housekeeping Supervisor on 04/02/19 at 1:32 PM, revealed that she has been assisting with MOD audits on weekends to ensure that nursing staff were completing the Twenty-four (24) hour Push Reports, and updating care plans and assessing the residents for elopement status. 14. All audit results will be shared with the facility Medical Director and the Quality Assurance Performance Improvement (QAPI) team no less than monthly. The Medical Director was notified of the elopement, on 03/07/19 at 6:30 PM via telephone, and this was verified with the Medical Director during an interview, on 03/21/19 at 3:34 PM.

Based on observation, interview, record review, review of facility policy, and review of the facility's investigation, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision to prevent accidents. On 03/06/19, the facility admitted Resident #1 with diagnoses, which included Confusion. On 03/07/19 between 2:00 PM to 3:00 PM, the resident attempted to exit the building, unsupervised. The licensed nurse assessed the resident as a Moderate Risk for elopement and a wanderguard device (device that alarms to alert staff the resident is exiting the building) was placed on the resident's right ankle. The licensed nurse was aware the resident had been trying to leave through the South Hall door (front door) and was resistive to the wanderguard being applied. However, she did not increase the resident's supervision per facility policy, she only made the State Registered nurse Aides (SRNA's ) aware of the situation. At approximately 5:30 PM to 6:00 PM, the resident exited the building without any alarms sounding and without staff's knowledge. A citizen in the community found Resident #1 across the road from the facility, on the side of the road near a restaurant driveway, an estimated distance of 250-350 feet from the facility. Resident #1 had fallen and sustained abrasions to his/her knees and right hand. In addition, the licensed nurse failed to place Resident #1's name on the Elopement logbook at each nurse's station so all staff in the facility would be aware Resident #1 was an elopement risk, per facility policy. She also failed to document the resident's wanderguard on the Care Plans and Treatment Administration Record (TAR) to ensure the wander guard was monitored for placement and functioning every shift; and, that staff was aware the resident required a wanderguard; as required per facility policy. The facility's failure to provide adequate supervision to prevent accidents caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/14/19 and determined to exist on 03/07/19. The facility was notified of the Immediate Jeopardy on 03/14/19. An acceptable Allegation of Compliance (AoC) was received on 03/20/19. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/15/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (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, Safety and Supervision of Residents, last revised (MONTH) (YEAR), revealed it is the policy of the facility to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide policy. The Individualized, Resident-Centered Approach to Safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include documenting interventions. The Systems Approach to Safety includes supervision as a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards to the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility's policy titled, Electronic Wandering Transmitting Devices, last revised 02/15/10, revealed it is the policy of the facility to identify residents that utilize an electronic wandering transmitting device and periodically check to verify that the device is functioning properly. The procedure included: 1.) The names of residents requiring electronic wandering transmitting devices will be maintained on a log. 2.) The log will be periodically updated by the designated person. 3.) A designated individual will be assigned by the administrator to check the proper function of the electronic wandering transmitting devices. Closed record review revealed the facility admitted Resident #1 on 03/06/19 at 3:30 PM, with [DIAGNOSES REDACTED]. Further record review revealed there was no evidence an Minimum Data Set (MDS) was completed at this time, due to the resident being admitted on [DATE]. Review of an Elopement Risk Assessment Tool, dated 03/06/19, revealed the facility assessed Resident #1 as a two (2), due to the resident having a [DIAGNOSES REDACTED]. Review of a Progress Note, dated 03/07/19 at 2:53 PM, revealed a wanderguard bracelet was applied to the ankle of Resident #1 after he/she attempted to leave the facility. Review of an Elopement Risk Assessment Tool, dated 03/07/19, revealed the facility assessed Resident #1 to have a score of five (5), which indicated the resident was a moderate risk for elopement due to the resident verbalizing wanting to leave the facility. Review of Resident #1's Baseline Care Plan dated 03/06/19, revealed the resident was at risk for wandering/elopement due to exit seeking with a goal for the resident to remain safe and not leave the building. Further review revealed an intervention for a wanderguard bracelet with no documented date of when added to care plan. However, interview with the Assistant Director of Nursing (ADON) revealed she did not revise the Baseline Care Plan at the time the wanderguard was initiated but revised it after the resident eloped from the facility on 03/07/19. She also stated she did not initiate any increased supervision prior to the resident eloping from the facility. In addition, review of the SRNA Care Plan dated (MONTH) 2019, revealed there was no documented evidence the resident was an elopement risk and had a wanderguard in place. Review of the Elopement Book on 03/12/19 at 3:46 PM, revealed there was no documentation in the Elopement Book regarding Resident #1, per facility policy the resident's information should have been added. Review of Resident #1's (MONTH) 2019 TAR, revealed there was no documented evidence a wanderguard was placed on the resident. In addition there was no documentation for staff to do wanderguard checks for placement and function every shift per the DON's interview stating this information should have been on the TAR. Interview with SRNA #1, on 03/13/19 at 10:27 AM, revealed Resident #1 attempted to exit