Every finding on record at Bourbon Heights Nursing Home

Based on observation, interview, record review, review of Droplet Precautions signage, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, 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 and control the development and transmission of communicable diseases and to implement interventions to protect facility residents. Observations on 02/17/2026 and 02/18/2026 revealed staff cleaned a glucometer without donning (putting on) gloves; staff failed to sanitize blood pressure cuffs before using on residents and failed to place them on barriers while contaminated; staff failed to wear appropriate personal protective equipment (PPE) in a resident room designated with Droplet Precautions signage; and staff failed to remove a mask after exiting a room designated with Droplet Precautions signage, for 6 of 16 residents sampled for infection control. The deficient practice had the potential to affect the entire facility, with a resident census of 76. The findings include: Review of the facility's policy titled, Personal Protective Equipment-Using Gowns, revision date July 2009, revealed its purpose was to guide the use of gowns with the objective being to prevent the spread of infections. The policy revealed when the use of a gown was indicated, all personnel must put on a gown before treating or touching the resident. Review of the facility policy's titled, Personal Protective Equipment-Gloves, revision date July 2009, revealed gloves must be worn during tasks that included the likelihood of the employees' hands coming in contact with blood during all cleaning and decontaminating procedures. Review of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions, revision date August 2019, revealed transmission-based precautions (TBP) were initiated with symptoms of an infection or a laboratory confirmed infection, and the resident was at risk of transmitting the infection to other residents. Further review revealed TBP included contact, droplet, or airborne precautions. The policy revealed the Infection Preventionist (IP) determined the appropriate notification on the room entrance door so personnel and visitors were aware of the need and the type of precautions. Per the policy, the signage informed staff of the type of CDC precautions, instructions for the use of PPE, and/or to see a nurse before entering the room. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revision date September 2022, revealed resident care equipment, including reusable medical equipment, would be cleaned and disinfected according to CDC recommendations for disinfection. Review of the policy revealed implementation included using the [NAME] Classification System to distinguish levels of disinfection and sterilization necessary for items used in resident care. Review of non-critical items included blood pressure cuffs that came in contact with intact skin but not mucous membranes. Review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces, revision date 2019, revealed environmental surfaces would be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities. Continued review revealed non-critical surfaces would be disinfected with an Environmental Protection Agency (EPA) registered intermediate or low-level hospital disinfectant. Review of the resident room door signage for Droplet Precautions, undated, revealed a typed red laminated sign saying Stop!!! Droplet Precautions, required to enter this room, gowns, gloves, mask/eye protection, remember to wash your hands before and after contact. Further review of the signage revealed it did not state what type of mask or what type of eye or face protection. The signage did not state when to remove PPE and how to dispose of it. Review of the document Centers for Disease Control and Prevention (CDC) Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission, undated, revealed the resident should be placed on Droplet Precautions for confirmed or suspected seasonal flu. Review of the CDC guidance for Droplet Precautions included coverings for eyes, nose, and mouth.Review of the document CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, dated 2008, revealed to perform disinfection on non-critical equipment such as blood pressure cuffs, with a low-level disinfectant regularly including after each use. The guidelines used the [NAME] Classification System, a system which categorized disinfection of medical instruments to prevent infection and promote patient safety. Further review revealed blood pressure cuffs were categorized as a noncritical item and required disinfection with low level disinfection or a non-germicidal detergent.1. Review of Resident (R) 38's Face Sheet revealed the facility admitted the resident on 06/27/2022 with diagnoses to include dementia, peripheral vascular disease, and chronic kidney disease.Review of R38's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/24/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of two out of 15, which indicated R38 was severely cognitively impaired.Review of R38's Physician's Orders, dated 02/16/2026 at 4:02 PM, revealed an order for Droplet Precautions. Review of R38's Comprehensive Care Plan [CCP], with an initiation date of 02/16/2026, revealed the focus identified R38 as having Influenza A and currently on Droplet Precautions. Observation on 02/17/2026 at 12:07 PM revealed Licensed Practical Nurse (LPN) 1 in R38's room. LPN1 was only wearing a mask, and she did not have on any other Protective Personal Equipment (PPE). R38 had a red sign on the room directing staff and visitors that R38 was on Droplet Precautions. The signage stated gowns, gloves, mask, and eye protection were required when entering the room. During an interview with LPN1 at the time of the observation, she stated she did not know gown and gloves were required when entering the room. During an interview with LPN4/Quality Assurance Nurse on 02/17/2026 at 12:10 PM at the door of R38's room, she stated she audited the staff periodically to ensure they were wearing the correct PPE. When asked if staff entering R38's room should put on gowns, gloves, masks, and eye protection, she stated she did not know and would get back to the State Survey Agency (SSA) Surveyor with the answer. Additional interview with LPN4/Quality Assurance Nurse on 02/17/2026 at 12:22 PM, she stated she checked and staff entering a Droplet Precautions room should wear the PPE that was documented on the sign. 2. Review of R16's Face sheet revealed the facility admitted the resident on 08/03/2021 with diagnoses to include high blood pressure, chronic kidney disease, and cerebral infarction (stroke).Review of R16's annual MDS, with an ARD of 12/19/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Observation on 02/18/2026 at 9:05 AM revealed Kentucky Medication Aide (KMA) 1 preparing medication for R16 at the medication cart. KMA1 removed the blood pressure cuff from the top of the medication cart and carried the cuff and medication to R16's room. KMA1 administered R16's medication to her. Following the administration, KMA1 took R16's blood pressure on her right wrist without cleaning the blood pressure cuff. KMA1 removed the blood pressure cuff from R16's wrist and returned to the medication cart where the uncleaned blood pressure cuff was placed on top of the medication cart without a protective barrier. 3. Review of R47's Face Sheet revealed the facility admitted the resident on 06/19/2017 with diagnoses to include high blood pressure, chronic obstructive pulmonary disease (COPD) (limited airflow in lungs), and dementia. Review of R47's annual MDS, with an ARD of 01/05/2026, revealed the facility assessed the resident to have a BIMS score of zero out of 15, which indicated the resident's cognition was severely impaired.Observation on 02/18/2026 at 9:30 AM revealed KMA1 preparing medication for R47. After gathering the medication, KMA1 removed the uncleaned blood pressure cuff from the top of the medication cart and went to R47's room. KMA1 administered medication to R47. After the medication was administered, KMA1 obtained the blood pressure from R47's right wrist with the uncleaned blood pressure cuff. KMA1 returned to the medication cart and placed the uncleaned cuff on top of the medication cart without a barrier.During an interview with KMA1 on 02/18/2026 at 9:39 AM, she stated the blood pressure cuffs were supposed to be cleaned with bleach wipes after every use. The SSA Surveyor asked KMA1 where the bleach wipes were kept. KMA1 stated staff was not allowed to keep bleach wipes on the medication cart. Observation of KMA1 at the time of the interview revealed she walked into the nurses' station and unlocked a cabinet, removing a bleach wipe from a multi-use container. KMA 1 wiped down the blood pressure cuff and returned it to the medication cart. 4. Review of R72's Face Sheet revealed the facility admitted the resident on 08/12/2015 with diagnoses to include hypertension, stroke, and diabetes.Review of R72's quarterly MDS, with an ARD of 01/24/2026, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated R72 had moderate cognitive impairment.Observation on 02/18/2026 at 9:38 AM revealed State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) 7 entered R72's room and applied a blood pressure machine cuff to his right arm. After the blood pressure check, she placed the blood pressure machine cuff in her pocket. She then sanitized her hands and went to the medication cart. She placed the uncleaned blood pressure machine cuff on top of the medication cart without a protective barrier and looked into the computer; she then moved the blood pressure machine cuff over to the side of the medication cart, without sanitizing it. During an interview with SRNA/KMA7 on 02/18/2026 at 9:49 AM, she stated the policy was that she was to clean the blood pressure machine cuff with a Sani-Wipe (disinfectant) after each use. She stated she forgot and needed to go get the Sani-Wipes. She then got the Sani-Wipes and cleaned the blood pressure machine cuff. Continued observation revealed SRNA/KMA7 placed a medication cup on the top of the medication cart. She opened the drawer of the medication cart and began to pull medicine from the drawer. The SSA Surveyor asked SRNA/KMA7 if the top of the medication cart should be cleaned where the blood pressure machine cuff was placed. She stated, Yes. She then cleaned the top of the medication cart.5. Review of R3's Face Sheet revealed facility admitted the resident on 12/01/2023 with diagnoses to include diabetes, peripheral vascular disease, pressure ulcers, and dementia.Review of R3's annual MDS, with an ARD of 02/18/2026, revealed the facility assessed the resident to have a BIMS score of four out of 15, which indicated the resident's cognition was severely impaired. Review of the facility's document titled Precautions, undated, revealed it listed all residents in isolation and was given to the SSA Surveyor by the Infection Preventionist (IP). Further review revealed R3 was placed in Enhanced Barrier Precautions (EBP) on 01/26/2026 for an indwelling device. Observation on 02/18/2026 at 11:30 AM revealed Registered Nurse (RN) 1 entered the resident's room and donned (put on) PPE of a gown and gloves. RN1 performed a fingerstick on R3 to obtain a drop of blood for glucose testing. RN1 exited the resident's room at 11:39 AM holding the glucometer (used to obtain the blood glucose results after insertion of the glucose strip with the drop of blood on it) in an ungloved hand and cleaned the glucometer with a Sani-Wipe, without donning gloves. Additional observation revealed once the glucometer was cleaned and disinfected, RN1 placed the glucometer on a barrier of a paper towel on top of the dressing cart but did not practice hand hygiene. Observation revealed R3's room had a red laminated door sign which indicated Enhanced Barrier Precautions (EBP). The signage stated this isolation required the use of a gown, gloves, mask, and eye protection if there was a risk of fluids/drainage when providing care. The signage also stated to remember to wash hands before and after contact with the resident. During an interview with RN1 on 02/19/2026 at 9:55 AM, she stated she had received infection control training and received in-services periodically. She stated R3 was admitted with pressure wounds, developed one to the sacral area, and was in isolation. When asked about her technique used to clean the glucometer, she stated each resident had their own glucometer, and it was cleaned with Sani-Wipes after each use. When asked if she should have worn gloves while cleaning the glucometer, she stated, Yes. She stated the reason was the glucometer could potentially have blood on it. She stated gloves would prevent the spread of infection to staff or other residents and also would protect herself from the chemicals in the wipe. She stated she knew better and was not thinking. She stated, at times, she cleaned her hands with the wipe but should be wearing gloves and practicing hand hygiene after removing gloves.6. Review of R17's Face Sheet revealed the facility admitted the resident on 05/31/2025 with diagnoses to include high blood pressure, chronic kidney disease, and neoplasm of prostate.Review of the facility's document titled Precautions, undated and given to the SSA Surveyor by the IP, revealed R17 was placed on droplet precautions for Influenza A on 02/15/2026.Observation on 02/18/2026 at 2:15 PM revealed the room where R17 resided had a red stop sign indicating Droplet Precautions on the door, and the door was open. Further observation revealed House Keeping (HK) 1 in the room wearing a blue medical mask, gown, and gloves. However, HK1 was not wearing a face shield or eye protection. Additional observation revealed the bin by the door had PPE supplies of gowns and gloves. However, it did not contain surgical masks or face shields/eye protection. Prior to exiting the room, HK1 removed the gown and gloves but did not remove the mask.During an immediate interview with HK1, she stated staff was taught to change the face mask two to three times daily. She stated she did not change the mask after exiting each room. She stated she only changed the mask when they got moist, which was usually two to three times daily.Additional observation on 02/18/2026 at 2:20 PM revealed State Registered Nurse Aide (SRNA) 9 entered R17's room and wore PPE of a gown, gloves, and a blue medical mask. However, no face shield or eye protection was donned. Further observation revealed prior to exiting the resident's room, SRNA9 removed all PPE but failed to remove the mask before she walked up the hallway to the shower room.During an interview with SRNA9 on 02/18/2026 at 2:25 PM, she stated she had worked at the facility for about six months and had received infection control training. When asked if she had received training on types of isolation, she stated, Yes. When asked what PPE should be worn if the resident was on Droplet Precautions, she stated gloves, a gown, a face shield, and a surgical mask. She stated all PPE should be removed inside the room after providing care, and hand hygiene should be performed before and after care. When asked why it was important to wear proper PPE, she stated to protect residents and staff from germs. She stated it was important to remove PPE before leaving the isolation room, so germs did not get spread around. During an interview with the facility's Infection Preventionist (IP) on 02/19/2026 at 10:35 AM, she stated her tasks included tracking infections, antibiotic surveillance, and training staff of all departments on infection control. When asked how she presented the training, she stated it depended but mostly verbal with handouts. She stated she performed quizzes to check retention of information given in trainings. She stated staff was trained in isolation procedures including donning and doffing (removing) PPE. When asked what PPE staff was trained to wear entering a Droplet Isolation room, she stated they should be wearing all PPE, including eye protection such as a face shield. She stated she also believed glasses were available too. She stated the facility did not have any problems obtaining PPE. She stated staff should be removing PPE prior to exiting the rooms so germs were not taken to the hallway. She stated if PPE was not removed prior to exiting, there was a chance residents and staff would be exposed to germs which would place them at risk. She stated each resident had their own glucometer, and staff should be wearing gloves when cleaning them to reduce exposure and cross contamination. She stated blood pressure cuffs should be cleaned and disinfected with Sani-Wipes, and the Sani-Wipes were in individual packets kept on the medication cart. She stated there was no policy for not keeping the wipes on the medication cart. She stated staff should be following door signage for isolation, and if they were not, she would be concerned infection could be spread. When asked if it was a requirement for isolation room doors to be closed, she stated in the perfect world yes, but it was a safety issue for residents who had dementia or were fall risks. During an interview with facility's Director of Nursing (DON) on 02/19/2026 at 3:00 PM, she stated she had been the DON for approximately a year and oversaw clinical operations as well as the nurses. She stated she did not help with any of the training. She stated she expected staff to follow the trainings given to protect residents and staff from any Multi-Drug-Resistant Organisms (MDRO), outside infections, and spreading infections. She stated she expected staff to properly don and doff PPE as trained and as the isolation room signage guided them. The DON stated isolation signage for rooms was important since it let staff know what PPE to wear. She stated she would be concerned if staff was not donning PPE prior to entering and removing PPE when exiting rooms, since that could spread infection. She stated staff should properly clean equipment after usage to prevent contamination to themselves and residents and that included donning gloves when disinfecting equipment.During an interview with the Administrator on 02/19/2026 at 3:33 PM, he stated he provided oversite of the entire operation. He stated his expectations of staff were to follow policy and procedures to prevent infections spreading from one team member to another or to residents. He stated staff should follow their training, and if personal protective equipment (PPE) was required, they should be wearing the PPE that was required each time they went into that resident's room. He stated it was the residents' right to be protected from cross contamination and other infections they might not have.

Based on review of the facility's document and interview, the facility failed to ensure its binding arbitration agreement contained appropriate verbiage granting residents the right to rescind the agreement within 30 days of signing it. This deficient practice had the potential to affect 56 of the facility's current census of 76 residents.Review of a facility provided list of residents who had signed binding arbitration agreements revealed 56 residents had signed binding arbitration agreements. Review of the facility's document Agreement to Resolve Disputes by Mediation and Binding Arbitration, not dated, did not include the explicit verbiage granting residents or representatives the right to rescind the agreement within 30 calendar days of signing it.In an interview with the Admissions/Marketing Director (A/M) on 02/18/2026 at 8:43 AM, she stated she had been in that role with the facility for approximately one year, although she had been in the Admissions/Marketing role for 20 years. She stated the binding arbitration agreement had been in use when she took the A/M position. She stated she did inform residents or representatives of their right to rescind the agreement within 30 days of signing it. However, she stated she was not aware it was required to be documented on the form/document prior to the State Survey Agency (SSA) Surveyor reviewing the regulation with her. In an interview on 02/19/2026 at 10:02 AM with the Administrator, he stated the facility's binding arbitration agreement pre-dated the regulatory requirements, and he was unaware the required verbiage was not on the form. He stated, although not documented, his expectation would be residents would have the opportunity to rescind their binding arbitration agreement within the first 30 days after signing.

Based on observation and interview, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple occupancy rooms. Observation of eight dual-occupancy rooms (two residents per room) for Rooms 127, 128, 129, 130, 132, 133, 135 and 138, revealed each room measured less than the required square footage, with rooms measuring anywhere from approximately 17 square feet short (Rooms 127, 128, 129, 130) to approximately 26 square feet short (room [ROOM NUMBER]). The findings include:Observation with the Maintenance Director (MD) and the Maintenance Assistant (MA) on 02/18/2026 at 3:00 PM revealed Rooms 127, 128, 129, and 130 had the same layout, and measured 142.79 square feet in diameter, 17.21 square feet below the required 160 square feet for a dual occupancy room, or 80 square feet per resident. Observation of room [ROOM NUMBER] with the MD and the MA on 02/18/2026 at 3:04 PM revealed the room to measure 133.92 square feet, 26.08 square feet below the requirement for a dual occupancy room.Observation of room [ROOM NUMBER] with the MD and the MA on 02/18/2026 at 3:04 PM revealed the room to measure 135.86 square feet, 24.14 square feet below the requirement for a dual occupancy room. Observation of room [ROOM NUMBER] with the MD and the MA on 02/18/2026 at 3:05 PM revealed the room to measure 141.94 square feet,18.06 square feet below the requirement for a dual occupancy room. Observation of room [ROOM NUMBER] with the MD and the MA on 02/18/2026 at 3:05 PM revealed the room to measure 134.93 square feet, 25.07 square feet below the requirement for a dual occupancy room. In an interview on 02/19/2026 at 9:57 AM with the Administrator, he stated there had been a waiver years ago for the rooms in question. He stated when he had been at the facility previously, he had an architect look into adding additional rooms with the intent of changing rooms with less than the required footage to private rooms, as he did not want to give up needed licensed beds. He stated this was something he would like to do in the future, but currently, the facility was not in a financial situation to enable him to do this.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 15 residents sampled. The resident preferred to remain anonymous.Interview with 1 of 15 sampled residents who wished to remain anonymous stated their room was too small.Refer to F912The findings include:Review of facility's policy titled, Resident Rights, no date given, revealed the facility must protect and promote the rights of each resident to ensure a dignified existence and self-determination; and the resident had a right to be treated with dignity and respect. Further review revealed the resident rights included to retain and use personal possessions including furnishings and clothing as long as it did not infringe upon the rights, health, or safety of other residents. Review of the anonymous resident's Face Sheet revealed the facility admitted the resident in July 2025. Further review of the anonymous resident's record revealed the room the resident was residing in was the same room the resident was assigned when admitted . Review of the anonymous resident's latest quarterly Minimum Data Set [MDS], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Observation on 02/17/2026 at 9:34 AM revealed the anonymous resident's room appeared smaller than other rooms observed by the State Survey Agency (SSA) Surveyor, and the resident's personal items were stacked on top of each other.During an interview at the time of the observation on 02/17/2026 at 9:34 AM with the anonymous resident who resided in a semi-private room, she stated she had asked for a bigger or a private room. She stated she was told by the Administrator she would never have a private room or a bigger room. She stated, I feel like I am living in a box. When asked if she had enough space to store her personal belongings, she stated not really, and she had a lot of items at home and understood she could not bring all. Observation of the anonymous resident's room by the SSA Surveyor, with the Maintenance Director and the Maintenance Assistant, on 02/18/2026 at approximately 3:00 PM revealed the room was over 24 square feet below the requirement for a dual occupancy room.During an interview with the Administrator on 02/19/2026 at 3:33 PM, he stated he provided oversite of the entire operation. When asked if resident rights were violated if they resided in a room that was smaller than regulatory requirements, he stated room sizes had never impacted the health and care of residents and had never been raised as an issue. He stated the problem was identified on the form the survey team had him complete, and the facility had a waiver on the beds. When asked if he had a process to remedy the issue, he stated he had not had time to talk to anyone, but he would. When asked if any resident had ever complained about the size of rooms, he stated the only thing they complained about was incompatibility of roommates. He stated staff tried to accommodate residents and make changes if possible.