through the front door of the facility sometime between 2:00 PM - 3:00 PM on 03/07/19. She stated she was not working, but was attending a facility function in the building and was instructed by the ADON that the person trying to go through the door was a resident, and not to let him/her out of the building. SRNA #1 stated the ADON returned with the resident to the North Hall, which was where the resident's room was located. She stated she assisted the ADON with applying the wanderguard to Resident #1's right ankle. The SRNA stated, the resident just wanted out the door. SRNA #1 stated she was not sure if the resident knew the code to the front door. Interview with the ADON, on 03/13/19 at 10:00 AM, revealed she was the assigned nurse caring for Resident #1 at the time of the elopement. The ADON reported the resident had already attempted to exit through the front (South) door between 2:00 PM-3:00 PM on 03/07/19. She stated the resident was pushing on the front door trying to get out of the facility but the door would not open and then he/she tried to follow SRNA #1 out of the building. The ADON stated SRNA #1 assisted her in redirecting the resident, and the resident was difficult to redirect. She stated while she was trying to apply a wanderguard on the resident, the resident was resistive and was kicking at her. Further interview revealed SRNA #1 was able to place the wanderguard on the resident's right ankle while she distracted the resident with conversation about having a care meeting with his/her daughter. She stated Resident #1 stated that he/she knew that was the way out and he/she knew what the bracelet meant. The ADON stated she did not provide increased supervision even though the resident was being resistive to the wanderguard being applied and making the comment he/she knew what it was for. She stated she notified the SRNA's of how the resident was acting; however, she did not complete the paperwork for the wanderguard because she had not had time. The ADON reported she felt talking with the resident about his/her care plan meeting helped to redirect the resident and the resident also shook her hand, indicating to her the resident was satisfied. She stated she felt like the resident would not attempt to leave the building again due to the resident was here willfully and he/she was alert and oriented. Review of a Progress Note documented by the ADON dated 03/08/19 at 3:00 PM, revealed at approximately 6:00 PM-6:05 PM on 03/07/19, the Business Officer Manager (BOM) went to Resident #1's room to speak with him/her and he/she was not there. The ADON, Licensed Practical Nurse (LPN) #1 and State Registered Nurse (SRNA) #3 began searching for Resident #1. Further review of the Progress Note revealed LPN #2 received a call from a man, who was familiar with the facility, asking if the facility was missing someone as the staff were approaching the South Nurses Station. The caller stated he found Resident #1 on the side of the road, almost to a restaurant driveway, and he (the caller) had already called 911 (Emergency Services). Further review revealed the staff went to the roadside and asked the resident about his/her wanderguard bracelet and the resident stated I threw it in the trash. I was just going home. Emergency Medical Services' (EMS) arrived and transported the resident to the emergency room (ER). In addition, the progress note stated LPN #1 later found the wanderguard device in Resident #1's trashcan. Review of Resident #1's emergency room Physician documentation, dated 03/07/19 at 6:45 PM, revealed the resident was diagnosed with [REDACTED]. The resident returned to the long term care facility via private vehicle with his/her son and daughter. Observation, on 03/12/19 at 12:53 PM, of location where Resident #1 was found, revealed the area was down a hill, across the road and to the left of the facility. The road was a two (2)-lane road with moderate traffic flow. Further observation revealed the posted speed limit was forty-five (45) miles per hour (mph) where the resident was found. Interview (Post Survey) with the Maintenance Worker on 04/02/19 at 10:23 AM, revealed according to his measurement the resident had walked approximately 250-350 feet from the facility and was on the far shoulder of the road. Review of internet weather data for Thursday, 03/07/19, revealed sunset was at 5:47 PM, the high temperature was forty-two (42) degrees Fahrenheit (F) with a low of twenty-eight (28) degrees F. Review of the facility's investigation, dated 03/07/19, revealed the facility identified the root cause of Resident #1's elopement was Resident #1 knew the door code or went out when a visitor exited the building. Further review of the investigation revealed there was no documented evidence the facility identified the nurse failed to increase supervision for Resident #1 after he/she attempted to leave the facility approximately three (3) hours earlier. Interview with Resident #1's Son, on 03/13/19 at 11:11 AM, revealed on 03/07/19 around 2:00 PM, he was visiting the resident and the resident was getting more agitated and upset, stating I want to go home, so he left the facility. He stated the resident was ambulatory, alert and oriented at times, and lived alone prior to admission to the facility. He stated Resident #1 never told him how he/she got out of the facility. Interview with SRNA #2, on 03/12/19 at 4:54 PM, revealed he saw Resident #1 on 03/07/19 at 2:00 PM while doing rounds, and again at 4:00 PM, lying on his/her bed. SRNA #2 reported sometime between 5:30 PM - 6:00 PM, he passed the resident in the hallway and noted the resident was wearing two (2) shirts and shoes, but was not sure what pants the resident was wearing at the time. He revealed that when he took the resident's dinner tray in the room, the resident was not there. He stated he was aware Resident #1 had on a wanderguard because the ADON had made him aware. Interview with LPN #2, on 03/13/19 at 11:47 AM, revealed she did not hear an alarm sound before the resident was determined to be missing from the facility. She stated she was not aware Resident #1 had been identified as a elopement risk and required a wanderguard. Interview with LPN #3, on 03/12/19 at 4:22 PM, revealed she worked on 03/07/19, the day Resident #1 eloped. She stated she saw the resident around 2:00 PM, ambulating with a steady gait on the front hall headed toward the South Hall. She stated she did not hear any alarms go off during her shift prior to the elopement. Interview with LPN #1, on 03/13/19 at 4:36 PM, revealed she clocked in on 03/07/19 at 6:03 PM, when she observed the BOM looking for Resident #1. She reported that everybody (staff) was looking on every hall and when staff met at the end, they learned that LPN #2 received a phone call from a man who found Resident #1 by the road. She reported she responded with the ADON, LPN #2 and SRNA #3 to care for the resident. LPN #1 stated the wanderguard was not on the resident when he/she was found; she found the wanderguard in the garbage can in the resident's room. Interview with LPN #2, on 03/13/19 at 11:47 AM, revealed she was the person who received the phone call on 03/07/19 from the man who found Resident #1 at the road. The caller identified himself to the LPN and proceeded to tell her he had found someone out by the road, and he/she might be one (1) of the facility's residents. LPN #2 stated she, the ADON, SRNA #3 and LPN #1 went to the road to check on the resident. The resident was on the shoulder of the road across from the facility and there was no wanderguard on the resident. LPN #2 stated Resident #1 reported he/she had argued with his/her son because he/she wanted to go to the diner and get something to eat. She stated EMS arrived and took the resident to the hospital. Further interview with the ADON on 03/12/19 at 4:02 PM, revealed she had just finished doing a breathing treatment on the 200 Hall when she saw the BOM looking for Resident #1 on 03/07/19. She stated staff started looking for the resident in the hallways and gathering areas when LPN #2 asked staff if they were looking for someone, as she was on the phone with a man who found a resident across the road. The ADON stated the caller was told that staff would meet him there and three (3) staff (ADON, LPN #2 and SRNA #3) proceeded to go to the resident. She stated when they reached the resident, he/she was sitting upright on the shoulder of the road with the man who had stopped to check on him/her. The ADON stated the resident was alert, denied pain; and was not wearing a wanderguard. The resident was wearing shoes, flannel pants and a green coat, which was buttoned up. Interview with the Director of Nursing (DON), on 03/13/19 at 3:17 PM, revealed she was not in the building when the elopement occurred; however, staff notified her and she returned to the facility. Further interview with the DON, on 03/14/19 at 5:24 PM, revealed a wanderguard should be put in place when a resident was assessed by staff to be at risk for elopement. She stated the care plans (Baseline or Comprehensive, and SRNA) and TAR should have been updated when the wanderguard was initiated to include the wanderguard and checking for placement and functioning every shift. In addition, she stated the nurse should have added Resident #1 to the Elopement Book at each nursing station. The DON stated she expected staff to ensure resident's were safe. The DON reported that she would be a resource to supplement nursing needs as staffing required. She reported there were two (2) nurses in the building on second (2nd) shift and that she, ADON and Administrator were always available by telephone. Further interview (Post Survey) with the DON, on 04/02/19 at 9:44 AM, revealed when a resident received a wanderguard, the nurse should document the wanderguard on the care plan and add the resident to the elopement book. She stated when a resident was assessed at low risk for elopement, staff do not have to place an intervention on the care plan but a moderate to high-risk resident should be looked at individually to determine if he/she would require a wanderguard. She further stated Resident #1 had not been placed in the wanderguard book prior to his/her elopement. Interview with the Administrator and the Corporate Nurse, on 03/13/19 at 12:50 PM, revealed an Elopement Risk Assessment was completed upon admission on 03/06/19, and repeated on 03/07/19, after an elopement attempt. They stated wanderguards were checked every shift (6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM) by the assigned licensed staff to ensure the wanderguard was in place and functioning. They revealed there were nine (9) exit doors that led to the outside of the building, but the wanderguard system was only installed on the two (2) front doors. Further interview revealed the SRNA Care Plan did not get updated during the time before the resident eloped, but staff was made aware verbally. The Corporate Nurse revealed Resident #1's wanderguard was retrieved from the garbage can and was checked for appropriate functioning by LPN #1. The Administrator stated the ADON brought the concern to the Stand Down Meeting and the Baseline Care Plan was updated with the intervention for the wanderguard at that time. Further interview (Post Survey) with the Administrator on 04/02/19 at 9:28 AM revealed the Stand Down Meetings were held at 3:00 PM Monday through Friday. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Administrator and Regional Nurse Consultant (RNC) conducted a thorough investigation of the 03/07/19 event on 03/08/19. 2. The Administrator and RNC conducted a Root Cause Analysis to identify the variables that led to the process failure on 03/08/19. 3. The RNC and MDS Coordinator conducted a 100% audit of all other residents who had a wandering transmitter present to confirm placement and working status on 03/07/19. 4. The RNC and MDS Coordinator conducted a 100% audit of all care plans of residents with high risk of elopement to ensure accuracy of the care plan and appropriateness of interventions on 03/07/19, 5. The RNC conducted a 100% audit of all SRNA Care Plans of residents at high risk for elopement to ensure accuracy of the Nurse Aide Care Plan on 03/07/19. 6. The Maintenance Assistant changed the front door code on 03/07/19; and the Medical Records Clerk educated all facility staff not to divulge the code to visitors, residents, or family members on 03/07/19. 7. The Administrator placed a new, prominent door signage on the front door alerting visitors to be mindful of who they help exit the building on 03/07/19. 