Based on observation, interview, record review, and review of the facility's documentation and policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the total census of 74 residents. During the Abbreviated/Partial Extended Survey that concluded on 04/05/2024, Immediate Jeopardy was identified in the area of F880 (Infection Control), with the highest scope and severity (S/S) of an L. The facility alleged substantial compliance on 05/20/2024, however; failed to maintain substantial compliance. Legionella pneumophila SG1 and Legionella pneumophila SG2-15 were identified at uncontrolled growth levels in the Unit 3 shower on 05/28/2024. Review of the state's Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed DEHP made recommendations to mitigate outbreaks of occurrences of legionellosis. On 08/05/2024, the Administrator, Director of Nursing (DON) and the Infection Preventionist (IP) received an email from the Local Health Department (LHD), which communicated the DEHP's recommendation to mitigate the outbreak of Legionnaire's disease (LD). The facility failed to ensure the recommendations were implemented as communicated by the LHD, to prevent and control legionellosis. Additionally, the facility failed to maintain an infection control prevention and control program to provide a safe, sanitary and comfortable environment as evidenced by staff observed providing care without sanitizing hands, adhering to the Enhanced Barrier Precautions protocol, failure to label and properly store feeding tubes, and in handling clean laundry. Immediate Jeopardy (IJ) was identified on 10/11/2024 and was determined to exist on 08/05/2024, in the area of 42 CFR 483.80 Infection Control, F-880 at a Scope and Severity (S/S) of an L. The facility's Administrator was notified of the IJ on 10/11/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 10/22/2024, alleging removal of the IJ on 10/22/2024. The State Survey Agency (SSA) determined the IJ had been removed on 10/22/2024, as alleged, prior to exit on 11/22/2024, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The facility implemented the following: The findings include: Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), undated, revealed its purpose was for the facility to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Per policy review, the IPCP was to address facility-specific infection control needs. Continued review revealed the IPCP was a facility wide effort involving all disciplines and was an integral part of the (facility's) Quality Assurance and Performance Improvement (QAPI) program. Further review revealed the IPCP provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors. 1. Review of the facility's policy titled, Legionella Water Management Plan (WMP), undated, revealed the facility was to promote proactive steps to establish a healthy environment for residents, staff, and visitors. Per review of the Plan, contraction of Legionnaire's disease (LD) was often the result of exposure to inadequately managed building water systems, which could be prevented. Continued review revealed the facility's mission was to properly manage its water system to prevent exposure to LD. Policy review revealed the facility was to maintain documentation of its WMP in maintenance logs. According to policy review, if water quality did not meet appropriate parameters, further investigation was to take place, a plan of correction developed and implemented, and the results presented to the Quality Assurance and Performance Improvement (QAPI) Committee. Further review revealed hot water temperatures in resident areas, tubs, showers, full immersion wash stations, water heaters, and holding tanks was to be tested every week. Additionally, policy review revealed weekly sampling points for residents' rooms was to be rotated so all sinks were tested at least annually. Review of the policy further revealed if water quality was not within appropriate parameters, further investigation was to occur, a plan of correction developed and implemented if appropriate. Review of the Centers for Disease Control and Prevention's (CDC) Guideline, Developing a Legionella Water Management Program, updated 03/15/2024, revealed hot and cold water was to be flushed through all points of use (e.g., showers, sink faucets). Continued review of the Guideline revealed flushing was to continue until the hot water reached its maximum temperature. Per review, where possible, hot water at the tap was to reach at or above 120 degrees ( ) Fahrenheit (F), unless anti-scalding controls and devices had limited the maximum temperature at the point of use. Further review revealed the method, temperature, and duration of flushing was to be recorded daily in a log book. Review of the American Society of Heating and Air-Conditioning Engineers (ASHAE) Guideline, Managing the Risk of Legionellosis Associated with Building Water Systems, dated 12/2023, revealed flushing involved opening taps and letting the water run. According to the ASHAE Guideline, flushing standards, staff needed to flush the sinks and fixtures for at least three minutes daily with hot and cold water, and cold water was to be flushed before hot water. Continued review revealed to flush cold and hot water at all water points of use (faucets, showers, toilets, drinking fountains, and water using devices such as eye wash stations). Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 05/28/2024, revealed the sample result from the facility's Unit 3 shower, showed a positive result for Legionella pneumophila Serogroup 1 (SG1)Strain. Per review, the positive result was at 11.0 colony-forming unit per milliliter (CFU/ml) with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Continued review of the report for the Unit 3 shower showed Legionella pneumophila Serogroup 2 Strain (SG2-15) at 11.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Review of a written communication sent via the facility's internal Calling Post messaging system to residents and staff, dated 06/05/2024, revealed the facility notified its residents and staff about detected legionella in its water supply. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 06/14/2024, revealed testing for Unit 1 and Unit 2 showers. The sample result from the Unit 1 shower showed a positive result for legionella pneumophila SG1 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and legionella non-pneumophila at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. The sample result from the Unit 2 shower showed a positive result for legionella pneumophila SG1 at 0.8 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and legionella non-pneumophila at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 08/07/2024, revealed testing for room [ROOM NUMBER]. The sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 08/29/2024, revealed testing for room [ROOM NUMBER] and the Unit 2 shower. The sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Additionally, the report for the Unit 2 shower showed legionella pneumophila SG1 at 0.5 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 09/04/2024, revealed testing for the Unit 2 shower. The sample result from the shower showed a positive result for legionella pneumophila SG1 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 09/13/2024, revealed testing for room [ROOM NUMBER], the Unit 2 shower, and Physical Therapy (PT) sink. The sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Unit 2 shower showed legionella non-pneumophila 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Additionally, the report for the PT sink showed legionella pneumophila SG2-15 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Review of the microbiology analysis report, performed by a third party independent water systems company to test for legionella, dated 09/18/2024, revealed testing for room [ROOM NUMBER] and the Unit 2 shower. The sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Additionally, the report for the Unit 2 shower showed legionella non-pneumophila SG1 at 0.4 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Review of a written communication sent via the facility's internal Calling Post messaging system to residents and staff regarding updates of additional testing, revealed no documented evidence to support the facility notified residents and staff of detectable levels of legionella in its water supply detected on 06/14/2024, 08/07/2024, 08/29/2024, 09/04/2024, 09/13/2024, and 09/18/2024. Review of the Division of Epidemiology and Health Planning's (DEHP), Findings and Recommendations, dated 07/26/2024, revealed concerns identified by the state's Legionella Team and the Regional Epidemiologist were as follows: A.) The facility failed to document all the necessary elements of a proper WMP. The DEHP noted the facility's score on the WMP assessment was one out of nine (1/9), noting healthcare facilities should achieve a score of eight or higher (8/9). B.) Water sampling had been insufficient to evaluate the growth reservoir in the building's water system. C.) There were no documented logs to confirm the flushing procedures. Per further review of the report, the DEHP recommended the following steps to prevent future outbreaks or occurrences of legionellosis: A.) Remind healthcare providers to include legionellosis in their differential diagnoses. B.) Continue enhanced surveillance for new cases of legionellosis and review residents' charts daily for potential radiographs, lab tests, or diagnoses related to possible or atypical pneumonia. C.) Complete the Water Infection Control Risk Assessment (WICRA) before developing a WMP. D.) Create a WMP that incorporated the recommendations from the CDC. E.) Validate the plumbing diagram with greater detail according to the CDC guidelines and document the recirculation system. F.) Ensure all Water Management Team (WMT) members completed the CDC Prevent LD training module. G.) The third-party contractor was to familiarize themselves with legionella sampling protocols by completing the CDC's Prevent LD training module. H.) Submit sampling plans to the local health department before conducting any additional sampling. Review of an email, dated 08/05/2024, from the Public Health Director at the LHD to the facility's Administrator, DON, and IP, revealed the LHD attached the findings from the DEHP's Legionellosis Full Investigation Preliminary Findings, dated 07/26/2024. The Director requested that the recipients review the attachment and contact her with any questions. Review of a letter dated 08/20/2024, addressed to the facility's providers from the Infection Preventionist (IP) revealed the facility's water system had shown detectable levels of legionella. Per review, the letter recommended facility providers obtain a urine antigen test for legionella, along with a chest radiograph, whenever a suspected case of pneumonia or pneumonia-like illness was identified. Further review revealed the letter was sent out 15 days after the facility received the DEHP's recommendations and not immediately after receival of the recommendations on 08/05/2024. Review of the facility's Certificates of Training for the CDC's Prevent Legionnaires' Disease course revealed only five of the eight members of its Water Management Team (WMT) had certificates of completion. Per review, the five members who completed the course included the Director of Nursing (DON), Infection Preventionist (IP), Dietary Manager (DM), Quality Assurance (QA) Nurse, and the Certified Legionella Water Safety Expert (CLWSE) had certificates of completion. The Administrator, Director of Maintenance (DOM), Housekeeping Director (HSKD), and third-party contractor had not completed the recommended training. The facility did not provide documentation logs of daily water flushes for the showers in Units 1, 2, and 3. Furthermore, there was no documentation of daily flushes in empty rooms. There was no documentation of the method and duration of flushing. Observation on 10/03/2024 at 9:50 AM, of resident rooms in Units 1, 2, and 3 revealed that none of the residents had bottled water in their rooms. Units 1 and 2 did not have any gallon jugs of spring water available for use, while Unit 3 had only one gallon jug located in the nurse's station. Additionally, there were no individual bottles of water found in the nourishment refrigerators. Continued observation of Unit 1, 2, and 3 showers revealed [NAME] filters had been placed on the showers. During interview with Family 1 (F1) on 10/03/2024 at 10:32 AM, he stated that there had been ongoing water contamination at the facility for at least four weeks. He stated he was not notified of the water situation and only found out after asking the Administrator about it directly. He stated that the Administrator informed him legionella bacteria was detected in Unit 2's shower during a test. He stated that he purchased water for R1, so she had clean water to wash her hands and face and use it to brush her teeth, as the facility only provided water for drinking. During telephone interview with Family (F)6 on 11/15/2024 at 2:45 PM, she stated she was informed about something in the water several months earlier during a conversation with a nurse on the evening shift. F6 reported when she inquired about what steps the facility had taken to address the issue, the nurse told her it was not the facility's fault. She said the nurse told her the local water department was responsible for remediation of the water issue; however, when she contacted the local water department, they informed her the issue was indeed within the facility. In continued interview on 11/15/2024 at 2:45 PM, F6 reported the first time the facility had been somewhat transparent about the issues related to legionella had been approximately six weeks ago when she saw a notice related to legionella posted inside the elevator. During the interview, F6 described the Administrator as evasive when she asked questions, and he claimed that the facility was following all recommendations from the local health department. She further stated the Administrator told her the water was safe to drink and there were no risks to residents, staff, or visitors. During interview with State Registered Nurse Aide (SRNA) 3, on 10/03/2024 at 11:25 AM, she stated the facility had provided water for drinking and medication passes which were water jugs brought to the floor by staff and/or maintenance. The SRNA stated at no time had the facility's administration provided bottled water for distribution to the residents to use for their daily hand hygiene, or oral care. She reported staff were using the water from the sinks to perform hand hygiene, and residents could use water from the faucets in their rooms for bed baths, washing their hands, and oral care. During interview with SRNA 1 on 10/03/2024 at 11:45 AM, she stated there were no gallon jugs of spring water available on the floor that morning, so staff members just passed ice to residents. She expressed concerns about the facility's water quality. She said staff had been providing bed baths for residents, but the residents continued to use the sink faucets in their rooms for hand hygiene, washing their faces, and oral care. The SRNA reported staff were also using the water from the sinks for their own hand hygiene. She stated the administration had not provided individual bottled water for residents for daily hand hygiene or oral care, but had provided water for drinking and for medication administration. SRNA 1 said she had received education on the IPCP, and the risks associated with legionella. She stated people could become infected with Legionella when they inhaled microscopic water droplets containing the bacteria, which could be present in the spray from a shower or faucet. During interview with SRNA 5 on 10/03/2024 at 11:49 AM, she stated the facility provided water for drinking and medication passes; however, residents and staff used water from the faucets for bed baths, washing hands, and oral care. SRNA 5 said she had been educated on the IPCP. She further stated legionella was contracted when microscopic water droplets containing legionella bacteria were inhaled. During interview with Kentucky Medication Aide (KMA) 1 on 10/03/2024 at 11:10 AM, she stated the facility supplied water for drinking and medication passes. Per interview, she stated staff could use water from the faucets in resident rooms to provide bed baths, washing hands, and oral care. The KMA also stated she had received education on the IPCPs and Legionella. During interview with Licensed Practical Nurse (LPN) 1 on 10/03/2024, at 10:15 AM, she stated the facility used spring water from gallon jugs for both hydration and medication administration. She reported the water jugs were delivered to the facility or obtained by staff from the kitchen. LPN 1 said residents and staff were also allowed to use water from the faucets for performing/providing activities of daily living (ADLs), such as bed baths, handwashing, and oral care. She further stated she had received education from the IP on IPCPs and Legionella. During an interview with Registered Nurse (RN) 1 (an agency nurse) on 10/03/2024 at 11:35 AM, he stated he believed the facility provided water for drinking and medication passes but stated the KMA's and SRNA's were responsible for those tasks. RN 1 stated residents could use water from the faucets in their rooms for bed baths, handwashing, and oral care. He said he could not remember whether he had received education related to the IPCP and Legionnaire's Disease. RN 1 indicated he was unable to explain how residents and staff might become infected with legionella bacteria. Review of the facility document titled, Housekeeping Helpers Schedule revealed weekly duties included Run hot water for about 5 minutes in sink and tub. Further review revealed however, no documented instructions on flushing the shower head or cold water faucets. During interview with Housekeeping Aide (HA) 1 on 10/09/2024 at 1:18 PM, she stated she flushed the water lines in Rooms 120 through room [ROOM NUMBER] every Monday and documented the completed task on her housekeeping sheet. When asked by the SSA surveyor who instructed her to flush water lines, she stated the Housekeeping Director (HSKD). HA 1 stated when she performed a water line flush, she turned on the hot water in the sink, shower, and tub and ran the water for five minutes. She further stated however, she did not check the temperature of the water. During interview with HA 2 on 10/09/2024 at 1:22 PM, she stated she flushed the water lines in rooms 130 through 140 every Wednesday and documented the completed task on her housekeeping sheet. When asked by the SSA Surveyor who instructed her to flush water lines, she stated the HSKD. HA 2 stated when she performed a water line flush, she turned on the hot and cold water in the sink, shower, and tub and ran the water for fifteen minutes. The HA further stated however, she did not check the temperature of the water. During interview with the HA 3 on 10/09/2024 at 1:29 PM, she stated she flushed the water lines while cleaning her rooms every Monday. She stated she was responsible for rooms 241 through 256, and she said she documented the completed task on her housekeeping sheet. When asked by the SSA Surveyor who instructed her to flush water lines, she stated the HSKD. HA 3 stated when she performed a water line flush, she turned on the hot water in the sink and tub and ran it for awhile. She further stated she did not run the cold water and did not run water through the showerhead. HA 3 further stated she did not check the temperature of the water. During interview with the HSKD on 10/09/2024 at 10:49 AM, she stated housekeeping staff went from room to room once a week and ran the water for five minutes in the showers, the bath, and the sink. When asked by SSA Surveyor who instructed her on how to flush water lines, she stated, No one. She stated her staff documented their weekly flushing on their Housekeeping Helpers Schedule sheets. The HSKD reported however, she had not kept a log of all the weekly flushing to include the locations, temperature, or duration. She further stated she had not received the CDC training on preventing LD. During interview with the Maintenance Assistant (MA) on 10/09/2024 at 2:20 PM, he stated he flushed the water lines in all vacant rooms daily. He stated he had been performing that task since February 2023, but had not kept detailed logs or documentation. When asked by the SSA Surveyor who instructed him on how to flush water lines, the MA stated the DOM. The MA reported when performing a water line flush, he first flushed the commode, then turned on the hot and cold water simultaneously in the sink and the tub and ran the water for 20 minutes. He stated he did not run the water through the shower head, and did not check the temperature of the water. Review of an email to the Director of Maintenance (DOM) from the IWSC on 10/02/2024 at 9:46 AM, revealed the email included recommendations from the CLWSE. Per review, the CLWSE made the following recommendations: continue weekly testing for legionella; and maintain and replace all point-of-use ([NAME]) filters as specified by the manufacturer, including routine checks to ensure they were functioning correctly. Additionally, review revealed the recommendations noted while the recommendations were based on industry standards and best practice it remained the facility's responsibility to assess implement and manage the risk associated with legionella. During interview with the Director of Maintenance (DOM) on 10/04/2024 at 10:50 AM, he stated the facility's WMT had participated in online meetings with the Local Health Department (LHD), State Public Health Department (KDPH), IWSC, and CLWSE to discuss ongoing positive legionella results. The DOM stated the CLWSE had conducted an onsite visit and he had just received his (CLWSE's) recommendations, but had not yet reviewed them. He stated that housekeeping had been flushing unused water sources such as faucets in empty rooms and unused tubs, showers, and sinks on a weekly basis. The DOM stated since April 2024, maintenance had been flushing faucets in empty rooms and dead-end water sources daily. He reported however, there was no documented evidence of the daily flushing being performed. The DOM said the facility had not yet acted on the DEHP's recommendations because they were awaiting action from the CLWSE. He stated during an online meeting with the LHD and KDPH, the DON said the CLWSE had informed the team he was capable of writing a WMP for the facility and would take care of doing that. During an additional interview with the DOM on 10/09/2024 at 1:33 PM, he stated he had not received formal training on how to properly flush water lines. He stated he instructed his Maintenance Assistant (MA) to open both the hot and cold water lines in the tub and sink faucets and run the water for 20 minutes. The DOM stated he had not instructed the MA to run the water through the shower wands as he stated he didn't know if he was supposed to do that or not. He further stated no external water hoses were currently being used, but he did not perform a flush on those. During an additional interview with the DOM on 11/20/2024 at 10:45 AM, he said the facility has expanded their water testing. The DOM said the recent testing which began on 10/10/2024, had shown increased levels of legionella SG1 and non-pneumophila throughout the building. He said it had been found in the rooms where residents resided. The DOM reported the sinks in the Activity Room tested positive. He stated based on the results, dated 10/31/2024, the CLWSE recommended a whole facility monochloramine treatment. The DOM stated however, the facility had yet to do the recommended whole building monochloride treatment despite continued positive testing. In continued interview on 11/20/2024 at 10:45 AM, the DOM stated the monochloride treatment had been delayed due to broken water valves. He stated the water softener had a water feed valve, a bypass valve, and a discharge valve. The DOM reported the bypass valve was broken in the closed position, and the discharge valve was broken in the open position. He said in order to do the monochloramine treatment, the softener must be bypassed to ensure the monochloramine was not diluted, which meant the valve could not be opened to do that. During telephone interview with the IWSC on 10/11/2024 at 9:58 AM, he stated he had provided third-party water testing and treatment services for the facility. The IWSC said his company provided the facility with legionella testing, which included assessing the cooling tower, water heaters, and other areas of concern. He reported his main focus concerns had been on the shower units and room [ROOM NUMBER], which was currently vacant. The IWSC stated they had performed two system-wide disinfection procedures in the facility, with the most recent one conducted was on 06/25/2024. The IWSC stated however, despite their efforts, tests at point-of-use shower heads and the faucet in room [ROOM NUMBER] continued to show the growth of legionella pneumophila. In continued interview on 10/11/2024 at 9:58 AM, the IWSC said he participated in online meetings with representatives from the facility, the LHD, the KDPH, and the DEHP. He stated during those meetings, which had taken place since legionella pneumophilia was discovered in the facility in early 2023, the EOCPM advised the facility to employ a CLWSE's services and follow the recommendations from both the DEHP and CLWSE. The IWSC said he consulted with a CLWSE, who did an onsite visit and assessment of the facility in September 2024. He stated the CLWSE recommended continued flushing and the installation of medical-grade filters. The IWSC reported the facility was not in a contractual relationship with the CLWSE at that time. He confirmed in the interview, it was not until 10/04/2024, that he received a signed contract from the facility to hire the CLWSE to develop a water management program and purchase a water management software program. The IWSC stated the CLWSE sent recommendations to the facility on [DATE], which stated it was the facility's responsibility to make decisions based on their due diligence. During a telephone interview with the CLWSE on 10/04/2024 at 2:42 PM, he stated the IWSC had consulted with him to diagnose and evaluate the facility's water system, water management plan, current control measures, and to determine if the facility needed additional control measures or a supplemental disinfection system. He stated he assessed the building and its water system, and reviewed the remediation efforts that had been carried out since legionella was discovered in February 2024. The CLWSE said the IWSC performed weekly legionella testing, and it was his understanding the facility randomly tested water temperatures and flushed its water system. He stated the facility had installed [NAME] filters on three ice machines and all four shower heads, but per his assessment, the facility had no other control measures in place. In continued telephone interview on 10/04/2024 at 2:42 PM, the CLWSE stated that although there was no known safe concentration of legionella bacteria, the CDC had provided guidance on the concentration of legionella test results. He said any detection of bacteria up to 0.9 CFUs/mL indicated that the legionella growth appeared well-controlled. The CLWSE reported the facility must conduct a more comprehensive sampling for legionella testing to maintain ongoing protection. He stated the [NAME] filters and other water management strategies provided adequate protection if the legionella results remained non-detectable or at low levels. The CLWSE stated however, if CFUs/mL increased, remediation was necessary. He said it was important the facility ensured all the [NAME] filters were installed, maintained, and replaced according to the manufacturer's instructions. Per the CLWSE in interview, if the [NAME] filters were not appropriately managed, including regular replacement as specified by the manufacturer and routinely checked to ensure they functioned correctly, the [NAME] filters could lose their effectiveness over time. In additional telephone interview on 10/04/2024 at 2:42 PM, the CLWSE stated the facility did not develop a decision-making tree to provide clear instructions on the actions to take based on the testing parameters. He said since September 2024, he had repeatedly informed the facility that while he provided recommendations based on industry standards and best practices, it was ultimately their responsibility to assess, implement, and manage the risks associated with legionella. During an additional telephone interview on 10/09/2023 at 9:38 AM, the CLWSE explained the IWSC initially contacted him to consult on the water contamination issues at the facility. He said he participated in a call with the KDPH's Environmental and Occupational Countermeasures Program Manager (EOCPM) to discuss ongoing contamination problems. The CLWSE stated during that call it was expressed the facility needed to hire a CLWSE to inspect, assess, and help develop a WMP in accordance with CDC guidelines and industry standards. He reported he had not had a con [TRUNCATED]

Based on interview, record review, review of the facility's plan of correction from the 04/05/2024 survey, and review of the facility's policy, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility was cited for infection control related to legionellosis and their water management system during the 04/05/2024 survey, and the facility submitted a plan of correction to address the deficiency. However, the facility failed to follow the plan of correction to complete a Water Infection Control Risk Assessment (WICRA) and develop a Water Management Plan (WMP). On 05/28/2024, Legionella pneumophila SG1 (the most serious and most likely to cause Legionnaires' disease in people who are exposed to it) and Legionella pneumophila SG2-15 (less dangerous forms of Legionella bacteria compared to serogroup 1) were identified at uncontrolled growth levels in the Unit 3 shower. Therefore, the facility stopped allowing showers for all residents. The facility received recommendations from the Division of Epidemiology and Health Planning's (DEHP) on 08/05/2024; however, the facility did not implement the recommendations to mitigate the spread of legionellosis. Immediate Jeopardy (IJ) was identified on 10/11/2024 and was determined to exist on 08/05/2024, in the area of 42 CFR 483.75 Quality Assurance and Performance Improvement, F-867 at a Scope and Severity (S/S) of an L. The facility was notified of the IJ on 10/11/2024. The facility provided an acceptable IJ Removal Plan, on 10/22/2024, alleging removal of the IJ on 10/22/2024. The State Survey Agency (SSA) determined the IJ had been removed on 10/22/2024, prior to exit on 11/22/2024, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F835, F837, and F880 The findings include: Review of the facility's policy titled, Quality Assessment and Assurance, undated, revealed the program was designed to systematically monitor and evaluate the quality and appropriateness of resident care provided in the facility. Per the policy, the Director of Nursing Services (DON) was responsible for the establishment and maintenance of the program. Through committee review, the program committee would facilitate efficient operation of the facility and monitor infection control. In addition, the program committee would develop appropriate plans of action to correct identified and confirmed quality concerns and implement those plans of action. Continued review revealed the program committee would identify and prioritize issues, with clear expectations established regarding resident safety, quality, and rights. Review of the Plan of Correction (POC) to address the water deficiency cited for the Abbreviated Survey with an exit date of 04/05/2024, and a completion date of 05/20/2024, revealed: 1) the QAPI Committee had been working with the local health department (LHD) and state infection prevention team to develop a water maintenance plan (WMP) and ensure the facility's water maintenance policy was followed and would meet monthly to review compliance, to adjust as deemed necessary to maintain compliance; and 2) the QAPI Committee would assess and modify the action plan as needed to ensure continued compliance. Review of the microbiology analysis report, performed by a third party independent water system company (IWSC) to test for legionella, dated 05/28/2024, revealed the sample result from the facility's Unit 3 shower, showed a positive result for Legionella pneumophila Serogroup 1 Strain (SG1). Per review the positive result was at 11.0 colony-forming unit per milliliter (CFU/ml) with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Continued review of the report for the Unit 3 shower showed Legionella pneumophila Serogroup 2 Strain (SG2-15) at 11.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 06/14/2024, revealed testing for Unit 1 and Unit 2 showers. Per review, the sample result from the Unit 1 shower showed a positive result for Legionella pneumophila SG1 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and Legionella non-pneumophila at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Continued review revealed the sample result from the Unit 2 shower showed a positive result for Legionella pneumophila SG1 at 0.8 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and Legionella non-pneumophila at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the facility's QAPI Agenda, dated 06/29/2024, attended by the Quality Assurance (QA) Nurse, Infection Preventionist (IP), Director of Nursing (DON), Housekeeping Director (HSKD), Dietary Manager (DM), Administrator, Activities Director (AD), Human Resources Director (HR), and the Director of Maintenance (DOM), revealed the agenda had the WMP, the Water Policy, and the WICRA listed under Other Business. There was no documentation supporting the development or implementation of a plan of correction by QAPI when the facility's water quality did not meet appropriate parameters according to third-party testing results. Review of the facility's QAPI Agenda, dated 07/25/2024, attended by the QA Nurse, HSKD, DOM, Rehabilitation Services Manager (RSM), IP, Minimum Data Set (MDS) Nurse, DM, HR, Social Services (SSW), Pharmacist (RPh), Medical Director, and the Administrator revealed the agenda listed WMP, the Water Policy, and the WICRA listed under Other Business. There was no documentation supporting the development or implementation of a plan of correction by QAPI when the facility's water quality did not meet appropriate parameters according to third-party testing results. Review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed several concerns identified by the state's Legionella Team and the Regional Epidemiologist. These concerns included the following: 1) the facility failed to document all the necessary elements of a proper WMP as evidenced by the facility's unacceptable score on the WMP assessment of one out of nine (acceptable score was eight or higher); 2) water sampling had been insufficient to evaluate the growth reservoir in the building's water system; and 3) there were no documented logs to confirm the flushing procedures. Further review of the DEHP's Findings and Recommendations, dated 07/26/2024, revealed the DEHP recommended steps to prevent future outbreaks or occurrences of legionellosis. These steps included the following: 1) remind healthcare providers to include legionellosis in their differential diagnoses; 2) continue enhanced surveillance for new cases of legionellosis and review resident charts daily for potential radiographs, lab tests, or diagnoses related to possible or atypical pneumonia; 3) complete the Water Infection Control Risk Assessment (WICRA) before developing a WMP; 4) create a WMP that incorporated recommendations from the Centers for Disease Control and Prevention (CDC); 5) validate the plumbing diagram with greater detail according to CDC guidelines and document the recirculation system; 6) ensure that all water management team (WMT) members completed the CDC Prevent [Legionnaires' Disease] LD training module; 7) the third-party contractor should familiarize themselves with legionella sampling protocols by completing the CDC's Prevent LD training module; and 8) submit sampling plans to the local health department (LHD) before conducting any additional sampling. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 08/07/2024, revealed testing for room [ROOM NUMBER]. Continued review of the report revealed the sample result from room [ROOM NUMBER] showed a positive result for Legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review further revealed the room [ROOM NUMBER] sample result also showed a positive result of Legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. No QAPI Agenda was provided for August 2024. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 08/29/2024, revealed testing for room [ROOM NUMBER] and the Unit 2 shower. Per review, the sample result from room [ROOM NUMBER] showed a positive result for Legionella pneumophila SG1 at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and Legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Additionally, further review of the report revealed for the Unit 2 shower the results showed Legionella pneumophila SG1 at 0.5 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and Legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/04/2024, revealed testing for the Unit 2 shower. Continued review revealed the sample result from the shower showed a positive result for Legionella pneumophila SG1 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth; and Legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the facility's QAPI Agenda, dated 09/05/2024, attended by the QA Nurse, HSKD, DOM, RSM, IP, MDS Nurse, DM, HR, SSW, Pharmacist (RPh), Medical Director, and the Administrator, revealed the agenda listed WMP/Policy and the WICRA listed under Other Business. There was no documentation supporting the development or implementation of a plan of correction by QAPI when the facility's water quality did not meet appropriate parameters according to third-party testing results. Furthermore, there was no documentation indicating the QAPI Committee was made aware of or addressed the DEHP's preliminary findings and recommendations. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/13/2024, revealed testing for room [ROOM NUMBER], the Unit 2 shower, and the Physical Therapy (PT) sink. Per review, the sample result from room [ROOM NUMBER] showed a positive result for Legionella pneumophila SG1 at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Continued review of the report revealed the Unit 2 shower testing results showed Legionella non-pneumophila at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Additionally, review of the report further revealed for the PT sink results showed Legionella pneumophila SG2-15 at 0.1 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/18/2024, revealed testing for room [ROOM NUMBER] and the Unit 2 shower. Continued review of the report revealed the sample result from room [ROOM NUMBER] showed a positive result for Legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and Legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Further review of the report revealed for the Unit 2 shower results showed Legionella non-pneumophila SG1 at 0.4 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Review of the facility's Ad Hoc QAPI Agenda, dated 10/03/2024, attended by the QA Nurse, HSKD, IP, MDS Nurse, DON, RSM, Administrator, DOM, HR, DM, Billing/Accounts Receivable Director (AR), SSW, and the Medical Director via telephone, revealed the agenda had the WMP, the Water Policy, and the WICRA listed under Other Business. There was no documentation supporting the development or implementation of a plan of correction by QAPI when the facility's water quality did not meet appropriate parameters according to third-party testing results. Review of the facility's Ad Hoc QAPI Agenda, dated 10/14/2024, attended by the QA Nurse, DOM, RSM, MDS Nurse, DM, Admissions, HSKD, IP, HR, and the Administrator, revealed the meeting minutes included updates on the SSA findings and the Immediate Jeopardy (IJ) Removal Plan. It discussed that the CDC Prevent LD online course must be completed by required staff. Further discussion included updates to the WICRA, discussion of the WMP, and infection surveillance for LD. Furthermore, there was no documentation indicating the QAPI Committee was made aware of or addressed the DEHP's preliminary findings and recommendations. Review of the facility's Ad Hoc QAPI Agenda, dated 10/18/2024, attended by the DM, MDS Nurse, Admissions, RSM, HR, IP, DOM, AR, QA Nurse, Administrator, and the HSKD, DON, SSW, and Medical Director via telephone, revealed the meeting minutes included review of the IJ Removal Plan, approval and submission of the WICRA to the LHD, adoption of the WMP, and compliance monitoring. Review of the facility's Ad Hoc QAPI Agenda, dated 10/21/2024, attended by the QA Nurse, HR, DM, AR, Scheduler, HSKD, IP, Admissions, and the Administrator, revealed the meeting minutes included review of the IJ Removal Plan. During an interview with the QA Nurse, on 10/23/2024 at 3:10 PM, she stated she was a member of the QAPI Committee. She stated she had attended QAPI, and the issues with legionellosis contamination test results were discussed and control measures to close the Unit 2 shower were decided. She stated she could not recall any other specific items related to water contamination or mitigation discussed in previous QAPI meetings. She stated the DEHP's recommendations were discussed at an Ad Hoc QAPI meeting when the committee discussed the IJ Removal Plan. She further stated the WMP, CDC training, and infection surveillance was discussed. The QA Nurse stated the committee awaited guidance from the LHD and Certified Legionella Water Safety Expert (CLWSE) to proceed with the WMP. The QA Nurse further stated it was important to follow the DEHP's recommendations to ensure the safety of residents. During an interview with the IP, on 10/08/2024 at 9:10 AM, she stated in August 2024 the DEHP provided recommendations for the facility to follow to help mitigate the spread of LD in the facility. She stated she attended QAPI meetings and these were discussed at the QAPI Committee and WMT meetings, but she could not state when this occurred. She further stated she informed all providers to include legionellosis in their differential diagnoses. Furthermore, the DEHP advised testing any resident with suspected healthcare-associated pneumonia for LD by conducting a urine antigen test and, if possible, a sputum culture. The IP confirmed that she had implemented these measures for all suspected cases of healthcare-associated pneumonia. The IP stated the facility conducted enhanced surveillance for new cases of legionellosis and reviewed patient [residents] charts daily for potential radiographs, lab tests, or diagnoses related to possible or atypical pneumonia. However, the IP stated she had no surveillance data or chart review logs documenting the recommendations were performed. During continued interview with the IP, on 10/08/2024 at 9:10 AM, she stated the WMT worked on a WMP earlier in the year, but the DEHP reviewed the WMP and indicated the WMP did not meet CDC criteria. She stated the DEHP recommended revising and resubmitting it. She stated the QAPI committee and the WMT did not attempt a revision to the WMP because they had been waiting for the CLWSE to write the plan for the facility. She stated the WICRA was a component of water management programs. The IP stated WMT members could use a WICRA to evaluate water sources, modes of transmission, patient [resident] susceptibility, patient [resident] exposure, and program preparedness. She stated she had not submitted the facility's completed WICRA to the LHD, but she completed the form several months ago. She stated the WICRA had not been approved yet by the QAPI committee and the WMT. During an interview with the Minimum Data Set (MDS) Nurse, on 10/23/2024 at 3:10 PM, she stated she was a member of the QAPI Committee and had attended Ad Hoc QAPI committee meetings where the committee discussed the State Survey Agency's (SSA's) findings and the facility's plan for IJ removal. She stated the committee was waiting on the LHD and the CLWSE to provide direction on the WMP. She stated the committee had moved forward in the last couple of weeks to include CDC training and increased flushing and had approved and submitted the WICRA. During an interview with the HSKD, on 10/23/2024 at 4:09 PM, she stated she was a member of the QAPI Committee and had attended Ad Hoc QAPI Committee meetings where the committee discussed the SSA's findings and the facility's plan for IJ removal. Prior to that, she stated issues with legionellosis contamination test results were discussed, but the committee was waiting on the LHD and the CLWSE to provide direction on the WMP. The HSKD could not remember the specific items discussed in previous QAPI meetings. She stated as part of the DEHP's recommendations, she completed the CDC's LD training. During an interview with the SSW, on 10/24/2024 at 8:55 AM, she stated she was a member of the QAPI Committee. She stated the committee reviewed water test results, which had continuously shown some level of contamination. She stated the committee had discussed changes to the WMP at the most recent meetings. She further stated the water contamination issue was on the QAPI agendas, but she did not remember the specific items discussed in previous QAPI meetings. During an interview with the DM, on 10/24/2024 at 10:09 AM, she stated she was a member of the QAPI Committee and had attended Ad Hoc QAPI committee meetings where the committee discussed the SSA's findings and the facility's plan for IJ removal. She stated she could not provide details on prior QAPI meeting discussions. She further stated the committee was waiting on the LHD and the CLWSE to provide direction on the WMP. During an interview with the AD, on 10/24/2024 at 10:15 AM, she stated she had been a member of the QAPI Committee since September 2024. She stated she attended Ad Hoc QAPI committee meetings where the committee discussed the SSA's findings and the facility's plan for IJ removal. During an interview with the AR Clerk, on 10/24/2024 at 10:26 AM, she stated she had attended QAPI Committee meetings. She stated the committee discussed issues related to legionellosis contamination test results and control measures to mitigate the spread of LD. She further stated she could not elaborate on prior meeting discussions; however, most recently, the facility reviewed the plan for removal of the IJ and approved a new WMP. During an interview with HR, on 10/24/2024 at 10:32 AM, she stated she had attended QAPI Committee meetings. She stated the committee discussed issues related to legionellosis contamination test results and control measures to mitigate the spread of LD. She further stated most recently she attended an Ad Hoc QAPI committee meeting where the committee discussed the SSA's findings, the facility's plan for IJ removal, and voted to adopt a new WMP. During an interview with the RSM, on 10/24/2024 at 10:40 AM, she stated she had been a member of the QAPI Committee for seven years. She stated during the most recent Ad Hoc QAPI meeting, the committee discussed issues related to legionellosis contamination test results and control measures to mitigate the spread of LD. In addition, she stated they discussed the SSA's findings, the facility's plan for IJ removal, and voted to adopt the new WMP provided by the CLWSE. During an interview with the former DON, on 10/08/2024, at 9:21 AM, she stated the QAPI Committee had decided to reopen the showers in Unit 1 and Unit 3 for all residents on 10/04/2024. Prior to this decision, she stated all showers had been closed for over a month, and residents received bed baths instead. The DON stated she was aware of the recommendations from the DEHP; however, she stated the IP was responsible for implementing all infection control and health department guidelines. Additionally, she stated the IP was tasked with sending out a letter to providers, informing them of the DEHP's recommendations for enhanced surveillance of LD. She stated the QAPI Committee did not approve to submit the WICRA assessment to the LHD because they were waiting for the CLSWE to submit his recommendations. She further stated the QAPI Committee and the WMT did not attempt a revision to the WMP because it had been waiting for the CLWSE to write the plan for the facility. During an additional interview with the former DON, on 10/09/2024 at 10:40 AM, she stated the QAPI Committee had yet to follow up on the DEHP's recommendations because they were waiting for the CLWSE to do this for the facility. The DON stated during an online meeting with the LHD and the State Department of Public Health (KDPH), the CLWSE indicated to the WMT that he knew how to write a WMP and would do that for the facility. She stated she took that to mean he would write the WMP follow-up on the DEHP recommendations. During an interview with the former Administrator, on 10/04/2024 at 2:32 PM, he stated the QAPI Committee had collaborated closely with the LHD and the KDPH to develop a WMP. The Administrator stated the KDPH's Environmental and Occupational Countermeasures Program Manager (EOCPM) recommended the facility seek out a certified water safety and management expert (CLWSE) to address the building's contaminated water lines. He stated the facility's water testing company was responsible for finding the expert, which they did. The Administrator stated the CLWSE conducted an onsite visit in September 2024 and provided the facility with recommendations on 10/02/2024 based on that visit. The Administrator stated the QAPI process after May 2024 was primarily focused on waiting for recommendations from the DEHP and the LHD to prevent and control legionellosis. During an additional interview with the former Administrator, on 10/25/2024 at 12:45 PM, he stated he was not aware the 08/05/2024 email from the LHD contained an attachment with the DEHP's preliminary findings and recommendations until the SSA Surveyor brought the recommendations to his attention. Therefore, he stated it was not brought to the attention of the QAPI Committee. He stated, The e-mail came but I didn't look at it [attachment]. He further stated it was the responsibility of the IP to have communicated the receipt of the recommendations to him. During a telephone interview with the Medical Director, on 10/24/2024 at 11:01 AM, he stated he was a member of the QAPI Committee and had attended both scheduled and Ad Hoc QAPI meetings to address ongoing issues related to bacterial contamination in the water. He stated it was his expectation that the facility's QAPI Committee followed policy to ensure the safety and well-being of the residents and staff.

Based on interview, record review, review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, review of the facility's Bylaws, and review of the facility's policies, it was determined the facility's Governing Body failed to ensure the facility's policies were implemented regarding the management and operation of the facility for the total census of 74 residents. On 04/04/2024, Immediate Jeopardy (IJ) was identified in the area of F880 (Infection Control) during an Abbreviated Partial Extended Survey with an exit date of 04/05/2024. The facility submitted a Plan of Correction (POC) for deficiencies, cited on 04/05/2024, alleging substantial compliance on 05/20/2024. However, during the Recertification/Abbreviated Survey concluded on 11/22/2024, it was determined the facility failed to maintain substantial compliance. The facility failed to implement their plan of correction as described in the documents issued to the State Survey Agency, which included to follow the direction of the Local Health Department (LHD). Legionella pneumophila SG1 and Legionella pneumophila SG2-15 were identified at uncontrolled growth levels in the Unit 3 shower on 05/28/2024. Review of the state's Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed DEHP made recommendations to mitigate outbreaks of occurrences of legionellosis. On 08/05/2024, the Infection Preventionist (IP) received an email from the Local Health Department (LHD), which communicated the DEHP's recommendation to mitigate the outbreak of LD. However, the facility's Governing Body failed to provide effective oversight to ensure the facility's Administration implemented recommendations from the state's DEHP recommendations as communicated by the Local Health Department (LHD), to prevent and control legionellosis. IJ was identified on 10/11/2024 and was determined to exist on 08/05/2024, in the area of 42 CFR 483.70 Administration, F-837 at a Scope and Severity (S/S) of an L. The facility was notified of the IJ on 10/11/2024. The facility provided an acceptable IJ Removal Plan, on 10/22/2024, alleging removal of the IJ on 10/22/2024. The State Survey Agency (SSA) determined the IJ had been removed on 10/22/2024, prior to exit on 11/22/2024, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F835, F867, F880 The findings include: Review of the facility's Amended and Restated Bylaws ., dated 06/2007, revealed the Board of Directors (BOD)/(Governing Body) managed the facility to include dealing with issues brought to them by the Administrator. Review of the facility's policy titled, Quality Assessment and Assurance and Quality Assessment and Performance Improvement, undated, revealed the Governing Body was responsible and accountable for ensuring that an ongoing quality assurance and performance improvement program was defined, implemented, maintained, and addressed identified priorities. Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), undated, revealed its purpose was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Furthermore, the IPCP provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors. Review of the facility's policy titled, Legionella Water Management Plan, undated, revealed the facility would promote proactive steps to establish a healthy environment for residents, staff, and visitors. According to the Water Management Plan (WMP), contraction of Legionnaire's Disease (LD) was often the result of exposure to inadequately managed building water systems, which could be prevented. The facility's mission was to properly manage its water system to prevent exposure to LD. Review of the facility's POC for deficiencies cited during the Abbreviated Partial Extended Survey with an exit date of 04/05/2024 and compliance date of 05/20/2024, revealed the facility alleged the following was implemented: Education was provided to the IP by the DON to follow the direction of the health department and state personnel related to infection control procedures. Further review revealed the QAPI committee worked with the local health department and state infection prevention team to develop a water maintenance plan and ensure the facilities water maintenance policy was being followed. Continued review of the PoC revealed the QAPI committee assessed and modified the action plan as needed to ensure continued compliance. Review of the microbiology analysis report, performed by a third party independent water system company (IWSC) to test for legionella, dated 05/28/2024, revealed the sample result from the facility's Unit 3 shower, showed a positive result for Legionella pneumophila Serogroup 1 Strain (SG1). Per review the positive result was at 11.0 colony-forming unit per milliliter (CFU/ml) with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Continued review of the report for the Unit 3 shower showed Legionella pneumophila Serogroup 2 Strain (SG2-15) at 11.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Review of the microbiology analysis reports, performed by the IWSC to test for detectable levels of legionella on 06/14/2024, 08/07/2024, 08/29/2024, 09/04/2024, 09/13/2024, and 09/18/2024, revealed continued detectable levels of legionella. (Refer to F880) Review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed several concerns identified by the state's Legionella Team and the Regional Epidemiologist. These concerns included: 1) the facility failed to document all the necessary elements of a proper WMP as evidenced by the facility's unacceptable score on the WMP assessment of one (1) out of nine (9) (acceptable score was eight or higher); 2) water sampling had been insufficient to evaluate the growth reservoir in the building's water system; and 3) there were no documented logs to confirm the flushing procedures. Review of the DEHP Findings and Recommendations, dated 07/26/2024, revealed recommendations to mitigate outbreaks or occurrences of legionellosis. Recommendations included: 1) remind healthcare providers to include legionellosis in their differential diagnoses; 2) continue enhanced surveillance for new cases of legionellosis and review resident charts daily for potential radiographs, lab tests, or diagnoses related to possible or atypical pneumonia; 3) complete the Water Infection Control Risk Assessment (WICRA) before developing a WMP; 4) create a WMP that incorporated recommendations from the Centers for Disease Control and Prevention (CDC); 5) validate the plumbing diagram with greater detail according to CDC guidelines and document the recirculation system; 6) ensure all water management team (WMT) members completed the CDC Prevent LD training module; 7) the third-party contractor should familiarize themselves with legionella sampling protocols by completing the CDC's Prevent LD training module; and 8) submit sampling plans to the LHD before conducting any additional sampling. However, the facility's Governing Body failed to ensure the facility followed the DEHP's recommendations. Review of an email from the Director of the LHD, dated 08/05/2024, to the Infection Preventionist (IP), Director of Nursing (DON), and Administrator, revealed the document titled, [Facility Name] Preliminary Report was attached in the email. The message from the Director stated, Please see attached preliminary report with findings and recommendations. In an interview with the IP, on 10/25/2024 at 12:15 PM, she stated she received the email sent on 08/05/2024 from the LHD, which contained the DEHP findings and recommendations in the attachment at the top of the email. She stated the DON and the Administrator were also copied on this email. The IP stated the attachment at the top portion of the email contained the DEHP document. She further stated, following receipt of the email, she, along with the DON and the Administrator, discussed the DEHP's preliminary findings and recommendations. Additionally, she stated, based on those recommendations, she sent a letter to the providers on 08/20/2024, which was approved by both the DON and the Administrator. Review of a letter dated 08/20/2024, addressed to facility providers from the IP, revealed the facility's water system had shown detectable levels of legionella. The letter recommended facility providers obtain a urine antigen test for legionella, along with a chest radiograph, whenever there was a suspected case of pneumonia or pneumonia-like illness was identified. Review of a Memorandum, dated 10/18/2024, authored by the Certified Legionella Water Safety Expert (CLWSE), revealed the CLWSE trained all seven (7) Board Directors on: 1) the findings and recommendations from the DEHP dated 07/26/2024; 2) the importance of ensuring the administration under the BOD's oversight complied with the recommendations from the DEHP and the LHD to prevent further legionellosis outbreaks; and 3) the deficiencies specifically directed at the facility's administration and the BOD, highlighting the failure to implement timely water management infection control measures. During an interview with Family Member (F)1, on 10/03/2024 at 10:32 AM, he stated there had been ongoing water contamination at the facility for at least four weeks. However, he stated he was not notified of the water situation and only found out after asking the Administrator about it directly. F1 stated showers were not available, and the Administrator told him the LHD and the State Department for Public Health (KDPH) had been discussing when the facility could resume shower usage. He stated the Administrator told him legionella bacteria was detected in Unit 2's shower during a test. He further stated the Administrator told him the issue of whether there was a risk to residents if they used the shower on the second floor had been under discussion. In further interview, F1 stated the Administrator told him neither the LHD nor the KDPH had provided the facility with a clear answer on whether to open the showers. F1 further stated he purchased water for his resident family member so she had clean water to wash her hands and face and to brush her teeth, as the facility only provided water for drinking. During a telephone interview with the Director of the LHD, on 10/03/2024 at 10:42 AM, she stated the facility had been dealing with contaminated water since November 2023. She stated the facility had been working closely with the LHD and the KDPH. In further interview the Director of the LHD, stated the facility hired an independent water service company (IWSC) that had conducted weekly water tests. After conducting ongoing tests of four shower heads and random room sink faucets since the State Survey Agency's (SSA's) last inspection in April 2024, reports had shown varying results regarding the presence of legionella contaminants. She stated in response, the KDPH's Environmental and Occupational Countermeasures Program Manager (EOCPM) recommended the facility enlist the resources of a Certified Legionella Water Safety Expert (CLWSE) to address the facility's ongoing contamination issues. According to the Director of the LHD, in September 2024, a third-party Certified Legionella Water Safety Expert (CLWSE) was consulted to do an onsite building assessment. During an interview with the KDPH's EOCPM, on 10/04/2024 at 3:13 PM, she stated in April 2024, she recommended the facility hire a qualified water safety management expert. However, the EOCPM stated the facility did not consult with a CLWSE until September 2024. Additionally, she stated she had neither contributed to nor approved the facility's WMP, and to date, had yet to see any updates to it. She stated during her conversations with the Administrator, she told him the facility's current water sampling practices were inadequate. She further stated the facility's independent water service company (IWSC) needed to conduct comprehensive testing, which should include 25 to 50 samples from all water sources within the building. She stated this approach would involve much more than the current limited testing conducted on showers and a few rooms. During a telephone interview with the CLWSE, on 10/04/2024 at 2:42 PM, he stated the IWSC had consulted with him to diagnose and evaluate the facility's water system, WMP, current control measures, and to determine if the facility needed additional control measures or a supplemental disinfection system. He stated he assessed the building and its water system in September 2024 and reviewed the remediation efforts that had been carried out since legionella was discovered in February 2024. He further stated the IWSC performed weekly legionella testing, and it was his understanding the facility tested random water temperatures and flushed the water system. Additionally, he stated the facility had installed [NAME] filters on three ice machines and all four shower heads. However, he stated per his assessment, the facility had no other control measures in place. The CLWSE stated the facility must conduct a more comprehensive sampling for legionella testing to maintain ongoing protection. He further stated it was important to keep using the showers and faucets, as stagnant water and warmer temperatures could encourage the growth of legionella bacteria. During continued telephone interview with the CLWSE, on 10/04/2024 at 2:42 PM, he stated he assessed the risk as acceptable, and even though there was no scientific reason against using showers based on the recent test results, They still chose not to use showers. He stated he had discussed the possibility of temporary showers, but the facility opted not to implement that solution. In addition, he stated the facility did not develop a decision-making tree to provide clear instructions on the actions to take based on testing parameters. The CLWSE stated since September 2024, he had repeatedly informed the facility that while he provided recommendations based on industry standards and best practices, it was ultimately their responsibility to assess, implement, and manage the risks associated with legionella. However, he stated he thought the facility wanted a third party to assume the risk and tell them what to do. Furthermore, the CLWSE stated he noted concerns during his assessment of the facility, specifically the lack of documentation for a flushing plan and inadequate sampling for a building of that size. He pointed out they sampled the same areas repeatedly, but the sampling needed to be more comprehensive. He further stated a well-developed plan was crucial to prevent stagnation in the water system, which was a leading cause of bacterial growth. During an additional telephone interview, with the CLWSE, on 10/09/2024 at 9:38 AM, he stated he did not have a contractual relationship with the facility in early September 2024. He stated he provided an estimate for his services to the IWSC on 10/04/2024, and was contracted to develop a water management plan for the facility. During a telephone interview with Board Director (BD)1, on 10/10/2024 at 4:33 PM, he stated it was his understanding there had been a legionella outbreak earlier in 2024, and the problem with contaminated water had been an ongoing issue. BD1 stated the last Board of Directors (BOD) meeting occurred on 09/26/2024, and the agenda included a discussion about the facility's ongoing issues with contaminated water. He further stated the Administrator was in regular communication with the LHD to ensure problem-solving efforts were progressing and to find solutions and steps for remediation to guarantee the water was safe. Additionally, BD1 stated his overall impression was that it was a challenging situation. However, BD1 stated he believed the Administrator was collaborating with all parties involved and working toward a consensus. Per the interview, BD1 was not aware of the specific information concerning the DEHP's recommendations and actions the facility had taken to put the recommendations in place. During an additional telephone interview with BD1, on 10/24/2024 at 10:48 AM, he stated the CLWSE provided him with legionella education through an online training meeting. During this meeting, he stated the CLWSE discussed the findings and recommendations from the DEHP dated 07/26/2024. According to BD1, the training provided was the first time he had learned about the DEHP's recommendations, and he was unaware the facility had not acted on them promptly. He stated the CLWSE highlighted the importance of ensuring the administration, under the oversight of the BOD, complied with the DEHP and LHD recommendations to prevent future legionellosis outbreaks. Additionally, he stated the CLWSE reviewed the current deficiencies concerning the facility's administration and the BOD's failure to implement timely water management infection control measures. During a telephone interview with the Chairman of the BOD (CBOD), on 10/10/2024 at 4:43 PM, she stated the Administrator had communicated regularly regarding positive legionella test results. The CBOD stated the last BOD meeting occurred on 09/26/2024, and the agenda included a discussion about the facility's ongoing issues with contaminated water. She stated the BOD did not partake in the day-to-day management of the facility. However, she stated she believed the Administrator had managed the situation correctly. She further stated the facility was in continual contact with the local and state health departments for guidance and were waiting for their recommendations. During an additional interview with the CBOD, on 10/24/2024 at 10:20 AM, she stated she was provided education by the CLWSE via an online meeting regarding the facility's continued issues with legionella bacteria in the water system, the approved WMP, and steps for more comprehensive testing in the future. She stated the CLWSE updated the BOD on water sampling and testing. According to the CBOD, moving forward, it was her expectation the Administrator update the BOD frequently on the status of the WMP and Quality Assurance and Performance Improvement (QAPI) activities. During a telephone interview with BD4, on 10/24/2024 at 10:55 AM, he stated the BOD was aware of the situation regarding legionella bacteria in the facility's water system. However, he stated they were not fully aware of the severity of the problem. He stated the Administrator communicated with the board on a monthly basis and by text messages. Additionally, he stated at a recent board meeting, directors discussed several options for addressing the legionella issue and explored corrective actions and ongoing solutions. He stated he was not aware of the DEHP's preliminary findings and recommendations until he received training from the CLWSE. BD4 stated, according to legal counsel, the BOD was responsible for overseeing the Administrator, while the Administrator was responsible for the day-to-day running of the facility. During a telephone interview with BD6, on 10/24/2024 at 11:45 AM, he stated the BOD was aware of the situation regarding legionella bacteria in the facility's water system. He stated he received legionella training from the CLWSE, which the facility hired to consult on the WMP. He further stated the CLWSE provided him with legionella education through an online training session. During this training, he stated the CLWSE discussed the findings and recommendations from the DEHP dated 07/26/2024. BD6 stated the Administrator explained to him the LHD sent an email with the DEHP's recommendations in an attachment sometime in August 2024. According to BD6, the Administrator told him he never received the email. In continued interview, on 10/24/2024 at 11:45 AM, BD6 stated he was concerned the Administrator did not receive the email from the DEHP, and he felt the facility should not be penalized for lack of action, primarily since the DEHP did not ensure their recommendations were sent in a reliable manner to guarantee receipt of the document. Additionally, BD6 stated, at a recent board meeting, the directors discussed several options for addressing the legionella issue and explored corrective actions and ongoing solutions. He stated he was aware the showers were not in use, a decision made by the Administrator for the safety of the residents. Furthermore, BD6 stated he believed the BOD and the facility's administration always did their best to ensure the safety and well-being of the residents. During a telephone interview with BD3, on 11/14/2024 at 4:25 PM, she stated she was made aware of legionella contamination in the facility's water the beginning of 2024. She stated the Administrator discussed water testing results during board meetings and he assured her and other board directors that the facility was doing everything the LHD recommended. She stated she was aware the showers were not in use for a time based on the water testing results. BD3 stated the Administrator had closed the showers for the safety of the residents. She further stated she learned of the Administrator's failure to follow the LHD recommendations after receiving the citation from the State Survey Agency (SSA). BD3 stated the Administrator told her he never received the email from the LHD with recommendations in August 2024. During a telephone interview with BD2, on 11/15/2024 at 10:30 AM, she stated she became aware of the legionella bacteria in the water while attending a recent board meeting. She stated the Administrator assured the BOD that the facility was following LHD recommendations. However, she stated she was only made aware of the seriousness of the situation regarding the facility's water system after the facility received the citation from the SSA. The BD2 stated the Administrator explained to the BOD that he never received the email with recommendations from the LHD in August 2024. During an interview with the Administrator, on 10/25/2024 at 12:45 PM, he stated he was not aware the 08/05/2024 email from the LHD contained an attachment with the DEHP's preliminary findings and recommendations until the State Survey Agency (SSA) Representative brought the recommendations to his attention. He stated, The e-mail came but I didn't look at it [attachment]. The Administrator stated the IP was tasked with calling the LHD regarding the status of the DEHP's report. He further stated it was the IP's responsibility to have communicated the receipt of the recommendations to him. The Administrator further stated it was his expectation the facility follow the facility's Infection Prevention and Control Program, policies to prevent the spread of infectious disease and to keep residents, staff, and visitors safe.

Based on interview, record review, review of the Director of Nursing Services (DON) and Administrator's Job Descriptions, review of the facility's employee agreement for the Administrator, review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, and review of the facility's policies, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the total census of 74 residents. On 05/28/2024, Legionella pneumophila Serogroup 1 Strain (SG1) and Legionella pneumophila Serogroup 2 Strain (SG2-15) were identified at uncontrolled growth levels in the Unit 3 shower. Review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed the DEHP recommended steps to prevent future outbreaks or occurrences of legionellosis. However, the facility's administration failed to review the findings and implement the DEHP's recommendations from 07/26/2024, as communicated by the Local Health Department (LHD), to prevent and control legionellosis. Test results reviewed through 09/18/2024 continued to show uncontrolled growth of legionella bacteria in other tested areas of the facility. Immediate Jeopardy (IJ) was identified on 10/11/2024 and was determined to exist on 08/05/2024, in the area of 42 CFR 483.70 Administration, F-835 at a Scope and Severity (S/S) of an L. The facility was notified of the IJ on 10/11/2024. The facility provided an acceptable IJ Removal Plan, on 10/22/2024, alleging removal of the IJ on 10/22/2024. The State Survey Agency (SSA) determined the IJ had been removed on 10/22/2024, prior to exit on 11/22/2024, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F837, F867, and F880 The findings include: Review of the facility's Job Description for Administrator, dated 10/03/2022, revealed the Administrator directed the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that governed nursing facilities to assure the highest degree of quality care could be provided to residents at all times. Further review revealed the Administrator's Scope of Duties included: the purchase of all commodities, supplies, and services required to operate the facility; the evaluation of the need for all new equipment; the maintenance of proper records of all transactions; overseeing and managing the maintenance of all the building and grounds that comprised the facility; ensuring the residents of the facility received quality care; and ensuring effective and timely communications with residents and their families. Review of the Facility Administrator Employment Agreement, dated 10/03/2022, revealed the Administrator was responsible for the day-to-day operations of the facility, including ensuring compliance with all federal, state, and local laws and regulations governing long-term care, ensuring residents received quality care, and overseeing and managing building maintenance. Review of the facility's Job Description for Director of Nursing Services, undated, revealed the DON planned, organized, developed, and directed the overall operation of the facility's nursing department in accordance with current federal, state, and local standards, guidelines, and the established policies and procedures that governed the facility to ensure the highest degree of quality care was maintained at all times. Per the Job Description, the DON's essential functions included: to participate in the developing and implementation of resident care; to direct and assure that quality assurance developed and implemented appropriate plans of action to correct identified deficiencies; and to serve on, participate in, and attend committees of the facility to include quality assurance and infection control. Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), undated, revealed its purpose was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's policy titled, Legionella Water Management Plan, undated, revealed the facility would promote proactive steps to establish a healthy environment for residents, staff, and visitors. According to the water management plan (WMP), contraction of Legionnaires' Disease (LD) was often the result of exposure to inadequately managed building water systems, which could be prevented. In addition, the facility stated its mission was to properly manage its water system to prevent exposure to LD. Review of the microbiology analysis report, performed by a third party independent water service company (IWSC) to test for legionella, dated 05/28/2024, revealed the sample result from the Unit 3 shower showed a positive result for Legionella pneumophila Serogroup 1 Strain (SG1) at 11.0 colony-forming units per milliliter (CFU/ml) with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Additionally, the report for the Unit 3 shower showed Legionella pneumophila Serogroup 2 Strain (SG2-15) at 11.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating uncontrolled growth. Review of other microbiology analysis reports, performed by the IWSC to test for legionella, showed uncontrolled growth on 1) 06/14/2024, the sample result from the Unit 2 shower showed legionella non-pneumophila at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; 2) 08/07/2024, the sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth and legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; 3) 08/29/2024, the sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth and legionella non-pneumophila at 3.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; the sample result for the Unit 2 shower showed legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; 4) 09/04/2024, the sample result from the Unit 2 shower showed legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; 5) 09/13/2024, the sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth; and 6) 09/18/2024, the sample result from room [ROOM NUMBER] showed a positive result for legionella pneumophila SG1 at 2.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth and legionella non-pneumophila at 1.0 CFUs/mL with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed several concerns identified by the state's Legionella Team and the Regional Epidemiologist. These concerns included: 1) the facility failed to document all the necessary elements of a proper WMP as evidenced by the facility's unacceptable score on the WMP assessment of one out of nine (acceptable score was eight or higher); 2) water sampling had been insufficient to evaluate the growth reservoir in the building's water system; and 3) there were no documented logs to confirm the flushing procedures. Further review of the DEHP's Findings and Recommendations, dated 07/26/2024, revealed the DEHP recommended steps to prevent future outbreaks or occurrences of legionellosis. These steps included: 1) remind healthcare providers to include legionellosis in their differential diagnoses; 2) continue enhanced surveillance for new cases of legionellosis and review resident charts daily for potential radiographs, lab tests, or diagnoses related to possible or atypical pneumonia; 3) complete the Water Infection Control Risk Assessment (WICRA) before developing a WMP; 4) create a WMP that incorporated recommendations from the Centers for Disease Control and Prevention (CDC); 5) validate the plumbing diagram with greater detail according to CDC guidelines and document the recirculation system; 6) ensure all water management team (WMT) members completed the CDC Prevent LD training module; 7) the third-party contractor should familiarize themselves with legionella sampling protocols by completing the CDC's Prevent LD training module; and 8) submit sampling plans to the LHD before conducting any additional sampling. Review of an email from the Director of the LHD, dated 08/05/2024, to the Infection Preventionist (IP), DON, and Administrator, revealed a document titled, [Facility Name] Preliminary Report was attached in the email. The message from the Director read, Please see attached preliminary report with findings and recommendations. Attached were the DEHP's Findings and Recommendations, dated 07/26/2024. Review of a letter dated 08/20/2024, addressed to facility providers from the IP, indicated the facility's water system had shown detectable levels of legionella. The letter recommended facility providers obtain a urine antigen test for legionella, along with a chest radiograph, whenever a suspected case of pneumonia or pneumonia-like illness was identified. Although the IP received the email from the LHD on 08/05/2024 which contained the DEHP findings and recommendations, the IP did not send the letter to the providers until 08/20/2024, 15 days later. During an interview with the IP, on 10/25/2024 at 12:15 PM, she stated she received the email sent on 08/05/2024 from the LHD, which contained the DEHP findings and recommendations in the attachment at the top of the email. She stated the Administrator and the DON were also copied on this email. The IP stated the attachment at the top of the email contained the DEHP document. She further stated, following the receipt of the email, she, along with the DON and the Administrator, discussed the DEHP's preliminary findings and recommendations. Furthermore, she stated, based on those recommendations, she sent a letter to the providers on 08/20/2024, which was approved by both the DON and the Administrator. During an interview with the Interim DON, on 10/08/2024 at 9:21 AM, she stated her role was to direct and implement all aspects of nursing care. The DON stated she was a member of the Quality Assurance and Performance Improvement (QAPI) Committee, which met every month to discuss issues concerning the quality of care in the facility. She stated the QAPI Committee had discussed the ongoing levels of legionella bacteria in the water. She further stated the committee decided to reopen the showers in Unit 1 and Unit 3 for all residents on 10/04/2024. Prior to this decision, she stated all showers had been closed for over a month, and residents received bed baths. The DON stated she was aware of the recommendations from the DEHP; however, she stated the IP was responsible for implementing all infection control and health department guidelines. In further interview with the Interim DON, on 10/08/2024 at 9:21 AM, she stated the IP was tasked with sending out a letter to providers, informing them of the DEHP's recommendations for enhanced surveillance of LD. Furthermore, the DON stated the IP conducted daily chart reviews, although there had only been three residents with a possible diagnosis of pneumonia. She stated per the DEHP's recommendations, any resident exhibiting symptoms related to pneumonia was required to undergo a chest radiograph and a urine antigen test to rule out LD. She further stated while the IP monitored healthcare-associated infections (HAI), it was not documented on a spreadsheet. The DON further stated she did not keep track of documentation for enhanced surveillance of possible new legionella cases. In further interview, the DON stated the facility had not yet completed and submitted the Water Infection Control Risk Assessment (WICRA) form to the LHD. She stated it was the responsibility of the IP, but the committee was waiting for the Certified Legionella Water Safety Expert (CLWSE) to write the Water Management Plan (WMP). During an additional interview with the Interim DON, on 10/09/2024 at 10:40 AM, she stated the facility had yet to follow up on the DEHP's recommendations because they were waiting for the CLWSE to write the WMP. She stated during an online meeting with the LHD and the State Department of Public Health (KDPH), the CLWSE indicated he knew how to write a WMP and would do this for the facility. The DON stated she took that to mean he would write the WMP and follow-up on the DEHP recommendations. When the DON was questioned whether the CLWSE had a contractual relationship with the facility, the DON replied, No. During an additional interview with the Interim DON, on 10/25/2024 at 12:01 PM, she stated the facility did not begin to implement the DEHP's recommendations upon receipt of the email on 08/05/2024. The DON stated she was unaware of the DEHP's preliminary findings until the State Survey Agency (SSA) Representative brought the recommendations to her attention. The DON stated following her conversation with the SSA Representative, she asked the IP about the recommendations. The DON stated the IP informed her the recommendations were included as an attachment in an email sent on 08/05/2024 from the LHD. The DON stated she then checked her email and found the email, but noted the attachment was hidden within it. She stated when she first opened the email, she did not realize it contained any document from the DEHP. The DON further stated it was the responsibility of the IP to have communicated the receipt of the recommendations to her and the Administrator. During an interview with the Administrator, on 10/03/2024 at 10:50 AM, he stated his role was to take care of the building for all departments, to make sure residents were taken care of, and to make sure their rights were upheld. During an additional interview with the Administrator on 10/04/2024 at 2:32 PM, he stated the facility had collaborated closely with the LHD and the KDPH to develop a WMP. The Administrator stated the KDPH's Environmental and Occupational Countermeasures Program Manager (EOCPM) recommended the facility seek out a certified water safety and management expert (CLWSE) to address the building's contaminated water lines. He stated the independent water service company (IWSC) was responsible for finding the expert. The Administrator stated the CLWSE conducted an onsite visit in September 2024 and the Ad Hoc QAPI Committee was scheduled to meet to discuss the CLWSE's recommendations sent on 10/02/2024. When asked if the facility had an acceptable WMP, the Administrator stated the facility's WMT consisting of the Administrator, DON, IP, Director of Maintenance (DOM), Housekeeping Director (HSKD), Dietary Manager (DM), and Quality Assurance (QA) Nurse participated in a meeting with the LHD, KDPH, IWSC, and the CLWSE to discuss continued positive legionella results. During that meeting, the Administrator stated the CLWSE told the group, I can write the plan. However, according to the Administrator, the facility had not yet established a contractual relationship with the CLWSE to develop a comprehensive WMP. The Administrator stated he was under the assumption the CLWSE was working pro [NAME] to help the facility. The Administrator stated he did not enter into a contractual agreement with the CLWSE until 10/04/2024, when he signed an agreement for the CLWSE to provide a WMP for the facility. During an additional interview with the Administrator, on 10/25/2024 at 12:45 PM, he stated he was not aware the 08/05/2024 email from the LHD contained an attachment with the DEHP's preliminary findings and recommendations until the SSA Representative brought the recommendations to his attention. He further stated it was the responsibility of the IP to have communicated the receipt of the email containing the attachment with the DEHP's recommendations to him.