8. The RNC and MDS Coordinator checked, on 03/07/19, to verify placement and function of wanderguard transmitters for all other residents who utilize them. 9. The Administrative Nurse, DON, ADON and MDS Coordinator reviewed all current residents' elopement risk evaluations to ensure that it accurately reflected the resident's status on 03/07/19. Any inaccurate evaluation had a new assessment completed at that time. 10. The Maintenance Assistant inspected all exit doors to verify functioning and alarm on 03/07/19. 11. The Administrator, DON, and Medical Records Clerk initiated education, on 03/07/19. House-wide education and in-service training was provided to all staff to include topics of elopement protocol, behaviors that might suggest high-risk elopement, use of the facility's Elopement Book, expectations surrounding responding to alarms, elopement/wandering monitoring and oversight, elopement notifications, elopement drill process, and only staff members will have access to the door codes. Licensed nurses also received education on completion of the Elopement Risk Assessment use and application. Education continued at the beginning of each shift, with oncoming staff members not previously trained. The training was provided prior to beginning work. No staff members were permitted to work prior to completing the training. The majority of employees were trained by 03/09/19 (80%) with all except PRN (as needed) staff or those staff on Medical Leave, who were trained by 03/13/19. Any employee not trained by 03/15/19 was sent a certified letter, informing them that they would not be permitted to work until education had been completed. The on-call supervisor has a list of those employees to ensure they were not called in to work prior to receiving the letter. The Administrator, DON, and Medical Records Clerk administered posttests on the above topics beginning on 03/07/19. The majority of employees were tested by 03/09/19 (80%), and all except PRN (as needed) staff or those on Medical Leave, were tested by 03/13/19. Any employee not trained and tested by 03/15/19 was sent a certified letter, informing them that they would not be permitted to work until education and the Posttest had been completed. The On-call Supervisor has a list of those employees to ensure they are not called in to work prior to receiving the letter. 12. The Administrator began unannounced elopement drills on 03/08/19 and the drills will be conducted weekly on each shift for two (2) weeks following the initial drill. After the initial monitoring elopement drills were completed on 03/08/19, ongoing monitoring will be continued with elopement drills conducted weekly on each shift x 4 weeks, then monthly on each shift x 6 months. 13. Starting on 03/08/19, each unit's 24-hour report and available push reports will be reviewed daily (M-F) in clinical meeting by the Administrator, DON, ADON's, MDS, Administrative Nurses or Regional Nurses to validate residents identified at-risk residents were appropriately monitored if wandering or exit seeking behaviors were present and required interventions initiated. The Nurse on Call will review on weekends. 14. Lastly, all audit results will be shared with the facility's Quality Assurance Performance Improvement (QAPI) team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's investigation data revealed the Administrator and the Regional Nurse Consultant (RNC) completed the investigation. Review of facsimile (fax) confirmation sheets revealed the Department of Community Based Services (DCBS) and the Office of Inspector General (OIG) received the facility's Initial Report (03/07/19), as well as the five (5) day/Final Report (03/13/19) of the self-reported incident. 2. Interview with the Administrator, on 03/21/19 at 3:29 PM revealed the Administrator and the Regional Nurse Consultant (RNC) identified variables that led to the process failure on 03/08/19 and concluded Resident #1 observed someone enter the door code or followed someone out of the facility. 3. Interview with the MDS Coordinator on 03/21/19 at 2:24 PM, and the DON on 03/21/19 at 3:11 PM, revealed together with the former ADON, they completed an audit of 100% of other residents with who utilized a wander transmitter device to confirm the placement and working status of the existing wanderguards. No concerns were identified. 4. Interview with the DON on 03/21/19 at 3:11 PM, and the MDS Coordinator, on 03/21/19 at 2:24 PM revealed the former ADON, DON and MDS Coordinator completed care plan reviews of 100% residents with wanderguards, on 03/07/19, to confirm the accuracy of the risk of elopement for each resident. 5. Interview with the DON on 03/21/19 at 3:11 PM and the MDS Coordinator, on 03/21/19 at 2:24 PM revealed the former ADON, DON and MDS Coordinator completed SRNA care plan reviews of 100% residents with wanderguards to confirm accuracy. 6. Interview with Maintenance, on 03/21/19 at 1:48 PM, revealed he changed the door codes successfully on 03/07/19, after the incident. Maintenance also reported he does not give out the door code to anyone. Interview with the Administrator on 03/21/19 at 2:15 PM, revealed the ADON no longer was employed at the facility, as she resigned over the weekend. Interviews on 03/21/19 with the Staffing Coordinator/SRNA, at 2:18 PM, MDS Nurse at 2:24 PM, SRNA #4 at 2:29 PM, SRNA #5 at 2:34 PM, SRNA #6 at 2:39 PM, Housekeeping at 2:44 PM, LPN #4 at 2:52 PM, LPN #5 at 2:58 PM, Business Office Manager (BOM) at 3:06 PM, DON at 3:11 PM and the Administrator at 3:29 PM revealed they were educated related to not giving the door code to visitors and residents. 7. Observation and interview with the Administrator, on 03/21/19 at 3:29 PM revealed she placed new door signage on the front door to alert visitors to not allow residents to exit the building on 03/07/19. 8. Interview with the MDS Coordinator on 03/12/19 at 2:24 PM, revealed after the incident on 03/07/19 with Resident #1, the Regional Nurse Consultant (RNC) and she checked all remaining residents in the facility to verify placement and functioning of the wanderguard. Observation, on 03/21/19 at 1:00 PM, with the Administrator revealed six (6) residents identified at risk for elopement had wanderguard devices in place and the wanderguards were functioning with no concerns identified. 