Based on observation, interview, and record review the facility failed to promptly identify and intervene for a change in the resident's condition and ensure the resident received prompt assessment and emergency care for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP) who ordered continued monitoring of the resident, with no additional orders. RN2's assessments noted R76's neurological (neuro) checks were within normal limits (WNL) and the resident was experiencing prolonged elevated blood pressure (B/P), with systolic readings consistently between 180 and 190 until 7:00 PM. However, RN2 failed to notify the NP about R76's elevated B/P. On 05/17/2024 at 8:00 AM and 4:00 PM, R76's B/P remained elevated and at 4:00 PM, the resident was also exhibiting a change in mental status, to include lethargy and incoherent speech. However, RN2 failed to document those findings and did not notify the physician of R76's change in condition. The resident's family arrived at 6:00 PM on 5/17/2024, and due to their concerns over R76's increased lethargy, confusion, and elevated B/P, they requested the facility send the resident to the hospital for evaluation. R76 was subsequently admitted to the hospital with a diagnosis of transient ischemic attack (TIA, a brief blood flow blockage to the brain). Immediate Jeopardy (IJ) was identified on 11/14/2024 and was determined to exist on 05/16/2024, in the area of 42 CFR S483.25 Quality of Care, F684 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 11/14/2024. The facility provided an acceptable IJ Removal Plan, on 11/22/2024, alleging removal of the IJ on 11/22/2024. The State Survey Agency (SSA) determined the IJ was removed on 11/22/2024, prior to exit on that date. With remaining non-compliance at a S/S of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F580 and F656 The findings include: Review of the facility policy titled, Quality of Care, undated, revealed quality of care was a fundamental principle that applied to all treatment and care provided by the facility. Per policy review, the facility must ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan, and the resident's choices. Review of the Face Sheet, found in R76's electronic medical record (EMR), revealed the facility admitted the resident on 08/22/2022, with diagnoses including essential (primary) hypertension, metabolic encephalopathy, and general anxiety disorder. Review of R76's Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severely impaired cognition. Per review, the facility also assessed R76 to be independent with mobility, toileting, transfers, and able to ambulate on her own with a walker and no assistance from a helper. Review of the Comprehensive Care Plan (CCP), dated 05/11/2024 for R76, revealed the facility identified a problem for the resident related to having hypertension (high blood pressure) on 10/10/2022. Per review, the goal dated 05/11/2024 and revised on 11/13/2023, for the resident to remain free of complications related to hypertension. Continued review revealed the interventions dated 10/22/2022 included: giving antihypertensive medications as ordered; and monitoring and documenting any edema. Further review revealed additional interventions included monitoring, documenting, and reporting any signs and symptoms of hypertension such as, headache, visual problems, confusion, disorientation, and lethargy. Review of the Nurse Progress Note, dated 05/16/2024 at 1:42 PM for R76, revealed State Registered Nurse Aide (SRNA) 6 found the resident lying on the floor. Continued review revealed the nursing assessment noted no redness or swelling to R76's head; full range of motion (ROM) to extremities; and neuro checks were at baseline. Per review of the Note, R76's B/P was 190/70, which was elevated from her baseline. Further review revealed the nurse notified the NP, and no new orders were received. In addition, the Note stated the resident's family, and the DON were also notified. Review of R76's Neurological Record, for 05/16/2024, revealed her neuro checks were conducted: every 15 minutes (four times); every 30 minutes (four times); every hour (four times); and every two hours (four times). Per review of the Record, the results of the neuro checks at 1:15 PM revealed: R76's B/P was 190/70; the resident was alert with coherent speech; had ROM in all extremities, and her pupils were equal and reactive at baseline. Continued review revealed subsequent neuro check assessments noted R76's neuro checks remained at baseline. Further review revealed R76's systolic B/P readings were as follows: 182/72 at 1:30 PM; 184/72 at 1:45 PM; 182/70 at 2:00 PM; 184/72 at 2:30 PM; 172/70 at 3:00 PM; 176/72 at 3:30 PM; 182/72 at 4:00 PM; 190/70 at 5:00 PM; and 182/70 at 6:00 PM. Additionally, review of the Record revealed R76's B/P was 133/56 at 7:00 PM and at 8:00 PM, the B/P reading was illegible. Review of R76's Neurological Record, for 05/17/2024, revealed her neuro checks, were conducted every four hours (three times); and then every eight hours (four times). Per review, R76 was alert, her speech was coherent, she had a full ROM in all extremities, and her pupils were equal and reactive at baseline. Continued review revealed at 4:00 PM, R76's level of consciousness (LOC) was initially marked as drowsy, stuporous, and unconscious; however, that was marked through with the word error handwritten over them. Further review revealed R76's B/P readings at 12:00 AM and 4:00 AM were illegible. In addition, review revealed R76's B/P at 8:00 AM, was noted as 148/78 and at 4:00 PM as 146/70. In interview with R76's Family (F) 3, on 10/04/2024 at 2:31 PM, she stated when she visited the resident on 05/17/2024, R76's systolic B/P had been severely elevated, reaching the 190's, was exhibiting garbled speech, and was confused, which was noticeably different from her baseline. She stated during her visit, R76 told her she (the resident) had hit her head during the fall and was having a headache. F3 reported the nurse on duty communicated to her that she (nurse) had notified the NP, and the NP's ordered monitoring R76's B/P. She further stated she requested R76 be sent to the hospital, where she was admitted for two nights. During telephone interview with SRNA6 on 10/07/2024 at 1:23 PM, she stated she responded to R76's call light and asked the resident if she needed help getting to the bathroom. She said R76 indicated she required assistance with her walker which she helped the resident with and assisted her into the bathroom. SRNA6 reported after that R76 exited the bathroom on her own with her walker and fell near the closet. She stated she had been in the room at the time but had not actually witnessed the fall. SRNA6 said she and another staff member, whom she could not recall, helped R76 off the floor and assisted her in returning to bed. Per SRNA6 in interview, R76 had no complaints except for a headache, and when RN2 came in to assess R76, she reported the resident's complaint of a headache to the nurse. She stated she conducted every 15-minute checks on R76 for two hours after her fall and her checks of the resident taking her vital signs. SRNA6 recalled that R76's blood pressure was higher than normal and she communicated that information to RN2. In telephone interview on 10/04/2024 at 1:33 PM, RN2 stated she was informed by a SRNA on 05/16/2024 at 1:00 PM, that R76 had sustained a fall while returning from the bathroom. She stated she assessed R76 with no injuries, and an elevated systolic B/P with readings in the 190's. The RN reported she performed neuro checks and vital signs according to the facility's fall protocol, and although the resident's B/P had been elevated, she had no concerns. She said R76 had not exhibited any change in her LOC. RN2 stated she notified R76's family, the DON, and the NP of R76's fall and elevated B/P. She stated the NP told her to follow the facility's protocols and let her know if there were changes, and no other new orders were received. RN2 shared that R76 did not have specific B/P parameters to follow. The RN further stated R76's B/P readings came within her baseline after several hours, and she did not call the NP back to update her on the resident's status. In continued telephone interview on 10/04/2024 at 1:33 PM, RN2 stated on 05/17/2024, R76 started exhibiting a change in mental status. RN2 said R76 became lethargic and was speaking incoherently at times. She stated she could not recall if the facility had provided an in-service related to the signs and symptoms (S/S) of a stroke. RN2 reported however, the S/S of a stroke were slurred speech, instability, weakness, and facial drooping. She said the family visited on 05/17/2024 at 6:00 PM, and expressed concern about R76's elevated B/P. The RN said she reassured them the NP had indicated the resident's elevated B/P was likely due to anxiety following her fall. She stated however, the family requested R76 be evaluated at the local hospital due to her increased lethargy and elevated B/P during the day. RN2 said she called the provider, who gave the order for R76's transfer to the hospital. She further stated she could not recall if she had read the facility's Quality of Care policy. Review of R76's Emergency Department [ED] Note dated 05/17/2024 at 7:05 PM, revealed the resident had been transferred from the facility after a fall. Continued review revealed the ED physician noted R76 had altered mental status and dysarthria (slurred speech). Per review, the ED physician also noted R76 had significantly elevated B/P, with systolic readings in the 170's and 180's compared to her normal range of 120's to 130's. Review further revealed R76 exhibited staccato and repetitive speech and rated a headache at five on a scale of one to 10, with 10 the worst for pain. In addition, review revealed due to those issues, R76 was being admitted to the hospital for observation and diagnosed with a TIA. In interview on 11/14/2024 at 9:51 AM, SRNA 1 (an agency SRNA) stated the S/S of stroke included limited movement and decreased activity. SRNA1 said she immediately reported anything abnormal in a resident to the nurse. She stated she had only worked at the facility for one week, but said she had not received any training when she onboarded. During interview with SRNA 9 (an agency SRNA) on 11/14/2024 at 10:08 AM, she stated the S/S of a stroke included one sided weakness, facial drooping, and slurred speech. SRNA9 stated she immediately reported anything abnormal in a resident to the nurse. She reported she would keep an eye on the resident and monitor their B/P and oxygen saturation. The SRNA said the frequency of assessments was up to the nurse; however, it was usually every 15 minutes. She further stated if there was no improvement in a resident's vitals and she felt the nurse was not doing anything about following the protocols, she would report her concerns to the nursing supervisor. In interview on 11/14/2024 at 10:14 AM, SRNA10 stated she had been employed at the facility since 06/2024. She stated the S/S of a stroke included changes in the face, eyes, and speech. SRNA10 stated she would report any change in a resident to the nurse immediately, and a resident experiencing S/S should be assessed by the nurse every 15 to 30 minutes. She further stated she received stroke in-service provided by the Infection Preventionist (IP) Nurse. During interview with SRNA11 (an agency SRNA) on 11/14/2024 at 10:38 AM, he stated he had worked at the facility through an agency for approximately six years. He stated the S/S of stroke were slurred speech, instability, weakness, and facial drooping. SRNA11 stated he would check a resident's vital signs every 15 minutes if they were displaying S/S. He stated he would report an elevated B/P to the nurse depending on the resident's history. SRNA11 said he could not recall any specific education related to S/S of a stroke. In interview on 11/14/2024 at 10:31 AM, Licensed Practical Nurse (LPN) 2 stated if staff observed any S/S of stroke including slurred speech, drooping face, and weakness that should be reported to the nurse immediately. LPN2 stated she would monitor a resident's B/P and heart rate (HR), if they were experiencing S/S, at least every 15 minutes. She said she received her education for stroke during an in-service, which were usually provided by Social Worker (SW), IP Nurse, or DON. LPN2 further stated the facility did not offer computer-based training modules. During interview with Kentucky Medication Aide (KMA) 2 on 11/14/2024 at 10:03 AM, she stated she had been employed at facility for over six years. She said any S/S of stroke, including slurred speech, drooping face, and weakness, should be reported to the nurse immediately. KMA2 stated the resident should be assessed by taking vital signs. She further stated neuro checks would be done by the nurse. She additionally stated she had received stroke education before; however, was not sure if it was at her previous employer or the facility. In interview on 11/14/2024 at 10:20 AM, the Staffing Coordinator/KMA stated she had been employed at the facility for over a year, and had received stroke education prior to her hire date. The Staffing Coordinator/KMA stated staff were to report any S/S of numbness, weakness, facial drooping to the nurse on duty. She further stated a resident's vital signs should be assessed every 10 minutes. During interview with LPN3 on 11/14/2024 at 10:42 AM, she stated she had been employed at facility for about four years. She stated the S/S of a stroke included numbness, weakness, slurred speech, and facial drooping. LPN3 further stated she would notify the provider after one or two hours if there were no improvement in a resident's vitals who might be experiencing S/S of a stroke. In interview on 11/14/2024 at 10:25 AM, RN3 (an agency nurse) stated she had been working at the facility since 05/2024. She stated the S/S of stroke were FAST which stood for facial drooping, arm weakness, speech difficulty, and time symptoms appeared. RN3 stated a resident experiencing S/S should be monitored for hypertension. She reported neuro checks and vitals were to be taken every 15 minutes times four; every 30 minutes times two; every one hour times six hours; and then every four hours. The RN further stated if a resident's B/P did not return to baseline or the resident changed in their mental status, she would notify the physician immediately. During interview with the Quality Assurance (QA) Nurse on 11/14/2024 at 9:45 AM, she stated the facility did not provide specific in-service training on the sign and symptoms of strokes. The QA Nurse stated, Licensed nursing staff should know the signs of stroke. She reported however, it was important for them to recognize the different signs and symptoms of a stroke, as a resident might require an increased level of care or emergency intervention. She reported she encouraged staff to report anything that seemed off with a resident to the nurse on duty. During interview with the NP on 11/15/2024 at 11: 22 AM, she stated it was her expectation that RN2 should have called her back to notify her of R76's continued elevated B/P readings. She said if the nurse had notified her, she would have sent R76 to the local hospital for further evaluation based on her elevated B/P. The NP stated quality of care dictated when there was a change in a resident's mental status, either she or the physician were to be notified immediately. She further stated making the provider aware of any change in condition was important for the safety and well-being of the resident. In interview on 10/09/2024 at 3:01 PM, the former DON stated the nurse on duty followed the facility's protocol for neuro checks. She reported however, the nurse should have sent R76 to the hospital for evaluation due to her elevated B/P and changes in mental status. The former DON stated she would have sent R76 out if I had been the nurse. She emphatically said when a resident experienced a change in condition or mental status, the nurse was to notify the medical provider. The former DON additionally stated R76's increased B/P and altered mental status could have indicated the resident had sustained an injury. During interview with the Interim DON on 11/21/2024 at 3:45 PM, she stated she expected all nursing staff to follow the facility's policies and procedures regarding quality of care. The Interim DON said she also expected staff to notify the physician immediately of any injury or decline in a resident's status. She stated following standards of practice related to a resident's change in condition ensured the resident received appropriate and timely care. The Interim [NAME] further stated her review of the facility and its operations to date had revealed there are no systems in place to ensure staff were following the facility's policies and protocols. In interview on 11/22/2024 at 2:02 PM, the Interim Administrator stated it was her expectation for staff to follow the facility's Quality of Care policy to ensure safe and appropriate care was provided for all residents. During interview with the Medical Director on 11/14/2024 at 1:45 PM, he stated the nurse on duty should have communicated the changes in R76's condition to the on call provider. The Medical Director said nurses should use their nursing judgment based on their standards of care and notify the provider on call in emergency situations. He stated there were standing orders regarding nursing parameters, which included elevated B/P. The Medical Director said any neuro changes was to have immediate notification to the provider. He further stated he expected nursing staff to follow all facility policies related to quality of care. The Medical Director said that was to ensure the residents received quality care according to current nursing care standards. The facility provided an acceptable IJ Removal Plan on 11/22/2024 that read verbatim: Root Cause: The facility failed to promptly identify and intervene for a change in a resident's condition when Resident 76 (R76) had an elevated blood pressure for a prolonged period. The resident's family requested for the facility to transport the resident to the hospital. The resident was admitted to the hospital with broken/repetitive speech and rated her headache at five out of ten for pain. The resident was diagnosed with a transient ischemic attack (TIA) (mini stroke). Resident Affected: o Resident 76 (R76) was the resident affected; however, all residents currently have the potential to be affected. o On 11/17/24 Quality Assurance Nurse (QA), Minimum Data Set Coordinator (MDS) and Infection Control Nurse (IP) called all resident's physicians to get blood pressure parameters. All resident orders and careplans were updated with blood pressure parameters given by the physician(s). o On 11/18/24 Administrator pulled up Risk Management and reviewed all falls since 11/1/24 to ensure physician or ARNP and responsible party was notified of the fall. All notifications were completed from 11/1/24 to current. o On 11/18/24, Administrator pulled up 72-hour report to review any residents with change of condition to ensure physician or ARNP was notified of the change. All notifications from the 72-hour report were completed. Education/Training: o Director of Nursing and or Administrator trained the Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day on Notification of Change Policy on 11/19/24. Staff will sign in for the education and complete a post test. o On 11/19/24 MDS, QA, IP and Director of Adult Day started education on Notification of Change Policy to all nursing staff to include Licensed Practical Nurses (LPN) and Registered Nurses (RN) to include any new hires and agency LPNs and RNs. All current RNs and LPNs will be educated by 11/21/24. Any LPN or RN who has not been educated will be educated prior to working their next shift to include new hires and agency staff. Education will be completed by Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day. Staff will sign in for the education and complete a post test. o Director of Nursing and or Administrator trained the Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day on Develop/Implementation of Care Plan Policy on 11/19/24. Staff will sign in for the education and complete a post test. o On 11/19/24 MDS, QA, IP and Director of Adult Day started education on Develop/ Implementation of Care Plan Policy to all nursing staff to include Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNAs) and Registered Nurses (RN) to include any new hires and agency LPNs and RNs. All current RNs, CNAs and LPNs will be educated by 11/21/24. Any LPN, CNA or RN who has not been educated will be educated prior to working their next shift to include new hires and agency staff. Education will be completed by Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day. Staff will sign in for the education and complete a post test. o On 11/19/24 MOS, QA, IP and Director of Adult Day started education to CNAs on how to find the Kardex charting tool on Point Click Care (PCC). This will enable the CNAs to see the resident's care plans. All CNAs will be educated by 11/21/24. Any CNA who has not been educated will be educated prior to working their next shift to include new hires and agency staff. Education will be completed by Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day. Staff will sign in for the education and complete a post test. o Director of Nursing and or Administrator trained the Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day on Falls Protocol to include monitoring resident who had a fall for next 72 hours and report any changes in vitals out of baseline to the physician immediately on 11/19/24. Staff will sign in for the education and complete a post test. o On 11/19/24 MDS, QA, IP and Director of Adult Day started education with RNs and LPNs to include new hires and agency staff on the falls protocol to include monitoring resident who had fall for the next 72 hours and report and changes in vitals out of baseline to the physician immediately. All current RNs and LPNs will be educated by 11/21/24. Any LPN or RN who has not been educated will be educated prior to working their next shift to include new hires and agency staff. Education will be completed by Minimum Data Set Coordinator (MDS), Quality Assurance Nurse (QA), Infection Control Nurse (IP), and Director of Adult Day. Staff will sign in for the education and complete a post test. Monitoring: o Starting 11/19/24 Director of Nursing (DON) or QA Nurse, MDS Coordinator, or IP Nurse will review all falls daily in morning clinical meeting to validate resident's care plan was updated. This will be part of the morning clinical meeting to check within 24 hours including weekends. o Starting 11/19/24, Director of Nursing, Administrator, QA Nurse, MDS Coordinator, or IP Nurse will monitor in daily clinical meeting any resident with a change of condition the residents care plan is updated. This will be part of the morning clinical meeting to check within 24 hours including weekends. o ADHOC QAPI was held on 11/20/24, the following members attended Medical Director, Administrator, DON, IP, MDS, Social Service Director/Activities Director, Maintenance Director, Human Resources, [NAME] Manager, Admission Director, Scheduler, Rehab Program Manager, Housekeeping Director and Dietary Director. During this meeting tag F684 was discussed and the plan of correction was discussed and reviewed with the team. o All monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) Committee weekly for the next six (6) months. The QAPI Committee consists of Medical Director, Administrator, DON, IP, MDS, Social Service Director/Activities Director, Maintenance Director, Human Resources, [NAME] Manager, Admission Director, Scheduler, Rehab Program Manager, Housekeeping Director and Dietary Director. If there are any issues found prior to the monthly QAPI meeting an ADHOC meeting will be called to address the issues.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP), who advised monitoring the resident, with no new orders given. RN2 noted R76 had prolonged elevated blood pressure readings, with systolic readings between 180 and 190 until 7:00 PM. However, RN2 failed to inform the NP of R76's continued elevated blood pressure readings. On 05/17/2024, R76's blood pressure continued to remain elevated, and the resident presented a mental status change which included: lethargy, confusion, and incoherent speech. However, RN2 failed to document the mental status changes observed and failed to notify the physician/NP of R76's worsening physical condition. R76's family arrived to visit the resident at 6:00 PM on 05/17/2024 and expressed their concerns about R76. They expressed concern over R76's increased lethargy, confusion, change in speech pattern, and persistent high blood pressure. RN2 then contacted the physician regarding the family's request for R76 to be transferred to the hospital for evaluation. R76 was admitted to the hospital for observation and diagnosed with a transient ischemic attack (TIA, temporary blockage of blood flow to the brain). Immediate Jeopardy (IJ) was identified on 11/14/2024 and was determined to exist on 05/16/2024, in the area of 42 CFR S483.10 Resident Rights, F580 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 11/14/2024. The facility provided an acceptable IJ Removal Plan, on 11/22/2024, alleging removal of the IJ on 11/22/2024. The State Survey Agency (SSA) validated the IJ had been removed on 11/22/2024 as alleged, prior to exit on 11/22/2024. Remaining non-compliance continued at a S/S of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F684 The findings include: Review of the facility's policy titled, Notification of Change of Condition, undated, revealed the facility was to inform the resident's physician when there was an accident involving the resident that resulted in injury and had the potential for requiring physician intervention. Additionally, the physician was to be notified when there was a deterioration in the resident's physical mental or psychosocial status. Review of the Face Sheet for R76, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 08/22/2022, with diagnoses to include metabolic encephalopathy, general anxiety disorder, and essential (primary) hypertension. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated severely impaired cognition. Continued MDS review revealed R76 was assessed as independent with mobility, toileting, transfers, and ambulated by herself with no assistance from a helper. Per review of the MDS, R76 was able to independently walk 150 feet with the assist of a walker. Review of R76's Nurse Progress Note, dated 05/16/2024 at 1:42 PM, revealed the resident had been found lying on the floor by a State Registered Nurse Aide (SRNA). Per review, the SRNA found R76 attempting to pull herself up off the floor using her walker and leaning against the wall. Continued review revealed R76 told the SRNA she bent down trying to pick something up and lost her balance, causing her to fall. The note stated R76 hit her head during the fall, but stated it had not caused her any pain. Further review revealed the nursing assessment noted no redness or swelling observed to R76's head; the resident had full range of motion (ROM); and her neurological (neuro) checks were at baseline. Per review of the Note, R76's blood pressure was 190/70, which was elevated from her baseline. Additionally, review revealed the nurse notified the NP, and no new orders were received. Review further revealed the note stated the resident's family, and the DON were notified. Review of the Neurological Record, for R76 dated 05/16/2024, revealed the neurological (neuro) checks, including vital signs, pupil size, level of consciousness, speech, and motor responses, were conducted at the following intervals: every 15 minutes times four; every 30 minutes times four; every hour times four; and every two hours times four. Review revealed the results of R76's neuro checks at 1:15 PM, revealed the resident's b/p was recorded as 190/70. Continued review revealed the 1:15 PM assessment noted R76 as alert; her speech as coherent; with full ROM in all extremities; and her pupils as equal and reactive at baseline. Subsequent review of the Neurological Record assessments showed R76's neuro checks remained at baseline. Further review revealed R76's systolic b/p readings remained elevated until 7:00 PM, and were documented as follows: 1:30 PM, 182/72; 1:45 PM, 184/72; 2:00 PM, 182/70; 2:30 PM, 184/72; 3:00 PM, 172/70; 3:30 PM, 176/72; 4:00 PM, 182/72; 5:00 PM, 190/70; and 6:00 PM, 182/70. Additional review revealed at 7:00 PM, R76's b/p was 133/56, with pupil response, speech, and motor responses remaining unchanged. Review further revealed the 8:00 PM b/p reading documented was illegible. Continued review of R76's Neurological Record, documentation dated 05/17/2024, revealed neuro checks, including vital signs, pupil size, level of consciousness, speech, and motor responses, were conducted at the following intervals: every four hours times three; and then every eight hours times four. Per review of the assessment documentation, R76 was alert; her speech was coherent; she had full ROM in all extremities; and her pupils were equal and reactive at baseline. Review of subsequent assessment documentation revealed R76's neuro checks remained at baseline. Continued review revealed at 4:00 PM, R76's level of consciousness (LOC) was initially marked as drowsy, stuporous, and unconscious; however, that information was marked with the word error handwritten over them. Further review of the assessment documentation revealed R76's b/p readings noted at 12:00 AM and 4:00 AM were illegible. Additional review revealed R76's b/p at 8:00 AM was 148/78 and at 4:00 PM was 146/70 (the last taken before the resident was transferred to the hospital). Review of R76's Nurse Progress Notes, dated 05/17/2024 at 7:10 PM, authored by RN2, revealed the resident was transferred to the local hospital via emergency medical services (EMS) per the physician's order and at family's request. Continued review revealed R76's family arrived at 6:00 PM on 05/17/2024, and requested the facility send R76 to the local hospital for evaluation of her increased lethargy and elevated b/p throughout the day. Further review revealed no documented evidence written in the Note related to any neuro changes exhibited by R76. During interview with Family Member (F)3 on 10/04/2024 at 2:31 PM, she stated she was told by her daughter (F4), that R76 had sustained a fall on 05/16/2024. F3 stated F4 was a SRNA who was employed at the facility at the time of the incident and had been at the facility for an in-service the day the fall occurred. F3 said F4 visited R76 on 05/16/2024, and the resident told F4 she sustained a fall. She stated R76 also told F4 she hit her head during the fall and was experiencing a headache. F3 reported when she visited R76 on 05/17/2024, the resident's systolic b/p was severely elevated, reaching the 190's, and she was exhibiting behavior that was noticeably different from her baseline. She stated the nurse on duty told her (F3) she had notified the NP and the NP's orders included monitoring R76's blood pressure. F3 said R76's speech was garbled, and she (the resident) seemed incoherent. She further stated she requested R76 be sent to the hospital, where she was admitted for two nights for BP monitoring and change in mental status. During telephone interview with RN2 on 10/04/2024 at 1:33 PM, she stated on 05/16/2024 at 1:00 PM, she was informed by the SRNA that R76 had sustained a fall while returning from the bathroom. She stated she assessed R76 and found no injuries, but the resident's systolic b/p had been elevated, with readings in the 190's. RN2 stated she performed neuro checks and vital signs according to the facility's fall protocol, and although the resident's b/p was elevated, she had no concerns. She said R76 did not exhibit any change in her LOC, and she notified the resident's family, the DON, and the NP of R76's fall and elevated b/p. The RN reported the NP told her to follow the facility's protocols and let her know if there were changes in the resident; and no other new orders were received. RN2 stated R76 did not have specific b/p parameters to follow. She stated the family visited and expressed concern about R76's elevated b/p; however, RN2 said she reassured them the NP indicated the elevated b/p was likely due to anxiety following the fall. RN2 further stated, R76's b/p came within her baseline after several hours, and she did not call the NP back to update her with R76's physical status. In continued interview on 10/04/2024 at 1:33 PM, RN2 stated on 05/17/2024, R76 started exhibiting a change in mental status. The RN said R76 was lethargic and was speaking incoherently at times. She stated when R76's family arrived at 6:00 PM that day, they requested the resident be evaluated at the local hospital due to her increased lethargy and elevated b/p during the day. The RN reported she called the provider, who gave the order for R76 to be transferred to the hospital. Additionally, RN2 said she could not recall if she had read the facility's Notification of Change policy. Review of R76's Emergency Department (ED) Note, dated 05/17/2024 at 7:05 PM, revealed the resident had been transferred there from the facility. Per review, the physician noted R76 had altered mental status; dysarthria (difficulty in speech due to weakness of speech muscles); and significantly elevated b/p, with systolic readings in the 170's and 180's compared to the normal range of 120's to 130's. Further review revealed R76 exhibited staccato (broken speech) and repetitive speech and rated a headache at five out of 10, on a scale of one to 10, for pain. In addition, review revealed due to those issues, R76 was admitted to the hospital for observation and diagnosed with a TIA. During interview with the DON on 10/09/2024 at 3:01 PM, she stated the nurse on duty followed the facility's protocol for neuro checks. The DON stated however, the nurse should have sent R76 to the hospital for evaluation due to her elevated b/p and changes in mental status. She stated, I would have sent her [R76] out if I had been the nurse. The DON emphasized that when a resident experienced a change in condition or mental status, the nurse was to notify the medical provider. She stated R76's increased b/p and altered mental state might have indicated the resident had sustained an injury. During interview with the NP on 11/15/2024 at 11: 22 AM, she stated it was her expectation that RN2 should have called her back to make her aware of R76's continued elevated b/p readings. She said she would have sent R76 to the local hospital for further evaluation based on the resident's elevated b/p. The NP stated when there was a change in a resident's mental status, either she or the physician were to be notified immediately. She further stated making the provider aware of any change in condition because that was important for the safety and well-being of the resident. During a telephone interview with the Medical Director on 11/14/2024 at 1:45 PM, he stated the nurse on duty should have communicated changes in the resident's condition to the providers. He stated nurses were to use their nursing judgment and notify the provider on call in emergency situations. The Medical Director stated there were standing orders regarding nursing parameters, which included elevated b/p's. He said any neurological changes in a resident should prompt immediate notification. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure the safety of the residents. During interview with the Interim DON on 11/21/2024 at 3:45 PM, she stated that it was her expectation for all nursing staff to follow the facility's policies and procedures regarding resident change in condition. She stated nursing staff should notify the physician immediately of any injury or decline in status as per the policies and procedures. The Interim DON said following procedures related to a resident's change in condition ensured the resident received appropriate and timely care. She further stated in her review of the facility and its operations to date there were no systems in place to ensure staff were following the facility's policies and protocols. During interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated that she expected staff to follow the facility's Notification of Change policy to ensure safe and appropriate care for all residents.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans (CCP's) interventions were implemented when a change of condition occurred for one of 26 sampled residents, (Resident (R)76). Review of the facility's CCP developed for R76 revealed the resident was care planned for hypertension to include interventions to monitor, document, and report to the medical provider any signs and symptoms of headache, confusion, and lethargy. R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 notified the Nurse Practitioner (NP) who advised monitoring the resident. RN2 documented normal neurological (neuro) checks for R76. However, the resident experienced prolonged elevated blood pressures (B/P's) with systolic readings between 180 and 190 (The resident's baseline systolic readings were 120 to 130) until 7:00 PM. R76 also verbalized a compliant of a headache to staff. However, RN2 failed to follow the care plan to monitor, document, and report R76's elevated B/P and headache to the NP. On 5/17/2024, R76's blood pressure readings remained elevated with the systolic between 140 and 150 and the resident exhibited a change in mental status to include lethargy and incoherent speech at 4:00 PM. However, RN2 again failed to follow R425's CCP's interventions to document the change in condition, the resident's complaints of headache, or report to the medical provider any signs and symptoms of elevated blood pressure. At the family's request, the physician was notified at 6:00 PM on that date, and R76 was transferred to the hospital for increased lethargy and elevated blood pressure. R76 was subsequently admitted to the hospital and diagnosed with a transient ischemic attack (a brief stroke-like attack). The facility's failure to have an effective system in place to ensure residents' care plans were implemented to address monitoring of residents with a change in condition is likely to cause serious injury impairment or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 11/14/2024, and was determined to exist on 05/16/2024, in the area of 42 CFR S483.21 Comprehensive Resident Centered Care Plan, F-656 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 11/14/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 11/22/2024, alleging removal of the IJ on 11/22/2024. The State Survey Agency (SSA) validated the IJ was removed on 11/22/2024 as alleged, prior to exit on 11/22/2024. Remaining non-compliance continued at a S/S of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F684 The findings include: Review of the facility's policy titled, Care Plan Development in the EHR [electronic health record] Policy and Procedure, undated, revealed the facility must create and implement a comprehensive, person-centered care plan for each resident in accordance with their rights. Per review, the care plan should include measurable objectives and timeframes. Continued review revealed the facility was required to develop and implement services aimed at helping residents achieve or maintain their highest possible levels of physical, mental, and psychosocial well-being, in consultation with the residents and their representative. Review of the facility's policy titled, Falls Policy and Procedure, revised 11/18/2024, revealed the facility was to care plan all residents who were at risk for falls. Review of R76's Face Sheet, located in the facility's electronic medical record (EMR), revealed the facility admitted the resident on 08/22/2022, with diagnoses to include general anxiety disorder, metabolic encephalopathy, and essential (primary) hypertension. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed R76 to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated severe cognitive impairment. Continued MDS review revealed R76 was assessed as independent with mobility, toileting, transfers, and ambulated by herself with no assistance from a helper. Additionally, MDS review further revealed R76 was assessed as able to walk 150 feet with the assist of a walker independently. Review of R76's CCP, dated 05/11/2024, revealed the facility identified R76 as as having hypertension on 10/22/2022, with a goal for the resident to remain free of complications. Continued review revealed the interventions included monitoring, documenting, and reporting any signs and symptoms of hypertension. Further review revealed the interventions staff were to monitor, document, and report the following signs and symptoms of hypertension which included headaches, visual problems, confusion, disorientation, and lethargy. Further review revealed however, the facility failed to implement the resident's care plan to ensure adequate assessmen, monitoring, and notification to the medical provider when the resident developed a sustained change in condition. Review of R76's Nurse Progress Note, dated 05/16/2024 at 1:42 PM, revealed the resident had been found lying on the floor by a State Registered Nurse Aide (SRNA). Per review, R76 reported hitting her head during the fall, but it was not causing her any pain. Continued review of the Note revealed the nurse's assessment noted no redness or swelling noted to R76's head and the resident had full range of motion (ROM). Further review revealed R76's neuro checks were documented as at baseline; however, the resident's B/P was noted at 190/70, which was elevated from her baseline. In addition, review revealed the nurse notified the NP who recommended monitoring R76, and no new orders received. Review of R76's Nurse Progress Note, dated 05/17/2024 at 7:10 PM, signed by RN2, revealed per R76's family's request and physician's order the resident had been transferred to the local hospital via emergency medical services (EMS). Per review of the Note, the resident's family arrived to visit R76 on 05/17/2024 at 6:00 PM, and requested she be transferred to the local hospital for evaluation of her increased elevated B/P and lethargy throughout the day. During telephone interview with SRNA6 on 10/07/2024 at 1:23 PM, she stated she responded to R76's call light on 05/16/2024, and asked her if she needed help going to the bathroom. SRNA6 stated the resident indicated she needed assistance with her walker so she assisted R76 with that and with going into the bathroom. SRNA6 reported the resident came out the bathroom on her own with her walker and sustained a fall near the closet. Per the SRNA in interview, she had been in the room at the time but had not witnessed R76 fall. She said she and another staff member, whom she could not recall, helped the resident up off the floor and assisted her back to bed. SRNA6 stated the resident no complaints other than a headache at the time. She said when RN2 came to assess R76, she reported the resident's complaint of a headache to the nurse. The SRNA stated she did every 15-minute checks of the resident for two hours following the fall, which included taking her vital signs. She further stated R76's blood pressure was higher than normal and she communicated that information to RN2. In a telephone interview on 10/04/2024 at 1:33 PM, RN2, she stated on 05/17/2024, R76 exhibited a change in her mental status, was lethargic and speaking incoherently at times. She stated R76's family arrived at 6:00 PM on 05/17/2024, and requested the resident be evaluated at the local hospital due to her increased lethargy and elevated blood pressures during the day. RN2 further stated she called the provider, who gave the order for the transfer. Review of R76's, Emergency Department (ED) Note, dated 05/17/2024 at 7:05 PM, revealed the resident presented to the local ED following a fall at the facility. Per review, the physician assessed R76 to have: an altered mental status; symptoms of dysarthria (slurred speech), staccato and repetitive speech; and prolonged elevated blood pressure. Continued review revealed R76's systolic B/P was noted as significantly elevated, measuring in the 170's and 180's, compared to the resident's systolic baseline range of 120's to 130's. In addition, review revealed R76 was admitted to the hospital for observation of her elevated B/P, change in speech and mental status, and diagnosed with a transient ischemic attack (TIA). In a telephone interview with RN2, on 10/04/2024 at 1:33 PM, she stated she had not updated R76's CCP to include additional interventions to prevent future falls after the resident sustained the fall on 05/16/2024. The nurse stated however, R76's CCP should have been updated immediately to include interventions to alert staff and to keep the resident safe. During interview with the MDS Nurse on 10/04/2024 at 1:10 PM, she stated no new interventions were added to R76's CCP following the resident's first fall on 05/16/2024. She stated however, the resident's CCP should have been updated with a new intervention to prevent further falls and to monitor her for changes in condition. The MDS Nurse stated all resident falls were discussed in the morning meeting, where the team developed interventions to prevent/reduce falls and injuries. She further stated an Interdisciplinary Team (IDT) Note should have been placed in the resident's chart related to the fall; however, she could not locate such a Note. In interview with the former DON (who was the DON at the time of the interview), on 10/09/2024 at 3:01 PM, she stated R76 should have been care planned with additional interventions after her fall on 05/16/2024. The former DON said adding interventions after the fall was to ensure all staff were aware of how to care for and monitor R76 for changes in condition. She stated it was the responsibility of the MDS Nurse to update and revise residents' CCP and she did not know why the MDS Nurse had not updated R76's CCP. The former DON further stated implementing residents' CCP's was essential because it instructed staff on how to best care for and keep residents safe. During interview with the Medical Director, on 10/25/2024 at 11:01 AM, he stated it was his expectation staff would adhere to the facility's CCP policy. He further stated it was his expectation staff revised care plans to ensure resident-centered care and safety for the residents. In interview with the former Administrator, on 10/25/2024 at 12:45 PM, he stated it was his expectation staff followed the facility's CCP policy. He said he expected staff to update care plans as needed to ensure care for residents was appropriate and safe. During an additional interview with the MDS Nurse on 11/14/2023 at 9:41 AM, all nurses had access to revise and update the CCP. The MDS Nurse stated R76's care plan should have been updated following her fall to include monitoring for changes in condition. Additionally, she stated R76's care plan should have incorporated interventions to notify the physician of prolonged elevated B/P, pain, and any changes in the resident's mental status. During additional interview with the Medical Director on 11/14/2024 at 1:45 PM, he stated the nurse on duty should have communicated the changes in R76's condition to the provider on call. Medical Director stated it was his expectation staff followed all facility policies, including the care plan policies, to ensure the safety of the residents. During interview with the Interim DON on 11/21/2024 at 10:45 AM, she stated the MDS Nurse was responsible for the comprehensive assessments of all residents. The Interim DON stated the MDS Nurse ensured residents' care plans were updated and revised as necessary and in a timely manner. She further stated however, all nurses had the authority to access, update, and revise the care plans if needed. During additional interview with the Interim DON on 11/21/2024 at 3:45 PM, she stated that it was her expectation that all nurses implemented and revised residents' CCP's as needed to ensure residents received comprehensive, patient-centered care. She stated R76 should have had a care plan developed with additional interventions to implement to ensure all staff were aware of how to care for and monitor her for a decline in condition, including altered mental status. The Interim DON further stated implementing residents' care plans was essential, as it provided instructions to staff on how to best care for the residents and ensure their safety. She additionally stated it was her expectation for staff to follow all facility policies to ensure the safety of the residents. In interview on 11/22/2024 at 2:02 PM, the Interim Administrator stated it was her expectation staff followed the facility's CCP policy and update care plans as needed to ensure the safe and effective care of all residents.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan for new residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of 26 sampled residents (Resident (R)425). R425 required hemodialysis treatments that included parameters for the resident's vital signs and had a known history of falls. However, the facility failed to implement a baseline care plan upon R425's admission to address his hemodialysis needs and risk for falls. Refer to F689 and F698 The findings include: Review of the facility's policy titled, Care Plan Development in the HER Policy and Procedure, dated 11/2016, revealed it was the policy of the facility that the care plan was a living document that was started upon admission. Per review, the care plan was started upon a resident's admission from information gathered from the resident, family, admission assessments completed by each department, physician's prescriptions and records from the transferring facility or referral source. Further review revealed every effort was made to assure the resident's individual history, patterns, preferences, and choices were included, as that information became available to the care plan team members. Review of R425's face sheet, located in the electronic health record (EHR) revealed the facility admitted him on 11/08/2024 with diagnoses of Congestive Heart Failure. Additional review of R425's EHR revealed End Stage Renal Disease (ESRD) with Hemodialysis listed on his medical diagnosis list. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R425 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Review of R425's EHR record revealed it contained no documented evidence of an admission assessment and baseline care plan completed upon the resident's admission on 11/08/2024. Further review revealed documentation from a hospital discharge summary dated 10/14/2024, with noted R425 was dependent on dialysis due to ESRD. Review of R425's Progress Notes dated 11/05/2024 at 12:59 PM, from his Personal Care medical record (where the resident resided prior to his transfer to the facility's skilled nursing on 11/08/2024) revealed he had sustained a fall on 11/05/2024. Review of the facility's Baseline Care Plan developed 11/11/2024, for R425 revealed a problem for falls with interventions being added on that date. Review of R425's Progress Notes dated 11/09/2024 at 11:08 AM, revealed the resident had a history of three or more falls in the past three months and a Fall Risk Score of 18.0, which indicated being at high risk for falls. Per review, R425's level of consciousness (LOC)/mental status was documented as intermittent confusion and his vision as adequate. Continued review revealed R425 was noted as being ambulatory; to require an assistive device; and as having a balance problem while standing. Further review revealed R425's systolic blood pressure was noted to have no drop between lying and standing. Recent hospitalization history in last 30 days: Review of R425's Progress Notes dated 11/09/2024 at 6:23 PM, revealed the resident sustained another fall on this date and was sent to the hospital for further evaluation. Per review, report on the resident was received from the emergency room (ER) at 6:00 PM, regarding the resident's return to the facility. Continued review revealed the ER discharge summary received upon R425's return, the resident sustained a subdural hematoma which was unchanged by the scan completed, and an abrasion to his scalp. Review of R425's Progress Notes dated 11/11/2024 at 6:13 PM, revealed the resident had experienced another fall. Continued review revealed R425 was sitting in the wheelchair in his room and was alert and oriented time three (x 3), to person, place, and time). Further review revealed R425's neurological (neuro) checks were within normal limits and his respirations were even and unlabored. In addition, review further revealed R425 had no signs/symptoms of adverse reaction related to the fall. Review of R425's Fall Risk Evaluation dated 11/13/2024, revealed a score of eight, indicating he was not a high fall risk. Interview was attempted on 11/19/2024 at 8:30 AM, with R425 however, the resident was confused and unable to tell the State Survey Agency (SSA) Surveyor anything about his falls. In interview on 11/21/2024 at 9:14 AM, Licensed Practical Nurse (LPN) 6 stated residents' baseline care plans were located in the admission packets. LPN6 further stated the baseline care plans were to be completed on a resident's admission then turned into the MDS Nurse. In interview on 11/21/2024 at 9:42 AM, the MDS Nurse stated all nurses on the floor were responsible for completing baseline care plans when a resident was admitted . The MDS Nurse said baseline care plans were important and helped in developing the comprehensive care plan. She stated the baseline care plan was also important to implement/revise appropriately and timely so staff knew how to care for residents. The MDS Nurse further stated she could not find the original baseline care plan for R425 and had completed one after being asked for it by the State Survey Agency (SSA) Surveyor. In interview on 11/22/2024 at 10:51 AM, Registered Nurse (RN) 7 revealed there was an admission packet on all units and it contained a baseline care plan for the admitting nurse to complete. In interview on 11/22/2024 at 12:51 PM, RN1 stated he had not completed a baseline care plan for R425 because he did not know the resident was being transferred from personal care to skilled care. He said he did not know that one needed to be completed because of that. RN 1 further stated he reached out to the Director of Nursing (DON) and she never got back with him. In interview on 11/22/2024 at 1:50 PM, the Interim DON stated all nurses had access to and were to complete baseline care plans for all new residents. She further stated baseline care plans were to be completed on all residents for the residents' safety. In interview on 11/21/2024 at 1:55 PM, the Interim Administrator stated it was her expectation for baseline care plans to get completed timely and accurately so staff could care for residents appropriately.