9. Review of documentation and interviews on 03/21/19 with the Administrator at 3:29 PM, DON at 3:11 PM, and MDS Coordinator at 2:24 PM, revealed all elopement risk assessments were reviewed for all residents with no concerns noted. 10. Interviews on 03/21/19 with the Administrator at 3:29 PM, and Maintenance at 1:48 PM, revealed all doors were checked for functioning by Maintenance on 03/07/19 and were found to be in working order. 11. Interviews on 03/21/19 with the Administrator at 3:29 PM, and DON at 3:11 PM, revealed all staff, except PRN (as needed) staff or those on medical leave were educated, prior to 03/13/19, and the remaining were alerted by mail that they must be educated prior to working another shift. Staff were required to complete a post-test, results were shared with the SSA and were provided in the packet provided by the facility. Interview with the Corporate Chief Nursing Officer (CNO), on 03/13/19 at 12:50 PM, revealed all staff were educated on elopement plan; behaviors that might suggest a resident was at high risk for elopement and verbalizations that they want to leave such as hanging around a door, attempting to open doors, following behind visitors or employees that were leaving, increased agitation or aggression with attempts to redirect away from the door. Staff were educated on the location of the elopement books and the fact that they all were responsible for looking at the book on a regular basis so that they would know which residents were at risk for elopement. Staff were educated on the need to immediately respond to any alarm and if unable to determine who activated the alarm, they should immediately check outside to verify that no resident has exited the building, Staff were educated that when a resident demonstrates such behavior, he/she should have increased monitoring/oversight. Residents that demonstrate an increased risk for behaviors should have an elopement reassessment. If indicated by the elopement assessment a wanderguard should be placed and the resident should be added to the elopement book and a care plan is to be initiated. In addition, the CNO stated the facility failed to educate licensed nurse on revision of care plan so education for licensed nurses began on 03/13/19 related to care plan developement/revision, to reflect interventions, placement of wanderguard alert transmitters in a secure manner to reduce opportunities for removal, and the need for enhanced monitoring for effectiveness and resident response for twenty-four (24) hours when new alert transmitter applied. She stated this educaion would continue at the beginning of each shift for any oncoming staff not previously educated and not staff would be allowed to work until educated. Elopement drills are to be done on all shifts and staff are to complete a post test after the elopement education. Education was provided by the Administrative team to include CNO, Administrator, DON and the Medical Records Clerk Interviews on 03/21/19 with the Staffing Coordinator/SRNA, at 2:18 PM, MDS Nurse at 2:24 PM, SRNA #4 at 2:29 PM, SRNA #5 at 2:34 PM, SRNA #6 at 2:39 PM, Housekeeping at 2:44 PM, LPN #4 at 2:52 PM, LPN #5 at 2:58 PM, Business Office Manager (BOM) at 3:06 PM, DON at 3:11 PM, and the Administrator at 3:29 PM; revealed they were educated on elopements, including what to do when a resident cannot be located, signs of a resident who may want to elope, the location of the wander book and that staff should immediately respond to alarms. 12. Review of Attendance Logs revealed unannounced elopement drills were conducted on 03/08/19 at 8:30 AM, 03/08/19 at 3:40 PM, 03/11/19 at 1:00 PM, 03/12/19 at 7:45 PM, 03/12/19 at 9:50 PM, 03/13/19 at 10:48 PM, 03/15/19 at 11:00 AM, 03/17/19 at 10:00 AM, 03/19/19 at 7:00 PM and 03/20/19 at 10:40 AM by the Administrator or designee. 13. Interview with the Administrator on 03/21/19 at 3:29 PM and 04/02/19 at 11:23 AM revealed she was the person that oversees all audits and maintains the logs for auditing the compliance and efficacy of the plan put in place. The Administrator stated the Push Reports and 24 hour reports were being reviewed daily Monday through Friday in morning meeting and the Nurse on Call reviewed them on the weekend. Interview with the Social Service/Admissions Director, on 04/02/19 at 1:31 PM, confirmed that she has been involved in the audit processes since the elopement of Resident #1. She stated this included review of the completion of the Twenty-four (24) hour push reports. Interview with the Housekeeping Supervisor on 04/02/19 at 1:32 PM, revealed that she has been assisting with MOD audits on weekends to ensure that nursing staff were completing the Twenty-four (24) hour Push Reports, and updating care plans and assessing the residents for elopement status. 14. All audit results will be shared with the facility Medical Director and the Quality Assurance Performance Improvement (QAPI) team no less than monthly. The Medical Director was notified of the elopement, on 03/07/19 at 6:30 PM via telephone, and this was verified with the Medical Director during an interview, on 03/21/19 at 3:34 PM.

Based on interview, record review, facility policy review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure medication was administered according to professional standards of practice for one (1) of four (4) sampled residents (Resident #1). On 08/26/17, Licensed Practical Nurse (LPN) #1 failed to ensure Resident #1 received the right medication according to the physician order. Resident #1 was ordered to receive [MEDICATION NAME] (anti-infective) Ophthalmic (Opth) drops (gtts), one (1) gtt both eyes three times a day (TID) times five (5) days. However, LPN #1 failed to administer the right medication and applied Penlac (nail Lacquer) to Resident #1's left eye resulting in a corneal abrasion. The findings include: Review of KBN AOS #14 Patient Care Orders, last revised (MONTH) (YEAR), revealed it defines Licensed Practical Nurse (LPN) job as the performance of acts requiring knowledge and skill such as are taught or acquired in approved schools for practical nursing in the administration of medication or treatment as authorized by a physician, physician assistant, dentist, or advanced practice registered nurse and as further authorized or limited by the board which is consistent with the National Federation of Licensed Practical Nurses or with Standards of Practice established by nationally accepted organizations of licensed practical nurses. Review of facility policy titled, Preparation and General Guidelines, IIA2 : Medication Administration-General Guidelines, last revised 12/18/12, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician, Residents are identified before medication is administered. Record review revealed the facility admitted Resident #1 on 07/11/16 with [DIAGNOSES REDACTED]. Review of the Physician Order, dated 08/21/17 revealed to administer [MEDICATION NAME] Opth gtts, one (1) to both eyes TID for five (5) days. However, review of a Progress Note, dated 08/26/17 at 11:39 PM written by LPN #1, revealed LPN #1 had grabbed a box from the drawer of the medication cart and had went into Resident #1's room and administered topical nail lacquer (belonging to another resident) into Resident #1's left eye instead of the [MEDICATION NAME] gtts. Review of written Telephone Order, dated 08/26/17, revealed Resident #1 was sent to the emergency room (ER) for evaluation of the left eye. Review of the Hospital ER record, dated 08/26/17 at 11:45 PM revealed Resident #1's eye was noted to be red, swelling, pain, burning, and matting. Review of the ER Encounter Record, dated 08/26/17 revealed the Poison Control Center was called with instructions for morgan lens irrigation with one (1) liter of normal saline, tetracaine drops to left eye, and an order for [REDACTED]. Interview with Ophthalmologist #1 on 11/21/17 at 1:09 PM revealed he provided treatment for [REDACTED].#1 on 08/28/17. He stated the treatment was for a cornea that was not clear (like a chemical burn), and at the time it would have been pretty painful. Interview with LPN #1 on 11/21/17 at 12:00 PM revealed she grabbed medication that she thought was eye drops from the medication cart but did not check the ensure it was the right medication. She stated she pulled Resident #1's left eyelid down and put the medication in the eye. Interview Registered Nurse (RN) #1 on 11/21/17 at 12:56 PM revealed the nurses should go through the five (5) rights of medication administration (right drug, right dose, right patient, right route, and right time) prior to administering the medication to a resident. Interview with the Director of Nursing (DON) on 11/22/17 at 2:23 PM revealed she expected the nurses to use the seven (7) rights of medication administration when giving medications--right patient, right route, right time, and right dose (the other three rights not quoted by the DON were right drug, right reason, right documentation). **The facility implemented the following actions to correct the deficient practice: 1. The facility nurse notified the Physician of incident, Resident #1 was sent to the ER for evaluation, the Administrative Nurse on call was notified, Guardian Services was notified, and Resident #1's eyes were flushed immediately after the the medication was placed in the resident's eye on 08/26/17. 2. The facility received orders on from ER and faxed to pharmacy. The ER contacted poison control and protocol was followed and continued upon returning to facility. 3. Resident #1 had follow ups with Ophthalmologists on 08/28/17 and 08/30/17. 4. The DON and RN #1 audited the medication carts on 08/27/17 to ensure for correct placement of medications in the carts, with removal of nail lacquer by RN #1 from the cart. 5. LPN #1 was drug tested on [DATE] with negative results. LPN #1 was suspended, on 08/27/17 and terminated on 08/28/17 as a result of an accumulation of performance issues. 6. All CMT's and Nurses were educated on the seven (7) rights of medication administration and medication storage on 08/27/17. 7. Medical Director made aware of the incident related to the nurse not following the seven rights of medication administration and the medication being stored inappropriately on 09/20/17 at the monthly QA meeting. 8. Pharmacy conducting medication cart audits and medication pass monthly to ensure medications stored in cart appropriately and that staff are using the seven rights of medication administration when administering medication. In addition, the DON is conducting random medication passes to ensure staff following the seven rights of medication administration. The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of event statement dated 08/27/17 revealed LPN #1 immediately flushed the resident eye, and called the on call ARNP with orders to send Resident #1 to the emergency room (ER) for evaluation. LPN #1 also called the on-call Administrative Nurse-Assistant Director of Nursing (ADON) to report the incident. LPN #1 then left a message of incident on the State Guardian phone service. Resident #1 was sent to the ER. and eyes were flushed for 20 minutes and returned to the facility with new orders that were faxed to the pharmacy. 2. Review of Telephone Order dated 08/27/17 revealed an order for [REDACTED]. 3. Review of ophthalmology examination records, dated 08/28/17 and 08/30//17 revealed Resident #1 to have an abrasion present in left eye with moderate defect being extensive and irregular in size with a positive fluorescent staining noted and the defect involving the visual axis of the eye. Review of the facility telephone order from 08/28/17 visit at ophthalmology revealed to start [MEDICATION NAME] ophthalmic ointment and apply inside lower lid of left eye three times a day (TID) for five (5) days, [MEDICATION NAME] ophthalmic solution (1) one drop to eye every (3) three hours X (5) five days. Follow up on 08/30/17. Follow up visit on 08/30/17 revealed Resident #1 to have excessive tearing noted or reported, and diffuse hyperemia of the conjunctiva with a corneal [MEDICATION NAME] abrasion present in left eye with mild defect with orders to stay on antibiotic (3) three times a day and ointment for five (5) more days. 4. Review of a written statement by ADON dated 08/28/17 revealed she and RN #1 had competed an audit of medication carts on 08/27/17 for correct placement of medications in the carts, with removal of nail lacquer by RN #1 from the cart. Observation of medication carts on 11/17/17 at 11:25 AM during med pass,11/20/17 at 4:09 PM, and 11/21/17 at 11:50 AM revealed no concerns with medication carts. 