Based on interview, record review, and review of the facility's policy, the facility failed to review and revise the comprehensive care plan (CCP) for one of 26 sampled residents (Resident (R)76). R76 fell on [DATE], and after having a change in mental status was transferred to the hospital on 05/17/2024, where she was diagnosed with a transient ischemic attack (a brief stroke-like attack). R76 returned to the facility on [DATE]. R76's family requested the resident remain in her room to rest after her hospitalization . However, staff on duty failed to update the CCP to include interventions aimed at preventing future falls or to incorporate the family's request for the resident to rest in her room. R76 sustained another fall on 05/19/2024, resulting in a fracture of the intertrochanteric region of her hip. Refer to F689 The findings include: Review of the facility's policy titled, Care Plan Development in the EHR [electronic health record] Policy and Procedure, undated, revealed the facility must create and implement a comprehensive, person-centered care plan for each resident in accordance with their rights. This plan should include measurable objectives and timeframes. Additionally, the policy revealed the facility was required to develop and implement services aimed at helping residents achieve or maintain their highest possible levels of physical, mental, and psychosocial well-being, in consultation with the residents and their representatives. Furthermore, the policy stated the facility was to ensure each resident's care plan was reviewed and revised as necessary to reflect any changes in their care needs during their stay. Review of the facility's policy titled, Falls Policy and Procedure, revised 11/18/2024, revealed that all residents who were at risk for falls would be care planned. Further review of the policy revealed care plans would be reviewed and updated quarterly, if indicated. Review of R76's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 08/22/2022 with diagnoses to include metabolic encephalopathy, general anxiety disorder, and essential (primary) hypertension. Review of R76's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated severe cognitive impairment. Further review revealed R76 was independent with mobility, toileting, transfers, and ambulation by herself with no assistance from a helper. The resident could walk 150 feet with the assist of a walker independently. Review of R76's CCP, dated 05/11/2024, revealed she was identified as a fall risk on 05/11/2023, related to gait/balance problems, psychoactive drug use, and a history of falling. Interventions initiated on 05/11/2023 included staff assist as needed for transfers, place the resident's call light within reach, and encourage the resident to use it for assistance as needed, respond promptly to the resident's requests for assistance, encourage resident to ring call bell for assistance prior to getting up, ensure resident had nonskid socks/slippers/shoes on at all times when up out of bed for fall safety, follow facility fall protocol, and keep walker in reach and encourage her to use when getting up. Review of R76's Nurse Progress Note, dated 05/16/2024 at 1:42 PM, revealed the resident was found on the floor by a State Registered Nurse Aide (SRNA). Per the note, the SRNA found the resident attempting to pull herself off the floor using her walker and leaning on the wall. Continued review revealed R76 stated she bent down trying to pick something up and lost her balance, causing her to fall. Review of R76's Nurse Progress Notes, dated 05/17/2024 at 7:10 PM and signed by Registered Nurse (RN) 2, revealed the resident was transferred to the local hospital via emergency medical services (EMS) as per the physician's order and at the family's request. Review of R76's Emergency Department (ED) Note, dated 05/17/2024 at 7:05 PM, revealed she presented to the local Emergency Department (ED) following a fall, and the physician assessed the resident as having an altered mental status, symptoms of dysarthria and prolonged elevated blood pressure. R76 was admitted to the hospital for observation of elevated blood pressure and change in speech and mental status. R76 was diagnosed with a transient ischemic attack (TIA). Review of R76's discharge MDS with an ARD of 05/17/2024, revealed the resident did not attempt a sit to stand due to medical conditions. Further, R76 required supervision (helper provided verbal cues and or touching, steadying, and or contact guard assistance as the resident completed the activity, assistance might be provided throughout the activity) from staff for mobility, toileting, transfers, and ambulation. Continued review revealed R76 had one fall resulting in a major injury. Further review of the CCP, revealed there were no revisions made or additional interventions initiated after R76's fall on 05/16/2024. Review of R76's hospital Patient Discharge Summary Report, dated 05/19/2024 at 10:12 AM, revealed the resident was diagnosed with a TIA and transferred back to the facility on [DATE]. New orders were given for medication to include acetaminophen 650 milligrams by mouth every six hours as needed for mild pain and Amlodipine 5 milligrams by mouth once daily for high blood pressure. The Summary did not include instructions related to activity or physical therapy. Review of R76's Behavior Note, dated 05/19/2024 at 3:13 PM, revealed the resident attempted to stand up from her wheelchair multiple times during outside activities, and the State Registered Nurse Aide (SRNA) redirected R76 to remain seated. Per the note, R76 was very confused and expressed a desire to go inside. The SRNA then assisted R76 back into the building; however, left her alone to care for another resident. The note stated, at 2:53 PM, R76 stood up, tripped, fell on to her right hip, and hit her head. Review of R76's Health Status Note, dated 05/19/2024 at 3:14 PM, revealed a SRNA alerted R76's nurse the resident was observed to have fallen outside the Activity Room. According to the note, there was no visible injury; however, R76 complained of pain in her right hip and neck and was transferred to the local hospital via emergency medical services (EMS). Review of R76's hospital Discharge Summary, dated 05/21/2024 at 3:40 PM, revealed the resident presented to the ED after experiencing an unwitnessed fall from a standing height, resulting in severe right hip pain and altered mental status. Per the Summary, R76 suffered a traumatic right hip fracture, which caused significant pain. R76's risk for general anesthesia and hip repair was high, and her wound healing ability was compromised due to poor overall and nutritional status. The Summary revealed R76 had been independent in her Activities of Daily Living (ADLs) prior to the fall, and at her baseline, she ambulated with a walker. Additional review revealed R76's family elected to forego any surgical intervention on the advice of both the physician and surgeon given the resident's low probability of successful healing and a high probability of harm due to surgery. Per the Summary, the resident was discharged to home with hospice care. During interview with F3, on 10/04/2024 at 2:31 PM, she stated when R76 returned to the facility on [DATE], the family requested the resident rest in bed and refrain from participating in any activities. However, F3 stated staff got R76 out of the bed and into a wheelchair within hours of her return from the hospital and took her to an outdoor activity. F3 stated R76 was unfamiliar with using a wheelchair and had not been assessed by physical therapy (PT) in order to use the wheelchair. She further stated she received a call from a nurse who stated R76 had been taken to an activity outside and sustained a fall near the Activity Room while trying to get out of her wheelchair. F3 stated R76 sustained a fracture of the intertrochanteric portion of her hip. According to F3, R76's family decided against surgical intervention due to the resident being a poor surgical candidate and her marked decline since the fall. F3 further stated R76 was taken home with hospice care. During an interview with Licensed Practical Nurse (LPN)5 on 11/20/2024 at 2:06 PM, she stated she was told nurses on the floor did not have access to update the residents' care plans. LPN5 stated if the MDS Nurse was unavailable, she would make the Director of Nursing (DON) aware of any updated needed. During an interview with LPN6 on 11/21/2024 at 9:14 AM, she stated that she was not aware that nurses had access to update care plans. LPN6 stated that only the MDS Nurse and the DON were responsible for updating the care plans. During an interview with RN1 on 11/22/2024 at 12:51 PM, he stated that only the MDS Nurse had access to update a resident's care plan. He revealed that he had not received training to make changes to a resident's care plan. RN1 stated if new interventions need to be added, he would communicate that information to the MDS Nurse. During a telephone interview with RN2, on 10/04/2024 at 1:33 PM, she stated she did not update R76's CCP to include additional interventions to prevent future falls after the resident sustained the fall on 05/16/2024. The nurse stated the CCP should have been updated immediately to include interventions to alert staff and to keep R76 safe. During an interview with the Minimum Data Set (MDS) Nurse, on 10/04/2024 at 1:10 PM, she stated no new interventions were added to R76's CCP following R76's first fall on 05/16/2024. She stated the CCP should have been updated with a new intervention to prevent further falls. Furthermore, the CCP should have included the family's request for the resident to rest in bed and avoid activities after returning from the hospital on 05/19/2024. During an interview with the former DON, on 10/09/2024 at 3:01 PM, she stated R76 should have been care planned with additional interventions to ensure all staff was aware of how to care for and monitor her after her fall on 05/16/2024. The DON stated the CCP should have included the family's request for the resident to rest in bed and avoid activities after returning from the hospital on 05/19/2024. Additionally, she stated it was the responsibility of the MDS Nurse to update and revise the CCP and she did not know why the MDS Nurse had not updated the CCP. The DON stated revising and implementing the CCP was essential because it instructed staff on how to best care for and keep the residents safe. During a follow-up interview with the MDS nurse on 11/14/2024 at 9:41 AM, she stated all nurses have access to revise and update the CCP. The MDS Nurse stated that R76's care plan should have been updated following her fall to include monitoring for changes in condition. During an interview with the Medical Director, on 10/25/2024 at 11:01 AM, he stated it was his expectation staff would adhere to the facility's CCP policy and revise care plans to ensure resident-centered care and safety for the residents. During an interview with the former Administrator, on 10/25/2024 at 12:45 PM, he stated it was his expectation staff follow the facility's CCP policy and update care plans as needed to ensure care for residents was appropriate and safe. During an interview with the Interim DON on 11/21/2024 at 10:45 AM, she stated the MDS Nurse was responsible for conducting baseline and comprehensive assessments on all residents. Additionally, the Interim DON stated the MDS Nurse ensured resident care plans were updated and revised as necessary and in a timely manner. The interim DON stated, however, the nurses have the authority to access, update, and revise the care plans if needed. During an interview with the Interim DON on 11/21/2024 at 3:45 PM, she stated that it was her expectation that all nurses implemented, updated and revised the CCP as needed to ensure residents received comprehensive, patient-centered care. She stated R76's care plan should have had a care plan developed with additional interventions to ensure all staff were aware of how to care for and monitor for the resident ' s decline in condition, including altered mental status. The Interim DON stated further that implementing the care plan was essential, as it provided instructions to staff on how to best care for the residents and ensure their safety. Further, she stated it was her expectation that staff followed all facility policies to ensure the safety of the residents. During an interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated it was her expectation that staff would follow the facility's CCP policy and update care plans as needed to ensure the safe and effective care of all residents.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of 26 sampled residents (Resident (R)76). 1. R76 sustained an unwitnessed fall on 05/16/2024 while ambulating from the bathroom to the bed. The resident had a change in mental status and was taken to the local hospital where she was admitted with dysarthria (a speech disorder caused by weak or hard-to-control muscles in the mouth, face or upper respiratory system), prolonged elevated blood pressure, and was also diagnosed with a transient ischemic attack (TIA) (a brief stroke-like attack). The resident returned to the facility from the hospital on 05/19/2024. Further, after R76's return from the hospital, the family requested that the resident remained in her room to rest after her hospitalization . Despite this, staff assisted the resident out of bed, placed her in a wheelchair, and took her outside for an activity. After the activity, R76 was left unsupervised in a hallway while she waited for help to return to her room. While unsupervised, R76 attempted to get out of the wheelchair without assistance, which caused her to fall. R76 sustained a comminuted (broken in at least two places) fracture of the intertrochanteric region of her right hip as a result of the fall on 05/19/2024. 2. Additionally, R425 was transferred to the facility from the Personal Care Home and was a risk for falls, having fallen while at the Personal Care Home. The facility; however, failed to care plan the resident for falls to ensure his safety. The facility admitted the resident on 11/08/2024 and since his admission, he fell two times on 11/09/2024 and sustained a subdural hematoma and an abrasion to his scalp, and he fell again on 11/11/2024. Refer to F657 The findings include: Review of the facility's policy titled, Falls Policy and Procedure, with a revision date of 08/2021, revealed the intent of the policy was to maintain the safety of residents, promote the highest level of physical functioning, and ensure the resident's environment remained as free from accidents and hazards as possible. Per review, the guidelines included fall risk assessments to be performed upon admission, readmission, quarterly, annually, and with a significant change of condition to identify fall risks. Continued review revealed referrals would be made to the therapy department. Further review revealed a care plan (CP) was to be implemented based upon the resident's risk of falls. 1. Review of R76's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 08/22/2022 with diagnoses to include metabolic encephalopathy, general anxiety disorder, and essential (primary) hypertension. Review of R76's Fall Risk Score Total, dated 03/31/2024 at 9:54 PM, revealed a fall score of seven, indicating she was not considered at high risk for falls. Review of R76's PT [Physical Therapy] Evaluation & Plan of Treatment, dated 04/23/2024, revealed PT assessed R76 as needing therapy due to documented physical impairments and associated functional deficits to prevent further decline in function and immobility and increased dependency on caregivers. According to the PT note, R76 had not been assessed for using a wheelchair. Review of R76's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident had severely impaired cognition. Continued review revealed R76 was independent with mobility, toileting, transfers, and ambulation by herself with no assistance from a helper. Per the MDS, the resident could independently walk 150 feet with the assist of a walker. Review of R76's Comprehensive Care Plan (CCP), dated 05/11/2024, revealed the resident was identified as a fall risk on 05/11/2023, related to gait/balance problems, psychoactive drug use, and a history of falling. Interventions placed on 05/11/2023 included staff assist as needed for transfers, place the resident's call light within reach and encourage the resident to use it for assistance as needed, respond promptly to resident requests for assistance, encourage resident to ring call bell for assistance prior to getting up, ensure resident had nonskid socks/slippers/shoes on at all times when out of bed for fall safety, follow facility fall protocol, and keep her walker in reach and encourage her to use it when getting up. On 10/04/2024 at 11:15 AM, the State Survey Agency (SSA) Representative requested the fall incident reports for falls R76 sustained on 05/16/2024 and 05/19/2024. However, according to the Director of Nursing (DON), the facility did not have these incident reports. Review of R76's Nurse Progress Note, dated 05/16/2024 at 1:42 PM, revealed the resident was found on the floor by a State Registered Nurse Aide (SRNA). According to the note, the SRNA found the resident attempting to pull herself off the floor using her walker and leaning on the wall. Further review revealed R76 stated she bent down trying to pick something up and lost her balance, causing her to fall. The note stated R76 hit her head during the fall, but stated it did not cause her any pain. Nursing assessment revealed no redness or swelling noted to the head; the resident had full range of motion; and neurological (neuro) checks were at baseline. Review of R76's Emergency Department (ED) Note, dated 05/17/2024 at 7:05 PM, revealed the resident presented to the local Emergency Department (ED) following a fall, and the physician assessed R76 as having altered mental status, symptoms of dysarthria and prolonged elevated blood pressure. As a result of these findings, R76 was admitted to the hospital for observation of elevated blood pressure and change in speech and mental status. R76 was diagnosed with a transient ischemic attack (TIA). Review of R76's Fall Risk Score Total, dated 05/17/2024 at 7:22 PM, after the resident was transferred to the hospital, revealed a fall score of 13, indicating she was considered at risk for falls. According to the fall risk assessment, R76's risk for falls increased in the past three months related to poor vision, use of a walker for ambulation, predisposing disease, and receiving three to four medications. Continued review of the CCP, revealed there were no revisions made or additional interventions placed after R76's fall on 05/16/2024. Review of R76's discharge MDS with an ARD of 05/19/2024, revealed the resident did not attempt a sit to stand due to her medical conditions. Additionally, R76 required supervision (helper provided verbal cues and or touching, steadying, and or contact guard assistance as the resident completed the activity, assistance might be provided throughout the activity) from staff for mobility, toileting, transfers, and ambulation. Further review revealed R76 had one fall resulting in a major injury. During an interview with the Minimum Data Set (MDS) Nurse, on 10/04/2024 at 1:10 PM, she stated no new interventions were added to R76's CCP on 05/16/2024, following R76's first fall. She stated the CCP should have been updated with a new intervention to prevent further falls. During an interview with Family Member (F) 3, on 10/04/2024 at 2:31 PM, she stated she was told by her daughter (F4), that R76 had sustained a fall on 05/16/2024. F3 stated F4 was a State Registered Nurse Aide (SRNA) and was employed at the facility at the time of the incident. Per the interview, F4 was at the facility for an in-service the day the fall occurred. F3 stated F4 visited R76 on 05/16/2024, and the resident told F4 she fell . F3 stated R76 also told F4 she hit her head during the fall and was experiencing a headache. F3 stated when she visited R76 on 05/17/2024, the resident's systolic blood pressure was severely elevated, reaching the 190s, and she exhibited behavior that was noticeably different from her baseline. During a telephone interview with F4, on 10/09/2024 at 1:47 PM, she stated she was employed at the facility as a SRNA, and happened to be at the facility for an in-service on 05/16/2024, the day R76's fall occurred. F4 stated the in-service was canceled, so she visited R76. F4 stated during the visit, R76 told her she had hit her head during the fall and was experiencing a headache. F4 further stated, She told me she was hurting. F4 explained R76's roommate told her R76 did fall near the closet. F4 stated she asked the SRNA on duty about a fall, and SRNA6 stated, Yes, she fell . F4 stated SRNA6 explained she came into the room and found R76 on the floor near the closet. F4 further stated the nurse on duty told her she had notified the Nurse Practitioner (NP) of the fall. During a telephone interview with SRNA6, on 10/04/2024 at 1:23 PM, she stated she was an agency SRNA, and she had only worked one shift at the facility. The SRNA stated she was responding to a call light and asked R76 if she needed help getting to the bathroom. The resident indicated she needed assistance with her walker, so SRNA6 helped R76 into the bathroom. SRNA6 stated the resident came out of the bathroom using her walker for ambulation, but then fell near the closet. The SRNA stated she was in the room, but did not actually see the fall happen. She stated she performed 15-minute checks on R76 for two hours to include vital signs. During a telephone interview with Registered Nurse (RN) 2 (an agency nurse), on 10/04/2024 at 1:33 PM, she stated on 05/16/2024 at 1:00 PM, she was informed by the SRNA that R76 had sustained a fall while returning from the bathroom. She stated she assessed the resident and found no injuries. RN2 stated she performed neurological checks and vital signs according to the fall protocol. She stated she notified the family, the DON, and the NP of R76's fall. During further interview with RN2, on 10/04/2024 at 1:33 PM, she stated on 05/17/2024, R76 started exhibiting a change in mental status. RN2 stated R76 was lethargic and was speaking incoherently at times. She stated when R76's family arrived at 6:00 PM on 05/17/2024, they requested R76 be evaluated at the local hospital due to increased lethargy and elevated blood pressures during the day. She stated she called the provider, who gave the order for the transfer. During an interview with the DON, on 10/09/2024 at 3:01 PM, she stated she did not have a fall incident report related to R76's fall on 05/16/2024 and noted there was no Interdisciplinary Team (IDT) note related to the fall in the resident's chart. Furthermore, she stated she could not explain why the documents were not in R76's chart. The DON stated the nurse on duty followed the facility's protocol for neuro checks. Review of R76's hospital Patient Discharge Summary Report, dated 05/19/2024 at 10:12 AM, revealed she was diagnosed with a TIA and transferred back to the facility on [DATE]. There were no instructions related to activity or physical therapy. Review of R76's Behavior Note, dated 05/19/2024 at 3:13 PM, revealed the resident attempted to stand up from her wheelchair multiple times during outside activities, and the SRNA redirected R76 to remain seated. The note revealed R76 was very confused and expressed a desire to go inside. The SRNA then assisted R76 back into the building, but left her alone to care for another resident. Per the note, at 2:53 PM, R76 stood up, tripped, fell on to her right hip, and hit her head. Review of R76's Health Status Note, dated 05/19/2024 at 3:14 PM, revealed a SRNA alerted R76's nurse that R76 was observed to have fallen outside the Activity Room. The note stated the nurse observed the resident on the floor. According to the note, there was no visible injury; however, R76 complained of pain in her right hip and neck. R76 was transferred to the local hospital via EMS. Review of the Computed Tomography (CT) scan of the pelvis, dated 05/19/2024 at 4:58 PM, revealed R76 sustained a comminuted, angulated, and mildly impacted non-displaced intertrochanteric fracture of the right femoral neck. Further review revealed there was a comminuted non-displaced right inferior pubic ramus fracture. Review of R76's hospital Discharge Summary, dated 05/21/2024 at 3:40 PM, revealed R76 presented to the ED after experiencing an unwitnessed fall from a standing height, which resulted in severe right hip pain and altered mental status. Per the Summary, the resident suffered a traumatic right hip fracture, which caused significant pain. The resident's risk for general anesthesia and hip repair was high, and her wound healing ability was compromised due to poor overall and nutritional status. The Summary stated R76 had been independent in her Activities of Daily Living (ADLs) prior to the fall, and at her baseline, she ambulated with a walker. Continued review revealed R76's family elected to forego any surgical intervention on the advice of both the physician and surgeon given the resident's low probability of successful healing and a high probability of harm due to surgery. According to the Summary, the resident was discharged to home with hospice care. During continued interview with F3, on 10/04/2024 at 2:31 PM, she stated when R76 returned to the facility on [DATE], they requested the resident to rest in bed and refrain from participating in any activities. However, F3 stated staff assisted R76 out of bed into a wheelchair within hours of her return from the hospital and took her to an outdoor activity. F3 stated R76 was unfamiliar with using a wheelchair and had not been assessed by PT to use the wheelchair. F3 stated she received a call from a nurse who stated the resident had been taken to an activity outside, and R76 had fallen near the Activity Room while trying to get out of her wheelchair. F3 stated the resident sustained a fracture of the intertrochanteric portion of her hip. She further stated the family decided against surgical intervention due to R76 being a poor surgical candidate and her marked decline since the fall. During an interview with SRNA8/Activity Aide (AA), on 10/04/2024 at 3:02 PM, she stated before R76's fall and recent hospitalization on [DATE], she had been a regular participant in activities and would typically use a walker to ambulate to the Activities' Room. SRNA8/AA stated, on 05/10/2024, staff brought R76 to a group activity where 10 to 15 residents were gathered outside in the courtyard. During the activity, R76 appeared disengaged and attempted to get in and out of her wheelchair. She further stated, R76 appeared confused, with nonsensical speech, and was not at her usual baseline. SRNA8/AA stated, after the activities concluded, she wheeled R76 back inside the building to a location near the entrance of the Activities' Room and secured her wheelchair. She stated she then left R76 alone briefly to get another resident. Upon returning, SRNA8/AA stated she discovered R76 trying to stand up. She stated the foot pedals on the wheelchair were engaged, and as R76 stood, she tripped over them and fell , landing on her side. During interview with the former DON, on 10/25/2024 at 12:01 PM, she stated R76 should not have been left unsupervised and alone in the wheelchair on 05/19/2024. She stated it was her expectation nursing staff followed the facility's Fall policy to prevent accidents and injuries and to keep residents safe. During an interview with the former Administrator, on 10/25/2024 at 12:45 PM, he stated it was his expectation staff followed the facility's Fall policy to prevent accidents and injuries and to keep residents safe. 51155 2. Review of R425's face sheet, located in the electronic health record (EHR) revealed the facility admitted him on 11/08/2024 with diagnoses of Congestive Heart Failure. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R425 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Review of R425's Progress Notes dated 11/05/2024 at 12:59 PM, from his Personal Care medical record (where the resident resided prior to his transfer to the facility's skilled nursing on 11/08/2024) revealed he had sustained a fall on 11/05/2024. Review of the facility's Baseline Care Plan developed 11/11/2024, for R425 revealed a problem for falls with interventions being added on that date. Review of R425's Progress Notes dated 11/09/2024 at 11:08 AM, revealed the resident had a history of three or more falls in the past three months and a Fall Risk Score of 18.0, which indicated being at high risk for falls. Per review, R425's level of consciousness (LOC)/mental status was documented as intermittent confusion and his vision as adequate. Continued review revealed R425 was noted as being ambulatory; to require an assistive device; and as having a balance problem while standing. Further review revealed R425's systolic blood pressure was noted to have no drop between lying and standing. Recent hospitalization history in last 30 days. Review of R425's Progress Notes dated 11/09/2024 at 6:23 PM, revealed the resident sustained another fall on this date and was sent to the hospital for further evaluation. Per review, report on the resident was received from the emergency room (ER) at 6:00 PM, regarding the resident's return to the facility. Continued review revealed the ER discharge summary received upon R425's return, the resident sustained a subdural hematoma which was unchanged by the scan completed, and an abrasion to his scalp. Review of R425's Progress Notes dated 11/11/2024 at 6:13 PM, revealed the resident had experienced another fall. Continued review revealed R425 was sitting in the wheelchair in his room and was alert and oriented time three (x 3), to person, place, and time). Further review revealed R425's neurological (neuro) checks were within normal limits and his respirations were even and unlabored. In addition, review further revealed R425 had no signs/symptoms of adverse reaction related to the fall. Review of R425's Fall Risk Evaluation dated 11/13/2024, revealed a score of eight, indicating he was not a high fall risk. Interview was attempted on 11/19/2024 at 8:30 AM, with R425 however, the resident was confused and unable to tell the State Survey Agency (SSA) Surveyor anything about his falls. During an interview on 11/21/2024 at 9:30 AM with Admissions Coordinator, she stated R425 had visited and toured facility prior to admission. She stated the resident was a falls risk, upon admission, and did not feel as though the resident was safely admitted from the Personal Care Home. During an interview on 11/21/2024 at 9:42 AM with the MDS nurse, she stated R425 should have been care planned for falls with interventions in place upon arrival to the skilled nursing facility for his safety. During an interview on 11/21/2024 at 9:59 AM with the Social Service Director (SSD), she stated it took a few weeks to move R425 to SNF because the facility was trying interventions to figure out if the change in environment was the cause of the resident's decline. She stated the resident had a noticeable decline from when he toured the facility to when he was admitted . In interview on 11/21/2024 at 9:42 AM, the MDS Nurse stated all nurses on the floor were responsible for completing baseline care plans when a resident was admitted . She stated the baseline care plan was important to implement/revise appropriately and timely so staff knew how to care for residents. The MDS Nurse further stated she could not find the original baseline care plan. During an interview with the Interim DON on 11/21/2024 at 10:45 AM, she stated it was her expectation that residents were assessed for falls so appropriate interventions were in place to keep residents safe. She stated further that it was her expectation staff followed the policies related to falls to prevent accidents and injuries and to keep residents safe. During an interview with Interim Administrator on 11/21/2024 at 10:50 AM, she stated it was her expectation that fall precautions were put into place to prevent any harm and for resident safety. She stated that it was her expectation staff followed facility policies to prevent accidents and injuries.

Based on observation, interview, poilcy review, and the facility assessment the facility failed to ensure the licensed nurses and other nursing personnel had the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. In interview agency staff stated they had not received training or education prior to being assigned to residents' care. The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety to the resident or other residents. Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc. undated, revealed there was no accommodation for agency staffing in the assessment. Per review of the Assessment, in the section titled, Table 3.1: Staff Competencies and Skills Based in Resident Population, the categories for training/assessment, competency approach, and competency listed licensed nurses, nursing assistants, dietary, environmental services, administration, therapy. However, continued review revealed no categories regarding agency staffing's training/assessment, competency approach, and competency. Continued review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc. undated, regarding Table 3.1 revealed it identified competencies for licensed nurse and nursing assistants were to be assessed during orientation, annually, and pre/post test. During interview on 11/20/2024 at 10:07 AM, the Schedule Coordinator (SC) stated she had been in her position since 08/14/2024, and was also a State Registered Nurse Aide (SRNA) and Kentucky Medication Aide (KMA). She stated her duties at the facility included employee onboarding and orientation. The SC said she had previously worked for a staffing agency and was familiar with the process for using agency staff. Per the SC in interview, for Unit 1, there were four nurse aides staffed, and during breakfast and lunch two of the aides went to the dining room and two stayed on the unit for resident care. She reported there was one Registered Nurse (RN) to cover the residents' needs and one Licensed Practical Nurse (LPN) who strictly passed medications. In continued interview on 11/20/2024 at 10:07 AM, the SC stated staff rotated through on the weekends with in-house and agency staff. She said having agency made things harder because the agency staff might not know the residents as well as facility staff. The SC stated having in-house staff made a difference with residents, and she was working with the Administrator to understand the facility's assessment and how to determine the Hours Per Resident Day (HPRD). She stated she was not currently familiar with the facility's assessment and its purpose. The SC reported when an agency employee started working at the facility, she set them up with a login for the facility's computer system, and agency staff could not pick up a shift if they were out of compliance with their trainings. She stated no one tracked the agency staff, but they were not allowed to provide care to residents if their online training was not current. She said when she was working for an agency, notifications were sent to her to complete necessary trainings or additional education before she was able to pick up shifts. In further interview on 11/20/2024 at 10:07 AM, the SC stated all agency staff were trained by their agency through a computerized training program which incorporated online videos and posttests to determine staffs' competency. She said once agency staff arrived for work at the facility all their training and certifications had already been imported from their agency. The SC reported agency personnel shadowed facility staff to become familiar with the resident, the charting system, and layout of the facility. She further stated agency staff competencies were completed prior to providing resident care, and they were not allowed to care for residents without passing their competencies. The SC also stated the agencies who supplied staffing for the facility were required to validate the credentials of staff who were to work at the facility. During interview on 11/22/2024 at 9:39 AM, LPN3 stated she was and agency nurse and had worked at the facility for a month. She stated the nurse aides who worked on the unit she did were mostly agency, but as they had worked at the facility for a long time, she felt like the aides knew the residents. The LPN said she received no education or training when she started working at the facility, and had not received any competency assessments since she started working. She stated her staffing agency made sure we have all of our trainings up to date. LPN3 reported she had not worked at the facility long enough to know if they provided check offs or had competency trainings. During interview on 11/22/2024 at 12:43 PM, R25 stated the agency staff did not know him or his preferences. He stated agency had to be told what to do, especially at night and on the weekends. R25 further stated, They don't know nothin, I have to tell them everything to do. During interview on 11/22/2024 at 12:51 PM, RN 2 (an agency nurse) stated when R425 came back from the hospital on 11/08/2024, they just dropped him off, and no one told him the resident was being admitted to skilled nursing from where he previously resided on the facility's personal care unit. He reported he texted the former Director of Nursing (DON) and received no response from her, so he called the house supervisor who assisted him. RN2 stated They didn't tell me I needed to do an initial assessment, I thought it was a transfer. He further stated when he told the former DON, she told him nothing, and said, You're basically left on your own. During an interview on 11/22/2024 at 2:01 PM, with RN1 (an agency nurse) he stated he worked on the facility's Unit 2. He stated he was the only nurse working on the unit and must pass medication, do treatments, assessments, discharges and admissions. The RN stated he felt overwhelmed at times, and said the nurse aides on his unit did not know the residents' needs and preferences. He said he was unsure if agency staff knew anything about the residents they were caring for. The RN reported he had not received any training from the facility or the agency he worked fro on competencies. He said when he was hired to work, there had been no education or skills check off, and the facility had not provided any additional skills or assessment verification. RN1 stated agency staff did not ensure continuity of care because some were not qualified or had not received proper training. He further stated he obtained his residents' vital signs because he did not trust the aides to accurately obtain them for him. During interview on 11/22/2024 at 1:15 PM, RN7 stated she had not received any training from the facility when she started. She stated there were a lot of new aides and it was hard to know if they were doing their jobs. The RN stated she had not received training from the agency she worked for; however, had been required to do online education. She further stated the facility had not provided her any skills check off or testing. During interview on 11/22/2024 at 2:04 PM, SRNA21 stated it was her sixth shift working at the facility, two shifts at night and the rest of the shifts during the day. She stated she was just placed on the floor to work with no training or had not been able to shadow another STNA. SRNA21 said she got report from the previous SRNA about her residents and that was it. She stated she completed some computer modules at the agency she worked for, and had been trained on Enhanced Barrier Precautions (EBP). During interview on 11/21/2024 at 1:19 PM, the Interim DON stated there was a huge problem with staffing from an agency stand point. She said she and the Interim Administrator figured the staffing was at 4.25 PPD which was high for the facility with the acuity level of the residents currently. The Interim DON reported we have a lot of agency staff currently, and when she looked at the staffing ratio for the last two days it revealed 68% of the facility's staffing was agency filled. She stated she and the Interim Administrator had presented their concerns to the facility's board of directors as recently as 11/20/2024. The Interim DON further stated with all the agency staff currently, there could not be continuity of care, and the residents needed to know who was going to be taking care of them consistently. During interview on 11/21/2024 at 2:09 PM, the Interim Administrator stated my role in developing the staffing schedule covered working with the Schedule Coordinator to ensure we have enough staffing to provide for the residents' needs.