5. Review of a STAT Test Preliminary Drug Screen Result Form revealed LPN #1 was drug tested on [DATE] with preliminary results showing LPN to be negative for all drugs. Review of a Employee Suspension Form revealed LPN #1 was suspended on 08/27/17 and review of an Employee Termination Notice revealed she was terminated on 08/28/17 at 3:45 PM. 6. Review of training and education revealed CMTs and Nurses were educated on the seven (7) rights of medication administration and drug storage on 08/27/17. Interview on 11/17/17 at 3:40 PM with LPN #2 revealed she received education on 08/271/7 to ensure medications were stored in the right cart and the right area of cart to ensure types of medication were stored separately and to administer medication according to the seven rights of medication administration. Interviews on 11/21/17 with CMT at 4:00 PM, CMT #1 at 1:48 PM. CMT #2 at 12:32 PM, and ensuring they used the seven medication rights and ensure types of medications were stored separately. 7. Interview on 12/08/17 at 12:40 PM with Administrator revealed she spoke with the Medical Director in QA regarding the med error with Resident #1 and the eye drops and placement in the medication carts on 09/20/17; when they had a formal QA meeting in the facility. 8. E-mails from Pharmacy revealed monthly audits of the medication carts and observation of medication passes were conducted on 09/05/17 and 10/16/17. There was no storing of different types of medication together (eye, nose, etc) and the staff follow the seven rights of medication administration. In addition random medication passes by Administrative staff were conducted on 08/31/17.

Based on interview, record review, facility policy review, and review of the Penlac manufacturer's printout, and review of hospital emergency room (ER) Encounter Record, it was determined the facility failed to ensure one (1) of four (4) sampled residents was free of any significant medication error (Resident #1). On 08/26/17, Licensed Practical Nurse (LPN) #1 administered Penlac (Cycloporix topical solution 8% nail lacquer) instead of [MEDICATION NAME] (anti-infective) eye drops to the left eye of Resident #1 which resulted in a significant medication error. Resident #1 was sent to the emergency room (ER) in pain and diagnosed with [REDACTED]. The findings include: Review of facility policy titled, Administering Medications, last revised (MONTH) 2012, revealed medications must be administered in accordance with the orders, including any required time frame, The individual administering medications must verify the resident's identity before giving the resident his/her medications. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of Penlac ([MEDICATION NAME] topical solution 8%) printout, dated 11/21/17, revealed the medication is for use on fingernails and toenails and immediately adjacent skin only and not for use in eyes. Avoid contact with eyes and mucous membranes. Record review revealed the facility admitted Resident #1 on 07/11/16 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/12/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. In addition, Resident #1 required extensive assistance with activities of daily living (ADLs). Review of the Physician Order, dated 08/21/17 revealed to obtain a culture and sensitivity (C & S) of the drainage from both of Resident #1's eyes and wound of abdomen; and, to administer [MEDICATION NAME] Ophthalmic gtts, one gtt to both eyes TID for five (5) days. Review of a Progress Note, dated 08/26/17 at 11:39 PM written by LPN #1, and Incident Report provided by the facility, last revised 08/28/17 at 9:36 PM, revealed LPN #1 had grabbed a box from the drawer of the medication cart and had went into the room of Resident #1 and put topical nail lacquer (Cycloporix - belonging to another resident) in his/her left eye. The resident was sent to the hospital. Review of a Physician Order, dated 08/26/17, revealed Resident #1 was sent to the emergency room (ER) for evaluation of the left (L) eye related to staff putting in nail lacquer in the eye. Review of Event Statement, dated 08/27/17 by LPN #1 revealed she had grabbed a box from drawer, went to Resident #1's room, opened the bottle, and put it into the eyes of Resident #1. She stated she then noticed it was not the right medication and sent the resident to the hospital. Review of the Hospital ER record, dated 08/26/17 at 11:45 PM revealed Resident #1's eye was noted to be red, swelling, pain, burning, and matting. Review of the ER Encounter Record, dated 08/26/17 revealed the Poison Control Center was called with instructions for morgan lens irrigation with one (1) liter of normal saline, tetracaine drops to left eye, and an order for [REDACTED]. Review of a Physician Order, dated 08/27/17 revealed to administer [MEDICATION NAME] Ophthalmic Solution (antibiotic eye drops) two (2) drops to left eye, four (4) times daily, hourly left eye rinses times twenty (20) minutes with normal saline (NS), [MEDICATION NAME] ophthalmic (antibiotic eye drops)) four (4) times daily, and follow up with ophthalmology on Monday for reevaluation for eye irritation. Interview with LPN #1, on 11/21/17 at 12:00 PM, revealed she had been late giving Resident #1's eye drops and grabbed what she thought was the eye drops from the medication cart but did not check the medication or turn the lights on. She stated she pulled Resident #1's left (L) eyelid down and put the medication in the eye without checking to make sure it was the eye drops. She stated staff should check the dosage, medication, the route and ensure it is the the right resident. Interview with LPN #4 (LPN Supervisor), on 11/19/17 at 6:36 PM and 11/21/17 at 12:55 PM, revealed LPN #1 had told her she had to send out Resident #1 because she had put the wrong drops in the resident's eyes. She stated LPN #1 told her that she had placed nail lacquer in the resident's eye and the resident's eye was red and swollen. LPN #4 stated she had received Resident #1 back from the hospital with the left eye swollen and red and the resident had to be seen by an ophthalmologist. Interview with Ophthalmologist #1, on 11/21/17 at 1:09 PM, revealed Resident #1 had been treated at his office on 08/28/17 for a cornea that was not clear, like a chemical burn. The Ophthalmologist stated at the time it would have been pretty painful and the resident had a corneal abrasion. Interview Registered Nurse (RN) #1, on 11/21/17 at 12:56 PM, revealed she came on duty the next shift after Resident #1 had the nail lacquer placed in the left eye. She stated when giving medication, the (5) five rights of medication administration should be gone through. Interview with Pharmacist #1 on 11/27/17 at 3:58 PM revealed if Cycloporix topical solution (8% nail lacquer) was put in the eyes it would be pretty irritating. He stated the solution was to be applied with a brush and was for nail fungus. Interview with the Director of Nursing (DON), on 11/22/17 at 2:23 PM, revealed she expected the nurses to use the seven (7) rights of medication administration when giving medications to try to ensure no medication errors occurred (right resident, right route, right time, right dose, right drug, right reason, right documentation). She stated staff were trained to follow the seven rights to try to prevent medication errors and it is the policy of the facility. **The facility implemented the following actions to correct the deficient practice: 1. The facility nurse notified the Physician of incident, Resident #1 was sent to the ER for evaluation, the Administrative Nurse on call was notified, Guardian Services was notified, and Resident #1's eyes were flushed immediately after the the medication was placed in the resident's eye on 08/26/17. 2. The facility received orders on from ER and faxed to pharmacy. The ER contacted poison control and protocol was followed and continued upon returning to facility. 3. Resident #1 had follow ups with Ophthalmologists on 08/28/17 and 08/30/17. 4. The DON and RN #1 audited the medication carts on 08/27/17 to ensure for correct placement of medications in the carts, with removal of nail lacquer by RN #1 from the cart. 5. LPN #1 was drug tested on [DATE] with negative results. LPN #1 was suspended, on 08/27/17 and terminated on 08/28/17 as a result of an accumulation of performance issues. 6. All CMT's and Nurses were educated on the seven (7) rights of medication administration and medication storage on 08/27/17. 7. Medical Director made aware of the incident related to the nurse not following the seven rights of medication administration and the medication being stored inappropriately on 09/20/17 at the monthly QA meeting. 8. Pharmacy conducting medication cart audits and medication pass monthly to ensure medications stored in cart appropriately and that staff are using the seven rights of medication administration when administering medication. In addition, the DON is conducting random medication passes to ensure staff following the seven rights of medication administration. The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of event statement dated 08/27/17 revealed LPN #1 immediately flushed the resident eye, and called the on call ARNP with orders to send Resident #1 to the emergency room (ER) for evaluation. LPN #1 also called the on-call Administrative Nurse-Assistant Director of Nursing (ADON) to report the incident. LPN #1 then left a message of incident on the State Guardian phone service. Resident #1 was sent to the ER. and eyes were flushed for 20 minutes and returned to the facility with new orders that were faxed to the pharmacy. 2. Review of Telephone Order dated 08/27/17 revealed an order for [REDACTED]. 3. Review of ophthalmology examination records, dated 08/28/17 and 08/30//17 revealed Resident #1 to have an abrasion present in left eye with moderate defect being extensive and irregular in size with a positive fluorescent staining noted and the defect involving the visual axis of the eye. Review of the facility telephone order from 08/28/17 visit at ophthalmology revealed to start [MEDICATION NAME] ophthalmic ointment and apply inside lower lid of left eye three times a day (TID) for five (5) days, [MEDICATION NAME] ophthalmic solution (1) one drop to eye every (3) three hours X (5) five days. Follow up on 08/30/17. Follow up visit on 08/30/17 revealed Resident #1 to have excessive tearing noted or reported, and diffuse hyperemia of the conjunctiva with a corneal [MEDICATION NAME] abrasion present in left eye with mild defect with orders to stay on antibiotic (3) three times a day and ointment for five (5) more days. 4. Review of a written statement by ADON dated 08/28/17 revealed she and RN #1 had competed an audit of medication carts on 08/27/17 for correct placement of medications in the carts, with removal of nail lacquer by RN #1 from the cart. Observation of medication carts on 11/17/17 at 11:25 AM during med pass,11/20/17 at 4:09 PM, and 11/21/17 at 11:50 AM revealed no concerns with medication carts. 5. Review of a STAT Test Preliminary Drug Screen Result Form revealed LPN #1 was drug tested on [DATE] with preliminary results showing LPN to be negative for all drugs. Review of a Employee Suspension Form revealed LPN #1 was suspended on 08/27/17 and review of an Employee Termination Notice revealed she was terminated on 08/28/17 at 3:45 PM. 6. Review of training and education revealed CMTs and Nurses were educated on the seven (7) rights of medication administration and drug storage on 08/27/17. Interview on 11/17/17 at 3:40 PM with LPN #2 revealed she received education on 08/271/7 to ensure medications were stored in the right cart and the right area of cart to ensure types of medication were stored separately and to administer medication according to the seven rights of medication administration. Interviews on 11/21/17 with CMT at 4:00 PM, CMT #1 at 1:48 PM. CMT #2 at 12:32 PM, and ensuring they used the seven medication rights and ensure types of medications were stored separately. 7. Interview on 12/08/17 at 12:40 PM with Administrator revealed she spoke with the Medical Director in QA regarding the med error with Resident #1 and the eye drops and placement in the medication carts on 09/20/17; when they had a formal QA meeting in the facility. 8. E-mails from Pharmacy revealed monthly audits of the medication carts and observation of medication passes were conducted on 09/05/17 and 10/16/17. There was no storing of different types of medication together (eye, nose, etc) and the staff follow the seven rights of medication administration. In addition random medication passes by Administrative staff were conducted on 08/31/17.