Based on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for the total census of 74 residents, which included (Resident (R)3, R6, R9, R21, R41, R55, and R67). On 08/29/2024, and 09/04/2024, the sample result for the Unit 2 shower showed legionella non-pneumophila at poorly controlled growth levels. Staff interviews revealed the facility failed to provide showers for residents starting in early September 2024, due to the showers on Unit 1, Unit 2, and Unit 3 being closed. During that timeframe residents were only offered bed baths. Recommendations were made by the independent water systems company (IWSC) and the certified water safety and management expert (CLWSE) to bring in portable showers as a temporary measure in order for residents to have the opportunity to shower; however, the facility declined to do that. Review of an electronic mail (e-mail) sent on 09/18/2024, from the facility's Infection Preventionist (IP) to the Director of the Local Health Department (LHD), revealed the facility inquired about reopening the showers on Units 1 and Unit 3 for resident use as those showers no longer showed detectable levels of Legionella pneumophilia bacteria. Per the email, the LHD Director noted if there was no detection of legionella in those showers, there was no reason residents could not use them. However, the showers on Units 1 and Unit 3 were not opened for resident use until October 2024. Resident interviews revealed they were not sure why they could not take showers as they had not been informed of any water concerns. The resident interviews revealed they missed taking their showers as bed baths only made them feel partially clean. Refer to F880 The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed the resident had a right to a dignified existence with access to services inside the facility. Per review, the resident had the right to receive care in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life. Further policy review revealed the resident had the right to receive services in the facility with reasonable accommodation of resident needs and preferences. Review of the facility's policy titled, Complete and Partial Bed Bath, undated, revealed all residents were bathed as often as necessary to maintain cleanliness, refresh, stimulate circulation, and prevent disease and infection. Continued review revealed a bed bath was to be given to residents who were unable to bathe themselves. Further review revealed a bed bath was given daily and/or as needed depending upon the condition and desires of the resident. Review of the microbiology analysis report dated 08/29/2024, performed by a third party IWSC to test for legionella, revealed the Unit 2 shower showed legionella non-pneumophila at 1.0 colony forming units per milliliter (CFUs/ml) with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. Continued review of the microbiology report dated 09/04/2024, revealed the sample result from the Unit 2 shower showed legionella non-pneumophila at 1.0 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating poorly controlled growth. 1. Review of R55's Face Sheet located in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 12/16/2022 with diagnoses to chronic obstructive pulmonary disease (COPD), acute respiratory failure, and unspecified osteoarthritis. Review of the Annual Minimum Data Set (MDS) Assessment for R55, with an Assessment Reference Date (ARD), of 09/13/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R55 to require partial to moderate assistance (helper doing less than half the effort) with bed baths/showers. Review of R55's Comprehensive Care Plan (CCP), dated 08/20/2024, revealed the facility identified the resident as having an activities of daily living (ADL) self-care performance deficit. Per review, interventions included R55 needed a weekly shower and partial bed baths all other days with the assistance of one staff. Further review revealed interventions initiated on 11/14/2022, included R55 was able to specify her preference for bathing or showering. During interview with R55's Family (F)1, on 10/03/2024 at 10:32 AM, he stated there had been ongoing water contamination at the facility for at least four weeks. He stated however, he had not been notified of the water situation and only became aware of it after asking the Administrator about it directly. F1 stated showers were not available, and the Administrator told him the Local Health Department (LHD) and the Kentucky Department for Public Health (KDPH) had been discussing when the facility could resume shower usage for residents. He stated the Administrator informed him legionella bacteria had been detected in Unit 2's shower during a test. He reported the Administrator told him the issue of whether there was a risk to residents if they used the shower on the second floor was being discussed. F1 stated according to what the Administrator told him, neither the LHD nor the KDPH had provided the facility with a clear answer on whether to open the showers. He further stated he purchased water for R55, so she would have clean water to wash her hands and face and use it to brush her teeth, as the facility only provided water for drinking. During interview on 10/09/2024 at 3:43 PM, R55 stated she did not realize how mentally and physically refreshing a shower was and how much she missed getting her showers over the past month. She stated, I had my shower on Sunday, and it was wonderful. Additionally, R55 stated the bed baths had never made her feel completely clean. 2. Review of R41's Face Sheet located in the EMR, revealed the facility admitted the resident on 05/26/2023, with diagnoses to include chronic obstructive pulmonary disease, anxiety disorder, and other specified depressive episodes. Review of the Quarterly MDS Assessment for R41, with an ARD of 09/18/2024, revealed the resident had not been assessed for mental status. Continued review revealed the facility assessed R41 to require partial to moderate assistance with bed baths/showers. Review of R41's CCP, dated 09/12/2024, revealed the facility identified R2 as having an Activities of Daily Living (ADL) self-care performance deficit and to require the assist of one staff for help with bathing/showering. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 1:20 PM, with R41's F2, she stated she was not aware the resident had not received showers in over a month. She stated the facility should have contacted her about the resident not getting showers. F2 further stated, It makes me upset that they did not communicate that to me. Additionally, F2 stated, it was not right that the residents were not provided showers for weeks. 3. Review of R9's Face Sheet located in the EMR revealed the facility admitted the resident on 11/19/2014, with diagnoses to include cerebral infarction, type 2 diabetes mellitus, and frequency of micturition (process of expelling urine from the bladder). Review of the Quarterly MDS Assessment for R9, with an ARD of 09/18/2024, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R9 to require partial to moderate assistance with bed baths/showers. Review of R9's CCP, dated 08/20/2024, revealed the facility identified R9 as having ADL self-care performance deficit, and was totally dependent on one staff to provide showers weekly and bed baths all other days. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 12:11 PM, R9 stated it had been a while since she had received a shower. She stated, They have had trouble with the showers and the water isn't okay. R9 stated staff currently assisted her with a partial bed bath. The resident said she missed taking her showers and, You just don't get clean [with a bed bath]. Additionally, R9 stated she had been told the facility was not to blame, but the Local Health Department (LHD), was the cause of the resident's shower closure. 4. Review of R21's Face Sheet located in the EMR revealed the facility admitted the resident on 09/12/2024, with diagnoses to include sciatica, morbid obesity, and type 2 diabetes mellitus. Review of the Admission MDS Assessment, with an ARD of 09/18/2024, revealed the facility assessed the resident as having a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility additionally assessed R21 to require substantial/maximal assistance (helper doing more than half the effort) with bed baths/showers. Review of R21's CCP, dated 09/13/2024, revealed the facility identified the resident as having an ADL self-care performance deficit and required assistance of one staff for bathing/showering. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/03/2024 at 11:58 AM, R21 stated she had no idea what was wrong with the facility's water. R21 stated someone had mentioned weeks ago residents could not use the showers, and they had to start getting bed baths. She stated staff assisted her with her bed baths; however, she did not like taking bed baths. R21 stated she missed taking showers, and You just don't get clean with a bed bath. I felt like I smelled. Additionally, R21 stated she had been informed the facility was not to blame for the shower closures; rather, it was the LHD that was responsible. 5. Review of R67's Face Sheet located in the EMR revealed the facility admitted the resident on 04/28/2024, with diagnoses to include type 2 diabetes mellitus, dementia, and personal history of urinary tract infections. Review of the Quarterly MDS Assessment for R67, with an ARD of 09/11/2024, revealed the facility assessed the resident to have a BIMS score of six out of 15, which indicated severe cognitive impairment. Continued review revealed the facility also assessed R67 as independent with bed baths/showers. Review of R67's CCP, dated 08/20/2024, revealed the facility identified R67 as having an ADL self-care performance deficit and required the assistance of one staff for bathing/showering. Review further revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:21 PM, R67 stated, the facility's shower system was down and she was not sure why she could not take a shower. Additionally, R67 stated she liked her showers and bed baths only made her feel partially clean and not refreshed. 6. Review of R3's Face Sheet located in the resident's EMR, revealed the facility admitted the resident on 11/21/2022, with diagnoses to include type 2 diabetes mellitus, Alzheimer's disease, and paroxysmal atrial fibrillation. Review of the Quarterly MDS Assessment for R3, with an ARD of 08/22/2024, revealed the facility assessed the resident as having a BIMS score of eight out of 15, which indicated moderate cognitive impairment. Further review revealed the facility also assessed R3 as requiring substantial/maximal assistance with bed baths/showers. Review of R3's CCP, dated 07/15/2024, revealed the facility identified the resident as having an ADL self-care performance deficit, and as totally dependent on one staff to provide a shower at least weekly with partial bed baths all other days as necessary. Further review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:30 PM, R3 stated he was not sure why he could not take a shower, and he had gone a long time without one. Additionally, R3 stated he missed taking showers, and said, I just feel dirty without a shower. 7. Review of R6's Face Sheet located in the resident's EMR, revealed the facility admitted the resident on 03/15/2023, with diagnoses to include cerebral palsy, Hemiplegia right side, and type 2 diabetes mellitus. Review of the Quarterly MDS Assessment with an ARD of 09/09/2024, revealed the facility assessed the resident as having a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Continued review revealed the facility also assessed R6 as dependent (helper doing all of the effort) with bed baths/showers. Review of R6's CCP, dated 08/20/2024, revealed the facility identified the resident as having an ADL self-care performance deficit, and to require the assistance of one staff to provide a shower at least weekly with partial bed baths all other days as necessary. Continued review revealed no documented evidence of interventions in place related to the resident's preference for bathing or showering. During interview on 10/09/2024 at 3:50 PM, R6 stated she did not know what was wrong with the facility's water, but residents had been told they could not use the showers and had to receive bed baths, which she disliked. R6 stated she missed taking showers, and said, You just don't get clean with a bed bath, and I miss getting my hair washed in the shower. I felt dirty. She further stated she had been told the LHD, not the facility, was responsible for the shower closures. Review of an e-mail sent on 09/18/2024 at 7:18 AM, from the facility's Infection Preventionist (IP) to the Director of the LHD, revealed the facility was inquiring about reopening the showers in Units 1 and Unit 3 for resident use as those showers showed no detectable levels of Legionella pneumophilia bacteria. Per review of the email, the LHD Director replied to the facility's IP: if there was no detection of legionella in those showers, there was no reason the residents could not use them. During interview with Licensed Practical Nurse (LPN) 1, on 10/03/2024 at 10:15 AM, she stated there had been no showers for residents for a while. She stated staff used spring water from gallon jugs for both hydration and medication administration. She additionally stated residents and staff were allowed to use water from the faucets for ADL care, such as bed baths, handwashing, and oral care. During interview with Kentucky Medication Aide (KMA) 1, on 10/03/2024 at 11:10 AM, she stated there had been no showers available for residents since September 2024. She stated the facility supplied jugs of spring water for drinking and medication administration. KMA 1 further stated staff used water from the faucets in resident rooms to provide bed baths, washing hands, and oral care. During interview with Registered Nurse (RN) 1 (an agency nurse), on 10/03/2024 at 11:35 AM, he stated he wasn't quite sure why there had been no showers for residents in over a month. He stated he believed the facility provided water for drinking and medication administration. RN1 further stated residents could use water from the faucets in their rooms for bed baths, handwashing, and oral care. During interview, with State Registered Nurse Aide (SRNA) 1, on 10/03/2024 at 11:45 AM, she stated the facility had closed the showers on all units sometime in September 2024. She stated since then residents had not been allowed to take showers, and staff had been providing them bed baths. She further stated the residents were upset they did not get showers. During interview with SRNA5, on 10/03/2024 at 11:49 AM, she stated there had been no showers available for residents since September 2024 due to legionella being in the water. She stated the facility provided water for drinking and medication administration. SRNA5 further stated residents and staff used water from the faucets for bed baths, washing hands, and oral care. During interview with the Quality Assurance (QA) Nurse, on 10/09/2024 at 10:59 AM, she stated she was a member of the facility's water management plan (WMP) team and attended those meetings regularly. She stated the WMP team discussed the water contamination issues and shower use. The QA nurse reported Unit 2's shower was closed and had been closed for about a month to keep residents safe due to the legionella bacteria in the water supply for that shower. She further stated however, she did not know why the Unit 1 and Unit 3 showers were not being used. The QA Nurse additionally stated the showers on Unit 1 and Unit 3 were now open, and residents residing on Unit 2 could use either shower. During interview with the Infection Preventionist (IP), on 10/03/2024 at 3:16 PM, she stated the control measures the facility was taking to protect the residents included providing bed baths instead of showers. She stated since February 2024, the facility had intermittently stopped and started using the showers due to the increased risk to residents. The IP said however, she could not explain why the facility did not utilize the showers on Unit 1 and Unit 3, as those units had no detectable bacteria. She stated recommendations the facility received from the LHD and the KDPH included closing Unit 2's shower while continuing testing and flushing. The IP reported the water was safe to drink, but out of an abundance of caution the facility provided gallon jugs of spring water to use for hydration and medication administration on all units. She said residents, and their families were frequently being updated on the results of the legionella testing, although she could not recall when the facility last notified them of the results. The IP further stated the last communication to staff on the results of legionella testing occurred through a telephone notification in June 2024. During telephone interview with an independent water systems company (IWSC) representative, on 10/11/2024 at 9:58 AM, he stated he had provided third-party water testing and treatment services for the facility. The IWSC representative stated the facility had been seeking guidance from the various health departments to make decisions for them. He stated, after the CLWSE's onsite assessment in September 2024, the facility awaited recommendations and repeatedly inquired about reopening the showers. The IWSC stated the CLWSE sent recommendations to the facility on [DATE], which stated it was the facility's responsibility to make decisions based on their own due diligence. The IWSC said he had suggested the facility bring in portable showers, but the facility opted not to do that. He stated not doing that he believed was detrimental to their situation, as it demonstrated a lack of responsibility for a temporary solution to the problem. The IWSC representative further stated, You can't have a nursing home without showers. During telephone interview with the CLWSE, on 10/04/2024 at 2:42 PM, he stated he had discussed the possibility of using temporary showers; however, the facility opted not to implement that solution. The CLWSE further stated he was unaware of any plans by the facility to manage the future use of its showers. He additionally stated there was no scientific reason not to use the showers based on the recent test results, but the facility still chose not to use the showers. During interview with the Director of Nursing (DON), on 10/08/2024 at 9:21 AM, she stated residents last received showers at the beginning of September 2024, and had since been receiving bed baths. The DON said the facility had waited for confirmation from the LHD regarding the safety of using the showers with no detectable bacteria levels. According to the DON in interview, no detectable levels of Legionella pneumophila were found in the showers on Units 1 and 3, while Legionella pneumophila was detected in the Unit 2 shower. When the State Survey Agency (SSA) Surveyor asked her why residents on Unit 2 were not taken to use the other showers, the DON stated all three shower rooms were closed out of extra precautions. She said the IP emailed the LHD in September 2024 asking if residents could use Units 1 and 3 showers. The DON reported however, the facility had yet to receive definitive instructions about using the showers from the LHD. She further stated she expected staff to follow facility policies in order to protect resident rights, as it was important for their quality of life and well-being. During interview with the Administrator on 10/03/2024 at 10:50 AM, he stated the facility closed all showers in early September 2024 due to positive results for Legionella pneumophila in the water testing. He stated after that, staff provided residents with bed baths instead of showers. The Administrator said it was safe for residents to use water from the faucets in their rooms for washing hands, face, and oral care. He reported although the Unit 1 and Unit 3 showers tested negative for any bacterial contaminants based on the microbiology analysis report dated 09/13/2024, the facility was awaiting the LHD and the CLWSE to confirm all showers were safe for resident use. Review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/13/2024, revealed testing for the Unit 2 shower showed Legionella non-pneumophila 0.1 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. Additionally, review of the microbiology analysis report, performed by a third party IWSC to test for legionella, dated 09/18/2024, revealed testing for the Unit 2 shower showed Legionella non-pneumophila SG1 at 0.4 CFUs/ml with a detection limit of 0.1 CFU/ml, indicating well-controlled growth. During a follow up interview with the Administrator on 10/25/2024 at 12:45 PM, he stated it was his expectation for all staff to adhere to the facility's Resident Rights policy to protect residents' rights to ensure their quality of life. During telephone interview with the Medical Director on 10/25/2024 at 11:01 AM, he stated the facility decided to close the showers until no legionella growth was detected to ensure the residents' safety. He stated further decision that it was his expectation all staff members adhered to the facility's policies and procedures regarding resident rights. The Medical Director further stated protecting resident rights was important to maintaining a high standard of quality of life. During interview with the SSW on 11/19/2024 at 8:01 AM, she stated the issue regarding legionella contamination was brought up by residents who attended the facility's Resident Council Meeting. She stated those residents in attendance were informed about the ongoing issues with contaminated water. The SSW reported she could not recall the specifics of what was discussed or the questions that were asked at those meetings, but she said the residents expressed their understanding of the situation. She stated however, the residents were not informed about the extent of the contamination. When asked by the SSA Surveyor whether all residents had the right to know about the extent of the contamination and what the facility was doing to address it, she responded, I guess. When questioned further about whether the facility had a duty to be transparent with its residents, she stated, Sure. During interview with the Interim Director of Nursing (DON) on 11/21/2024 at 3:45 PM, she stated it was her expectation that all nursing staff follow facility policies and procedures regarding resident rights. She stated protecting residents' rights was important to maintaining a high standard of quality of life. During interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated it was her expectation all staff followed the facility's Resident Rights policy to ensure the well-being of all residents.

Based on observation, interview, and review of facility documentation and it 2024 Facility Assessment, it was determined the facility failed to conduct and document a facility-wide assessment to determine the necessary resources for addressing the the ongoing legionella bacterial contamination in the facility's water system. Additionally, the facility failed to address the volume of agency staffing in its assessment to evaluate its resident population and identify resources essential for provision of the necessary care and services of those residents during day-to-day operations and emergencies. Refer to F880 and F726 The findings include: Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc., dated 06/01/2024, revealed under the Infection Control Risk Assessment section a requirement for a discussion on how the facility evaluated the effectiveness of its infection prevention and control program in identifying, reporting, investigating, and controlling infections and communicable diseases according to accepted national standards. However, continued review of the Infection Control Risk Assessment section revealed it had not been completed, and the facility's leadership failed to address or include legionella under that section of the Assessment when the legionella was first discovered in its water system in January 2024. Continued review of the facility's document titled, Facility Assessment [Facility Name], revealed the facility failed to update its Assessment to reflect the ongoing issues with legionella water contamination. Per review of the Additional Information section of the Assessment, the facility diminished the extent of legionella contamination in its water system, noting the contamination was only at traceable levels. (However, review of the testing documentation confirmed there was poorly controlled and uncontrolled levels of legionella bacteria found throughout the building). Further review of the Assessment revealed the facility noted it was following a Water Management Plan (WMP), (However, the facility's WMP had been determined as insufficient in the State's Division of Epidemiology and Health Planning's (DEHP) recommendations dated 07/26/2024, and communicated by the Local Health Department (LHD) to the facility on [DATE]). Additionally, review of the Assessment revealed the facility noted, The efforts to maintain legionella is ongoing and a collaborative approach with facility staff, contractors, [and the] state and local health department. Review of the DEHP recommendations dated 07/26/2024, revealed the recommendations included the facility needing to continue enhanced surveillance for new cases of legionellosis; to require an on-site water treatment consultant; complete the Water Infection Control Risk Assessment (WICRA); and complete a WMP, which incorporated the Centers for Disease Control and Prevention's (CDC) recommendations with a detailed plumbing diagram. In addition, the recommendations included the requirement for the facility to complete the CDC's course titled, Prevent Legionnaires' Disease, and follow accepted environmental sample protocols. During interview with the Director of Maintenance (DOM) on 11/20/2024 at 10:45 AM, he stated he was not familiar with the facility's Assessment or requirements. During interview with the Infection Preventionist (IP) on 11/21/2024 at 10:10 AM, she stated she was familiar with the facility's Assessment. She stated however, she was not involved in the process of determining its composition regarding infection control and prevention or the Infection Control Risk Assessment. During interview with the Interim Director of Nursing (DON) on 11/21/2024 at 3:45 PM, she stated she did not know why the former administration had not completed the Facility Assessment as required. She further stated in her review of the facility and its operations to date had revealed that there were no systems in place to ensure proper administration of the facility. During interview with the Interim Administrator on 11/22/2024 at 2:02 PM, she stated she did not know why the former administration had not completed the Facility Assessment as required. She stated the Infection Control Risk Assessment section should have been completed to describe the facility's current infection control risks, to include the ongoing legionella bacterial contamination in the facility's water system. The Interim Administrator further emphasized the need for a comprehensive assessment of the facility to adequately address the needs of the resident population and ensure the necessary resources for providing care and services. 2. Review of the facility's document titled, Facility Assessment Tool: [Facility Name] Inc dated 06/01/2024, revealed no documented evidence of an accounting for agency staffing located in the Assessment. Per review of the Assessment, it only addressed staff positions such as Registered Nurse (RN), Licensed Practical Nurse (LPN), and State Registered Nurse Aides (SRNA's)are direct care providers. Review of the facility's staffing sheets for the week of 11/18/2024 to 11/22/2024, revealed agency staffing personnel comprised 68% of the 24-hour staffing assignments for the facility. During interview on 11/20/2024 at 8:54 AM, Registered Nurse (RN) 4 stated the continuity of care for residents was not being addressed by the facility. She reported some of the agency SRNAs were not properly trained and the facility did not provide training for the agency staff before they started working on the floor. During interview on 11/20/2024 at 10:18 AM, the Schedule Coordinator (SC) stated agency staff received onboarding and orientation training from their staffing agencies before starting to work on the floor at the facility. She stated having agency staff made it harder because agency might not know the residents as well as staff employed by the facility. The SC reported a staff member called out (not reporting for work) that morning and she was able to fill the position with another in-house staff person. She further stated having in-house staff made a difference with residents and continuity of care. In interview on 11/22/2024 at 9:39 AM, LPN3 stated she was an agency nurse and had worked at the facility for a month. She stated she and the nurse got report from the previous shift nurses every morning on their residents. LPN3 stated the nurse aides who worked on the unit were mostly agency, but because they had been working here for a long time, she felt like they knew the residents. She reported she had received no education or training when she started at the facility. The LPN said she had not received any competency assessments from the facility since she started working there. She stated the staffing agency made sure we have all of our training up to date. Per LPN3 in interview, she had not worked at the facility long enough to know if they provided check offs or had any competency training. In interview on 11/22/2024 at 12:43 PM, Resident (R)25 stated agency staff did not know him or his preferences. He stated especially at night and on weekends agency staff had to be told what to do. R25 reported, They don't know nothin, I have to tell them everything to do. He further stated he had to tell a nurse aide everything he needed. In interview on 11/22/2024 at 1:15 PM, RN7 (an agency nurse) stated she had not received any training from the facility when she started. She stated there were a lot of new aides and it was hard to know if they were doing their job. The RN reported her agency required her to do online education. She further stated the facility had not provided any skills check off or testing. In interview on 11/22/2024 at 1:29 PM, State Registered Nurse Aide (SRNA) 16/Kentucky Medication Aide (KMA) 5 stated we have a few agency SRNA's who knew the residents; however, there were some SRNA's she did not know how they ever got their license. She reported there was no continuity of care, and they used to have education on every payday, but since the former DON came we got nothing. In interview on 11/21/2024 at 1:19 PM, the Interim DON stated there was a huge problem with the stand point of using staffing from an agency. She said she and the Interim Administrator figured the staffing was at 4.25 PPD which for the acuity level of the residents currently in the facility was high. The Interim DON stated We have a lot of agency staff currently. She reported she looked at the staffing ratio for the last two days and review revealed 68% of the staffing for the facility was agency filled. Per the Interim DON in interview, she and the Interim Administrator had presented their concerns to the facility's board of directors as recently as 11/20/2024. She further stated with all the agency staff currently, there could not be continuity of care for the residents. The Interim DON additionally stated residents needed to know who was going to be taking care of them.

Based on interview and review of facility policy, the facility failed to have systems in place to ensure there were an adequate number of staff always present who were properly trained and/or certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers to be able to provide CPR until emergency medical services arrived. The deficient practice had the potential to affect all facility residents who required CPR. The findings include: Review of the facility's policy titled, CPR Certification, dated ,d+[DATE], revealed all licensed nurses were responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Per review, all Kentucky Medication Aides (KMA) were also responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Review of the facility's list of all its nurses and KMA's with CPR certification, provided by the Interim Director of Nursing (DON), revealed eight nurses currently employed had expired CPR certifications. Per review of the list, two of the nurses, Licensed Practical Nurse (LPN) 2 and LPN6, were being staffed as charge nurses on [DATE]. During interview on [DATE] at 11:53 AM, Registered Nurse (RN) 4 stated several staff members in the building had expired CPR certification. She stated she knew that because her license had recently expired. RN4 reported prior to her CPR certification expiring, she went to Infection Preventionist (IP) Nurse to let her know. She stated the IP told her she had to get a class together because several employees' CPR certification had expired. RN4 stated however, a CPR class was never offered and her CPR certification expired. She further stated she ended up going to an outside company to renew her CPR certification, but she had worked as a charge nurse for one week with it expired. During interview on [DATE] at 2:00 PM, the IP Nurse stated she provided classes for CPR certification; however, it was not part of her job duties to keep up with who had expiring certification. During interview on [DATE] at 9:14 AM, LPN4 stated she did not know her CPR certification had expired. She stated she was attending a CPR class on that date provided by the IP Nurse. During interview on [DATE] at 10:05 AM, the Quality Assurance (QA) Nurse stated she was not the one responsible for keeping a record of CPR certifications for staff. She further stated she was not sure whose responsibility it was to do that. During interview on [DATE] at 10:34 AM, the Scheduler/Staff Coordinator stated, I do not keep up with CPR certifications of full-time staff. Agency staff falls on me. I would assume it would be the IP because she does the classes. She stated, I check agency and keep up with agency [staff]. The Scheduler/Staff Coordinator further stated it was important to have staff qualified with active CPR certification, Because when you have a code you need to know how to respond, it's good to be up to date with what studies show works best. During interview on [DATE] at 10:45 AM, the Interim DON stated the two nurses currently working today (LPN2 and LPN6) with expired CPR certifications now had active CPR certifications. She said the IP Nurse taught a class and got them re-certified. The Interim DON further stated the IP Nurse would now be the person responsible for keeping up with staff's CPR certifications and the expiration dates. During interview on [DATE] at 10:50 AM, the Interim Administrator stated it was her expectation that all nurses had active CPR certifications for the safety of all the residents.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of nine sampled residents reviewed for food temperatures (Residents (R)68, R29, R9, R65, and R58). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the lunch meal on 11/20/2024, revealed the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature. The findings include: Review of the facility's policy titled, Food Temperatures, dated 2003-2004, revealed the appropriate serving temperature (temp) of hot foods was for the food to be over 140 degrees (140 ) Fahrenheit (F) for hot foods. Review of the facility's Room Test Tray Evaluation Form, undated, noted the acceptable point of service (POS) temp for hot foods was 135 to 160 F. Review of the facility's form titled, Food Temperatures, undated, revealed the POS temp for hot foods was 115 to 125 degrees F. Review of the Test Tray Report Form, undated, (provided after review of the Room Test Tray Evaluation Form) noted the acceptable POS temp was greater than 120 F for hot foods, and less than 45 F for cold foods. Review of the facility's Resident Council Meeting Minutes, dated 08/05/2024, revealed a resident (R68) complained about the food being cold when the aides passed out trays. Per review, the resident who complained resided on the facility's Unit 2. Review of the Resident Council Meeting minutes dated 10/07/2024, revealed two residents (R68 and R29), who both resided on Unit 2, complained of their food being cold when it was delivered to their rooms. Review of the Resident Council Meeting minutes dated 11/04/2024, revealed R68 and R29 both reported their concerns regarding cold food. Continued review of the 11/04/2024 minutes revealed it was noted the residents' concerns had not been resolved and was an ongoing issue. During the Resident Group meeting held on 11/18/2024 at 3:30 PM, with nine residents in attendance, four residents complained about cold food. R9, from Unit 2, stated during the meeting the food was always cold, because it sits out in the hallway and gets cold. R9 additionally stated staff said they could not reheat the food. R29 also stated during the meeting, the food was always cold and R65, from Unit 1, agreed the food was always cold. R58, from Unit 2, also stated the food was only ever warm at best. Observation on 11/20/2024 at 11:30 AM of the steam table temperatures taken for food for the Unit 1, Cart 1 revealed: beef entree temp was 192 F; starch temp (noodles) was 186 F; and vegetable temp was 191 F. The Unit 1, Cart 1 was observed to leave the kitchen at 11:48 AM, and arrived on the unit at 11:52 AM. Observation revealed the last tray was delivered at 12:04 PM. The SSA Surveyor checked the palatability of the test tray at 12:04 PM, and determined both the entree/starch (beef and noodles) and vegetable medley had cool temperatures. Observation of the temp checks for the test tray food at POS was: 125 F for both the entree and starch, and 120 F for the vegetable medley. In interview on 11/20/2024 at 12:43 PM, the Dietary Manager (DM), when asked about the large drop in food temps from the tray line to the POS, she stated staff were up and down the hall multiple times opening and closing the food cart. The DM reported however, she was not certain that caused the food temps to drop. She stated she would have another test tray on Unit 1 tomorrow at lunch to see if the issue was isolated. Review of the Test Tray Report Form for lunch service on 11/21/2024, revealed the Unit 1, Cart 1 was loaded at 11:33 AM, was on the unit at 11:37 AM, and the last tray was delivered from the cart at 11:54 AM. Review revealed it was a total of 17 minutes on the unit or 21 minutes from the time the cart was prepped until the time the last tray was delivered. Review of the food temps on the Report form revealed: the starch (potato wedges) was 182 F on the steam table, but was 120 F at the POS; milk was 37 F on ice in the kitchen, but was temping at 47 F at POS. In follow up interview on 11/21/2024 at 10:54 AM, the DM stated she had used the wrong form yesterday, which was the Room Test Tray Evaluation Form. She stated the correct form was the Test Tray Report Form. The DM reported that, according to measures on the correct form, the entree yesterday had been in an acceptable range at 120 F, and the vegetable had been bordering on acceptable range. When asked by the SSA Surveyor if the DM had been able to determine why the food temps dropped so greatly yesterday from the steam table to POS, she said she was uncertain. In additional interview on 11/21/2024 at 12:42 PM, with the DM following the lunch service, she reported the entree (fish) temp was 136 F; the vegetable (potato wedges) at 120 F; [NAME] slaw at 41 F; coffee at 130 F; and milk at 47 at POS. When the DM was asked about the vegetable being below the desired temp of greater than 120 F, she stated they were not as dense and tended to lose their temp a lot faster. She stated there was only one aide and one nurse delivering trays on the floor at lunch service on Unit 1, as both other aides had been providing resident care at the time. The DM stated she was going to have maintenance look at the plate warmer to see if the temp could be increased, as a hotter plate might make a difference. When the DM was asked about the residents' complaints brought up in resident council meetings, the DM said those were reported to the dietician, who did test trays and had not noted any food temp concerns. In interview on 11/21/2024 at 1:02 PM, the Interim Director of Nursing (DON) stated she had not heard any concerns about cold food in her eight (8) days at the facility. She stated her expectation was that residents be satisfied with their food and the temperature of it. The Interim DON further stated she expected residents' food to be delivered to them warm. In interview on 11/21/2024 at 2:16 PM, the Interim Administrator stated in the short time she had been in the facility, no one had expressed concern to her regarding food temps. When the SSA Surveyor shared with her the various conflicting standards for expected food temps at POS, she stated her expectation was for there to be consistency in policy on what the facility's expectations were. She further stated the food temperatures should be acceptable to residents, with residents never getting cold food.

Based on interview and record review, it was determined the facility failed to ensure residents were notified of changes to services covered by Medicare and/or Medicaid as soon as possible for one of three sampled residents reviewed for appeal writes (Resident (R)38). R38 received therapeutic services; however, the facility failed to inform the resident in writing of the end date to services or of their right to appeal. The findings include: During the task of Beneficiary Notification Review, the State Survey Agency (SSA) determined for the three residents selected, there was no documented evidence one of the residents received form CMS 10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) or form CMS 10123 (Notice of Medicare Non-Coverage). Continued review revealed, of the three residents, one resident was voluntarily discharged from services as family elected hospice services (R125). Per review, a second resident opted to discharge from services and returned home with home health with almost two weeks remaining (R126). Further review revealed one resident (R38) should have received both the CMS 10055 and CMS 10123; however, did not receive that documentation. Review of R38's medical record revealed the facility readmitted the resident from the hospital on 08/22/2024. Continued record review revealed R38 was scheduled to receive Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) under Medicare Part A payment. Review of the resident census revealed R38's last covered day under Medicare Part A was 10/25/2024. However, further record review and review of facility documentation revealed no evidence the facility issued or resident representative was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) or form CMS 10123 Notice of Medicare Non-Coverage (NOMNC) form. In interview on 11/20/2024 at 9:24 AM, the facility's Admissions Coordinator (AC) stated R38 was not given a SNF ABN or NOMNC as she had not been informed or included in the email which was how she was notified of that information. She said since she had not received the email, she had no idea the resident or family should have received the SNF ABN and NOMNC letters. The AC reported it was important the letter(s) were available for informing both staff and the resident of the end date of the resident's skilled services. She further stated it was also important as well for providing residents or families other billing options for continued services or the opportunity to appeal if they desired to do that. In interview on 11/21/2024 at 1:09 PM, the Interim DON stated the SNF ABN and NOMNC were forms the facility completed. She stated she expected those forms to be discussing the resident's progress in morning meeting prior to the end of services for the resident receiving services. The Interim DON said the SNF ABN and NOMNC were important for payment of care residents were receiving, so that residents or family members could file an appeal if they felt services were still needed. She further stated the expectation was for residents or their responsible parties to be alerted in a timely manner so they had opportunity to respond. In interview on 11/21/2024 at 2:09 PM, the Interim Administrator stated the NOMNC should be issued to the resident or responsible party as appropriate, and should be issued prior to the cut off date. She stated the NOMNC was to be provided in order for the resident or responsible party to have time to respond and to have a plan for a safe discharge or to appeal. The Interim Administrator said she had only been at the facility four or five days, and did not know the facility's process for beneficiary notification. She further stated her expectation was for it to be issued timely, with the facility maintaining a copy, in addition to, those provided to the resident or responsible party. The Interim Administrator additionally stated the AC would be receiving training on her role in the SNF ABN/NOMNC process.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's census was 76. The facility failed to implement the state's Division of Epidemiology and Health Planning's (DEHP) recommendation as communicated by the Local Health Department (LHD) on 03/21/2024, to use faucet filters (or bottled water) until the facility completed further testing to prevent and control the spread of a water-borne infection with legionella. Staff interviews revealed they unaware of water contamination concerns and continued to use the sink faucets in residents' rooms for brushing the resident's teeth, hygiene, and drinking water, as well as hand hygiene for staff. The facility's failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 04/04/2024 and was determined to exist on 03/21/2024, in the area of 42 CFR 483.80 Infection Control, F-880 at a Scope and Severity (S/S) of an L. The facility was notified of the Immediate Jeopardy on 04/04/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 04/05/2024, alleging removal of the IJ on 04/05/2024. The State Survey Agency (SSA) determined the IJ had been removed on 04/05/2024 as alleged, prior to exit on 04/05/2024, with remaining non-compliance at a S/S of an F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Infection Control Program, undated, revealed its purpose was to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infections to residents and employees. Review of the facility's policy titled, Legionella Water Management Plan, undated, revealed the facility would document all aspects of the water management system and maintain maintenance logs. Per the policy, the facility would have a water management program in place to prevent detect and control water-borne contaminants and ensure water was safe for consumption and use. Documentation for all aspects of the water management program will be maintained within the maintenance logs. Hot water temperatures in residence areas, tubs, showers, full immersion wash stations, water heaters, and holding tanks will be tested every week. Additionally, weekly sampling points for residents' rooms will be rotated so that all sinks will be tested at least annually. If water quality is not within appropriate parameters per the water testing kit or parameters of the contracted testing site, further investigation will occur, a plan of correction developed and implemented if appropriate and the results brought to the facility Quality Assurance and Performance Improvement (QAPI). For abnormal water conditions that can pose risks to residents, visitors, and employees, the facility is to notify regulatory agencies and activate the appropriate emergency action plan. Review of the facility's policy titled, Water Emergency Policy, undated, revealed the facility would follow directions from the Health Department. During an interview with the Infection Preventionist (IP), on 03/29/2024 at 9:44 AM, she stated her job duties included monitoring and tracking infectious diseases within the facility, implementing and enforcing infection control protocols, and providing guidance and response to outbreaks. Additionally, the LP stated she was responsible for alerting the Local Health Department (LDH) of any reportable diseases. She stated the LHD called her asking about the facility's water system and made her aware that a PRN (as needed) employee at the facility became sick and was diagnosed with Legionnaires' Disease. She stated she could not recall the exact date of the call, but she believed it was in 10/2023. The IP stated an independent water service company tested the facility's water system in 02/2024 and recommended the facility flush the system and take the Unit 3 shower out of service. Additionally, the IP stated after the water testing, the LHD told her the only concern was the shower in Unit 3. The IP stated the facility was waiting for the results of the most recent water testing completed on 03/22/2024. She stated the only control measures the facility was taking was to provide bed baths instead of showers for all residents. During an interview with the LHD Infectious Disease Nurse (IDN), on 04/01/2024 at 11:24 AM, she stated she investigated a report from a local hospital in 11/2023 where a patient had tested positive for Legionnaires' Disease. She stated the identified patient was a former employee at the facility. Additionally, she stated she reached out to the facility's IP to inform her of the situation and recommended the facility test the water. The IDN stated the first test came back positive, so the facility was instructed to test again. She stated, after the second test results showed an increase in legionella, she sent the results to the state's epidemiologist. The IDN stated on 03/21/2024, during a conference call, the LHD conveyed the state's DEHP's recommendations to the facility's IP, for the facility to discontinue showers and switch to bed baths. She stated the recommendations also included the facility install a filter on every shower head and every faucet or use bottled water. Review of the microbiology analysis report, performed by a third party contracted by the independent water systems company to test for legionella, dated 02/08/2024, revealed testing for the Unit 1 and 3 showers, and the kitchen sink. The sample result from the Unit 3 shower showed a positive result for legionella pneumophila Serogroup 1 Strain (SG1) at 0.7 colony-forming unit per milliliter (CFU/ml) with a detection limit of 0.1 CFU/ml. Additionally, the report for the Unit 3 shower legionella pneumophila Serogroup 1 Strain (SG1) showed legionella non-pneumophila at 20.0 CFU/ml with a detection limit of 0.1 CFU/ml. No legionella was detected in the kitchen sink. Review of the microbiology analysis report, performed by a third party contracted by the independent water systems company to test for legionella, dated 02/23/2024, revealed testing for the Unit 1 breakroom ice machine, room [ROOM NUMBER]'s hot faucet, room [ROOM NUMBER]s sink, room [ROOM NUMBER]s bathroom, Unit 3 shower, and a sink on Unit 2. The sample result from the Unit 3 shower showed a positive result for legionella non-pneumonia at 5.0 CFU/ml with a detection limit of 0.1 CFU/ml. Additionally, the report showed room [ROOM NUMBER]s sink tested positive for legionella non-pneumonia at 0.4 CFU/ml with a detection limit of 0.1 CFU/ml. No legionella was detected in the other test sites. Review of an email from the DEHP, dated 03/21/2024, revealed the state's Legionella Team and the Regional Epidemiologist recommended using point-of-use filters for faucets and shower heads. The Local Health Department (LHD) communicated this recommendation to the facility's Infection Preventionist (IP) per email on 03/21/2024 at 4:00 PM. The email stated, After discussing with our Regional Epidemiologist [name], and the state Legionella Team, they are recommending sponge bed baths and faucet filters (or bottled water) until further testing is completed and results reviewed. Additionally, the Environmental Health Capacity Manager with the Kentucky Division of Public Health Protection and Safety provided examples of the faucet filters to use. Review of the microbiology analysis report, performed by a third party contracted by the independent water systems company to test for legionella, dated 03/25/2024, revealed testing results for the janitor's room, activity room, bathroom sink, kitchen sink, Unit 3 shower, room [ROOM NUMBER], and the therapy room kitchen. Unit 3 shower showed a positive result for legionella non-pneumonia at 0.1 CFU/ml with a detection limit of 0.1 CFU/ml. No legionella was detected in the other test sites. Review of an email to the IP from the LHD's PHD, on 03/29/2024 at 11:14 AM, revealed the facility should follow the state's original recommendations provided on 03/21/2024, which stated shower and faucet filters should be used if the facility decided not to provide residents with bottled water. Observations during the Survey from 03/25/2024 through 04/01//2024, revealed the facility did not provide residents with bottled water as recommended by the DEPH. Observation on 04/03/2024 at 9:35 AM, revealed Kentucky Medication Aide (KMA) #3 used water during medication administration that she obtained from a sink that did not have a faucet filter. During an interview with State Registered Nurse Aide (SRNA) 1, on 03/25/2024 at 10:00 AM, she expressed concerns about the facility's water quality. SRNA1 stated the facility closed the shower on Unit 3 several weeks ago. She further stated since then, the residents on Unit 1 were not allowed to take showers, and staff had provided bed baths. SRNA1 stated the facility had not explained to staff why the showers were not to be used. During continued interview, she stated the residents continued to use the sink faucets in their rooms for hand hygiene, brushing their teeth, and drinking water, SRNA1 stated administration had not provided bottled water for the residents. She stated staff was using the water from the sinks to perform their hand hygiene. During an interview with SRNA2, on 03/25/2024 at 11:30 AM, the SRNA stated staff had concerns that the water system was contaminated because several weeks ago the facility closed the showers on Units 1 and Unit 3 and residents were provided bed baths. SRNA2 further stated there were rumors the water was contaminated with legionella, but the facility had not apprised staff of any water contamination concerns. SRNA2 stated the residents continued to use water from the faucets in their rooms for hygiene, brushing their teeth, and drinking water. In continued SRNA2 stated staff was using the water from the sinks to perform hand hygiene. The SRNA stated at no time had the administration provided bottled water for distribution to the residents to use for daily hand hygiene, drinking, or oral hygiene. Furthermore, SRNA2 stated staff would not drink the water in the facility and would bring bottled water from home to drink throughout the day, stating they were afraid the water was contaminated. During an interview with Registered Nurse (RN) 6, on 04/05/2024 at 2:20 PM, she stated she was concerned management did not inform staff and residents about the water contamination when it occurred. RN6 stated it was an infection control concern for staff and residents, especially for those who were immunocompromised. Review of an email from the facility's IP to the LHD's PHD, on 03/29/2024 at 11:06 AM, revealed the IP was unaware the residents were drinking out of the sink faucets in their rooms. The IP stated in the email she had spoken with the Administrator about purchasing and installing filters for the sinks and showers and asked whether they should be using bottled water for the residents. During an interview with the Director of Maintenance (DOM), on 03/29/2024 at 9:26 AM, he stated the facility's water management program required routine testing of the water system's temperatures, but he could not provide documentation of any temperature logs. He stated the previous DOM did not record temperatures on the logs. The DOM stated he was hired after the water testing had already began and initially did not know why an independent water testing service was hired. He stated the water testing company had tested the water for legionella at various locations throughout the facility, but the 03/22/2024 test results had not been received. In continued interview, he stated the water service company recommended draining the water system, flushing it out, and treating it with 2 % (percent) chlorine. The DOM confirmed he had flushed and treated the Unit 3 shower on 03/20/2024. He further stated the only place where a positive test for legionella was found was in the Unit 3 shower. The DOM stated current control measures to mitigate the spread of waterborne infections included closing the showers on Units 1 and 3. During an interview with the LHD Health Environmentalist, on 04/01/2024 at 8:54 AM, he stated he was in touch with the facility to have the state's DEHP test their water supply. He further stated he recalled the issue had come up when the LHD received a report from a local hospital that an employee of the facility was hospitalized for pneumonia and tested positive for Legionnaires' Disease in November 2023. During an interview with the LHD PHD, on 4/01/2024 at 11:24 AM, she stated in 11/2023 she was made aware a former employee of the facility tested positive for Legionnaires' Disease and succumbed to the illness in 12/2023. She stated, after reviewing the facility's water testing results, she contacted the state's DEHP Epidemiologist who provided recommendations for the facility based on the positive results. The PHD stated the sponge bath recommendation was discussed on a conference call on 03/21/2024 with the DEHP, Senior Regional Epidemiologist, Environmental Health Capacity Manager, and the LHD Infectious Disease Nurse (IDN). She stated the Environmental Health Capacity Manager/EPI III for the state's DEHP sent a link with information for point-of-use filters he recommended the facility use if the facility was going to continue using the showers or if the facility was not providing residents with bottled water. She stated she forwarded the information in an email to the facility. Further, the PHD stated, on 03/29/2024, the IP reached out to her in an email and told her she (the IP) was unaware that the residents were drinking out of the sink faucets in their rooms. The PHD stated the IP, in the email, wrote that she had spoken with the Administrator about purchasing and installing filters for the sinks and showers and asked whether the facility should be using bottled water for the residents. Per the PHD, she stated she communicated to the IP that the facility should follow the state's DEHP original recommendation as sent to the facility on [DATE]. During a follow up interview with the IP, on 04/01/2024 at 3:15 PM, she stated she received a recommendation from the LHD last week to either install filters on all showerheads and faucets or switch to using bottled water. She also stated she informed the Administrator of the LHD's recommendation when she received the email. When interviewed related to the facility not providing residents with bottled water or not installing the point-of-use filters for faucets and shower heads as communicated to her on 03/21/2024 at 4:00 PM per the LHD email, the IP stated only that she had informed the Administrator of the LHD's recommendation when she received the email. Review of the microbiology analysis report, performed by a third party contracted by the independent water systems company to test for legionella, dated 04/02/2024, revealed testing for the Unit 3 shower showed no legionella pneumophila SG1 or legionella non-pneumophila was detected. During an additional interview with the DOM, on 04/03/2024 at 3:15 PM, he stated the facility ordered shower head filters and they would be installed immediately upon arrival. He further stated the water fountain and ice dispenser machines were out of order and not covered up due to water contamination. In continued interview, he stated during the last water test on 03/20/2024, he replaced the shower head and nozzle on Unit 3 and flushed and treated the water system. He stated the latest advisory from the LHD was to use bottled water until further testing results were analyzed. During an interview with the contractor from the independent water systems company, on 04/05/2024 at 9:12 AM, he stated on the first set of legionella tests dated 02/22/2024, there was a positive result of legionella non-pneumophila in the Unit 3 shower. The contractor stated because it was such a low detection, the company did not recommend sanitizing the system but only flushed the area. He further stated the Centers for Disease Control and Prevention (CDC) had changed their recommendations from flushing the system to sanitizing the system. Therefore the company sanitized the domestic hot and cold water systems on 03/20/2024 and retested for legionella on 03/22/2024. He stated those results showed one slight positive non-pneumonia at the same location in the Unit 3 shower as did the 02/22/2024 results. Additionally, the contractor stated he was not aware of the state's DEHP's and the LHD's recommendations to change the filter on shower heads and faucets or use bottled water. He stated the facility replaced the shower head and hose in the Unit 3 shower, and it was retested on [DATE]. He further stated the report from the third party contracted by the independent water systems company to test for legionella, dated 04/04/2024, showed no legionella of any type was detected. During an interview with the Director of Nursing (DON), on 04/04/2024 at 2:23 PM, and on 04/05/2024 at 12:54 PM, she stated the IP was responsible for implementing all infection control and health department guidelines and recommendations. She could not recall when she became aware of the presence of legionella in the facility's water system; however, the DON stated she was aware there were several times when water testing results on Unit 3 indicated legionella was detected, and the facility treated it and then did more testing. She stated the IP communicated to her and the Administrator regarding the closure of showers and the use of sponge bed baths. The DON stated, despite her concerns related to the water testing, she did not call the LHD to discuss their recommendations, as she expected the IP to perform her job. In continued interview with the DON, she stated she did not ask to read the DEHP's recommendations from 03/21/2024 because she did not know about the emails between the IP and the LHD. The DON stated she asked the IP to communicate the recommendations to the Administrator and DOM, and the IP stated she had. During continued interview with the DON, on 04/04/2024 at 2:23 PM, and on 04/05/2024 at 12:54 PM, she stated the IP did not mention the state's DEHP's recommendation from 03/21/2024 to install filters on all the faucets or provide bottled water to residents until a few days ago, at the end of March 2024. She stated she was not made aware the facility needed to use bottled water for resident care. She stated the IP never brought the recommendations up at previous Interdisciplinary Team (IDT) meetings; however, the team discussed them at the IDT meeting and Quality Assurance Performance Improvement (QAPI) meeting on 04/04/2024. The DON stated, retrospectively she should have called the LHD to clarify any recommendations, as it would have been important to receive clarification so the facility could have followed the health department's recommendation to prevent the spread of infection and keep staff and residents safe. The DON stated the facility started providing bottled water to the residents on 04/01/2024 per the LHD recommendations. The DON further stated the water was given to residents once per shift, which was every twelve 12 hours. In continued interview, the DON stated she was unaware a former employee had Legionnaires' Disease, and only knew he was sick and had pneumonia. She stated she did not know why the decision was made by the Administrator not to make staff, residents, or families aware of the water issue. However, she stated, If you put too much out there it creates a panic. During interview with the Administrator, on 03/26/2024 at 9:08 AM, the Administrator stated there was a water line break in front of the building in December 2023. The Administrator stated, as a precautionary measure, the facility hired an independent water systems company to test the water system for contamination. He stated a company tested the system on 02/22/2024, and the results indicated the presence of legionella in the water. However, the Administrator stated he did not immediately inform staff residents, or responsible parties about the results. During additional interview with the Administrator, on 04/05/2024 at 3:40 PM, he stated he was initially unaware of the state's DEHP's recommendation as communicated by the local health department on 03/21/2024, to use faucet filters (or bottled water) until the facility completed further testing in order to prevent the spread of legionella. He further stated after speaking with the LHD on 04/04/2024, the water results showed no legionella. He stated the plan moving forward would be to work with the LHD on a water management plan that would include testing. He further stated it was his expectation the facility followed CDC and LHD recommendations related to infection prevention and control. The Administrator stated he expected the maintenance staff to follow the water management plan and to document according to regulations. He further stated it was important to maintain infection control measures to prevent the spread of infections. During an interview with the Medical Director, on 04/05/2024 at 9:26 AM, he stated he had been the Medical Director at the facility for one year. He further stated he was made aware a former employee had passed away from legionella pneumonia. In continued interview, he stated the Administrator and DON had discussed the water contamination situation at the last QAPI meeting on 02/24/2024, and he was aware of the health department's recommendations. He stated he attended an Ad Hoc QAPI meeting via phone on 04/04/2024, and the meeting included the Administrator and DON. The Medical Director stated the committee members discussed the State Survey Agency's findings during the meeting and developed a plan to remove the immediate jeopardy. Furthermore, he stated it was essential to follow water management policies and the health department's recommendations to maintain resident safety and prevent the spread of infection. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 04/05/2024, alleging removal of the IJ on 04/05/2024. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 04/04/2024 at 1:00 PM the facility's Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Plant Maintenance Director (PMD) participated in a conference call with representatives from the state's Department of Public Health (DPH), Division of Epidemiology and Health Planning's (DEHP), Local Health Department (LHD), and the independent water systems company to determine an appropriate plan to move forward. 2. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 04/04/2024 with the Medical Director, the Administrator, and the DON to discuss the findings and plan for removal of the Immediate Jeopardy. The Quality Assurance Performance Improvement (QAPI) Committee would meet monthly starting on 04/04/2024, to review compliance and adjust as deemed necessary by the QAPI Committee to maintain compliance for recommendations and further follow-up regarding the plan of correction. 3. Beginning on 04/04/2024, the DON, IP, and the Minimum Data Set (MDS) Nurse would educate staff on Legionnaires' Disease. Staff must complete all education and post-testing before being allowed to work. The DON, IP, and MDS Nurse would educate agency staff before they worked assigned shifts. A post-test was given, requiring a minimum score of 100 percent. Those who did not receive a score of 100 percent were re-educated and tested again until they achieved a score of 100 percent. Any staff members not receiving education by 04/04/2024 would be provided with the education before working their next shift. The DON was responsible for tracking all education to ensure all facility and agency staff were educated before working. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. During interviews with the DOM on 04/05/2024 at 9:00 AM; the IP on 04/05/2024 at 9:20 AM; the DON on 04/05/2024 at 12:54 PM; and the Administrator on 04/05/2024 at 3:40 PM, they all stated they participated in a Zoom meeting call on 04/04/2024, with representatives from the state's DPH, DEHP, LHD, and the independent water systems company to discuss a plan of action moving forward. During a telephone interview with the independent water systems company's contractor on 04/05/2024 at 9:12 AM, he stated he participated in a Zoom meeting call with representatives from the state's DPH, DEHP, LHD, and the facility's leadership. During a telephone interview with the LHD's Infectious Disease Nurse (IDN), on 04/05/2024 at 2:58 PM, the IDN stated representatives from the state's DPH, DEHP, LHD, the independent water systems company, and the facility had a Zoom meeting to discuss the results of the water testing completed on 04/02/2024 and to develop a plan moving forward. Review of an email from the LHD's PHD who was the liaison at the health department to the state's DPH, DEHP, LHD, and the facility's leadership, dated 04/04/2024 at 4:20 PM, revealed there was a Zoom call to make a plan to work with the facility to develop a water maintenance plan, to include monitoring water testing results taken from the Unit 3 shower. Further review revealed the state's Infection Preventionist Team and the LHD's Environmentalist would visit the facility to monitor the water exposure using the CDC's Module 11 Infection Control Assessment and Response (ICAR) water exposure guide. Additionally, after completing the Module 11 ICAR, the facility, with the assistance of the state's Infection Preventionist Team and the LHD, would develop a water maintenance plan and test Unit 3's shower in two weeks to monitor water results. 2. During interview on 04/05/2024 with the DON at 12:54 PM, and Administrator at 3:40 PM, they confirmed participating in an Ad Hoc QAPI meeting held on 04/04/2024 with the Medical Director to discuss the findings and plan for removal of IJ. The Administrator and DON stated the QAPI committee would discuss the facility's performance improvement plan related to water management during monthly QAPI meetings in the future. During a telephone interview with the Medical Director, on 04/05/2024 at 9:26 AM, he stated he attended an Ad Hoc QAPI meeting via phone on 04/04/2024 and the meeting included the Administrator and DON. The Medical Director stated they discussed the State Survey Agency's (SSA's) findings during the meeting and developed a plan to remove the Immediate Jeopardy. Additionally, he stated as part of the facility's performance improvement plan, the QAPI committee would discuss water management at future monthly meetings. 3. Review of Legionnaires Disease education, posttests with a score of 100 percent achieved, and sign-in sheets, dated 04/04/2024, revealed 55 staff (47 full time employees and eight agency staff) were educated. The facility employed 123 full time staff. During interview with facility staff including RN7 on 04/05/2024 at 10:47 AM; SRNA14 on 04/05/2024 at 12:38 PM; Restorative Aide (RA) 1 on 04/05/2024 at 2:05 PM; SRNA1 on 04/05/2024 at 2:08 PM; SRNA15 on 04/05/2024 at 2:10 PM; SRNA16 on 04/05/2024 at 2:13 PM; RN6 on 04/05/2024 at 2:20 PM; Housekeeping Director on 04/05/2024 at 2:23 PM; SRNA17 on 04/05/2024 at 2:25 PM; Kentucky Medication Aide (KMA) 1 on 04/05/2024 at 2:29 PM; Courtesy Aide on 04/05/2024 at 2:31 PM; LPN8 on 04/05/2024 at 2:33 PM; Dietary Aide (DA) 1 on 04/05/2024 at 2:35 PM; DA 2 on 04/05/2024 at 2:43 PM; and, DA3 on 04/05/2024 at 2:51 PM, they confirmed the DON, IP, and the MDS Nurse provided education on Legionnaires' Disease. The education included a discussion about the disease and a handout was given to the staff. During the training, staff took a pre-test and post-test, and to pass, they had to score 100 percent. If a staff member failed to score 100 percent, nursing leadership provided re-education and the staff member retook the test.

Based on observation, interview, record review, review of the facility's policies, review of the local weather forecast history, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of ten (10) sampled residents, Resident #1, who had a history of exit seeking behaviors and verbalized wanting to leave the facility. On 05/05/2021 at approximately 2:15 PM, the facility received a call from a visitor outside the building informing them a resident in a wheelchair was seen at the back of the parking lot, headed toward the highway and told the visitor he/she was trying to hitch a ride to go home. Resident #1 was returned to the building, placed on fifteen (15) minute monitoring and a secure care bracelet was placed on his/her wrist. The facility failed to determine how and when the resident exited the facility without staff knowledge. Record review revealed the resident had a history of exit seeking behavior and/or verbalized wanting to leave the facility. On 06/28/2020 at 3:30 PM, staff found Resident #1 in the main lobby attempting to exit the front door and saying he/she was going home. The resident was determined to be at risk for elopement and was placed on fifteen (15) minute monitoring, from 06/28/2020 until 08/17/2020. Resident #1 refused to wear a Secure Care Alarm bracelet (a tracking device designed to prevent persons at risk for elopement from leaving the facility unless accompanied). The resident was removed from fifteen (15) minute monitoring, on 08/17/2020. However, per Resident #1's medical record, he/she was not care planned as an elopement risk. On 11/18/2020, Resident #1's medical record stated the resident was angry and said he/she wanted to leave this place. The resident was again placed on fifteen (15) minute monitoring for forty-eight (48) hours, from 11/18/2020 to 11/20/2020. However, per Resident #1's medical record, he/she did not have an Elopement Risk assessment done, and he/she was not care planned as an elopement risk. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 05/21/2021 and determined to exist on 05/05/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/01/2021, with the facility alleging removal of the Immediate Jeopardy on 05/25/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/25/2021, prior to exit on 06/02/2021, with the remaining non-compliance at a Scope and Severity 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, Elopement, dated 10/2014, revealed the policy's purpose was to ensure the safety of all residents. The policy stated that residents with a history of elopement or expressing a desire to leave the facility would be screened upon admission and when nursing judgment warranted it. In addition, per the policy, residents found to be at risk for elopement would be fitted with a secure care bracelet. Review of the facility's policy titled, Supervise: To Oversee, dated 10/2014, revealed it was the duty of the employees to provide supervision for the residents at all times. It stated when staff supervised residents, staff was making sure the residents were safe and not in any danger. In addition, the policy stated some residents could require closer supervision than others, and this information could be found on the resident's care plans and was also provided directly from supervisors. Per the policy, some tips on increased supervision included: were residents complaining more, were loved ones visiting more or less, and if residents were on fifteen (15) minute monitoring, staff must know where they were at all times. Further, per the policy, staff should report any of the noted issues immediately to the Supervisor/Charge Nurse. Review of the facility's Investigative Accident/Incident Report, signed by the Director of Social Services, Licensed Social Worker (LSW), on 05/07/2021, revealed a visitor reported when he was leaving the facility, at approximately 2:15 PM on 05/05/2021, he noticed Resident #1 rolling his/her wheelchair on the north side of the building in the rear parking lot. The resident appeared to be experiencing difficulty getting over the speed bump. Per the report, once the resident got over the speed bump, he/she went toward the left, headed to the highway; then, the visitor got out of his vehicle to see if he could be of assistance and stood in front of the resident to keep him/her from going further. Per the report, the visitor asked the resident if he needed help, and Resident #1 said, No, I just want to get out of here. Per the visitor, he told the resident he/she could not go across the road because it was dangerous, at which time the resident said, You get out of [MEDICATION(S)]. Per the report, the resident was about thirty (30) feet from the two-lane roadway. In addition, the report stated the visitor signaled his wife, who had remained in the vehicle, to call the facility, and the receptionist, who answered the phone, said she would get someone immediately. Per the report, the receptionist contacted the Adult Day Care Director who immediately went outside, and she tried to get Resident #1 to come into the facility, but he/she refused. Then, the visitor and the Adult Day Care Director stood between the resident and the roadway and summoned additional help. Per the report, the Director of Nursing (DON) and the scheduler arrived at the site and were able to talk Resident #1 into returning to the facility; Resident #1 was very angry and agitated. Further, per the report, the resident was placed on fifteen (15) minute monitoring, a secure care bracelet was applied to his/her left wrist, and staff notified the family and Physician. The report stated Resident #1's legs and feet were swollen, and the bracelet would not fit comfortably around his/her ankle without creating a circulation problem, so the bracelet was placed on his/her left wrist and tested for proper functioning. In addition, after Resident #1 was returned to the unit, staff immediately did a complete headcount on each unit and completed a full skin assessment and vital signs on Resident #1. No issues were identified. Review of the local weather history, obtained from Google local weather forecast history, revealed the temperature high, on 05/05/2021 was sixty-six (66) degrees Fahrenheit, and the weather was partly cloudy at the time Resident #1 was outside the facility. Observation of Resident #1, on 05/18/2021 at 1:50 PM, revealed the resident was in his room, sitting in a wheelchair and reading a book. Observed sitting at the resident's bedside was a person who identified herself as a feeding assistant, who was working at that time as a sitter to provide one-to-one (1:1) observation of Resident #1. Observed on the doorframe was a running man sign, indicating the resident was at risk for elopement. Interview with Resident #1, on 05/18/2021 at 2:00 PM, revealed the resident was very open and willing to talk about the recent elopement incident. The resident began the conversation by saying, Well, I did not get off the facility. The resident revealed he/she had a roommate whom he/she did not get along with well, adding they had many difficulties and argued over the television volume, especially at night. The resident stated this all built up over time, and he/she lost it and decided to leave the facility. The resident stated, I am really sorry. It all got backed up until I couldn't handle it. Resident #1 said he/she was able to get out the door unnoticed because there was a big, heavy-set young man in the facility who had trouble speaking. The resident stated the young man was at the receptionist's window and blocked the receptionist's view; the receptionist could not see over or around the man, so Resident #1 said he/she left behind the person who was exiting the door when the door opened. Continued interview with Resident #1, on 05/18/2021 at 2:00 PM, revealed the resident left the front porch, went around the corner to the back parking lot, toward the roadway. The resident stated there were two (2) speed bumps; the first bump was too high to get over, so he/she went to the second bump, which was not as high, and got over it. The resident revealed he/she was going to hitch-[NAME] in his/her wheelchair, adding, That was pretty stupid. The resident said a man visiting someone in the facility's apartments could tell he/she did not belong where he/she was. Per interview, the resident stated the visitor came from the apartments, got into his pick-up, and parked his truck in front of the resident to prevent him/her from going further. The resident added, He probably saved my life. I am so sorry for what I did. The resident said many staff came out of the facility and got him/her back into the facility. He/She stated, I have no idea who it was that let me out the door. I was just thinking about getting out. I just made a mistake, clear and simple. Per the resident, people living in the facility's apartments had cards and used them to enter and exit the doors. The resident added he/she now wore a bracelet, and if he/she got downstairs close to the exit door, the buzzer would go off to let someone know he/she was trying to get out. Telephone interview with Activities Staff (AS) #1, on 05/19/2021 at 4:40 PM, revealed she was letting a visitor out the front door when Resident #1 came to the door. She stated she asked the resident if he/she was going to sit on the front porch, and he/she replied yes. She stated she held the handicap button on the door while the visitor helped the resident navigate his/her wheelchair over the door threshold, and then AS #1 left. She said she did not think anything about letting Resident #1 out the door because she had seen him/her sitting on the porch several times before. She stated she did not hear of Resident's elopement attempt until later that day. She stated she was unaware of the resident's prior exit-seeking behavior or attempts. Telephone interview with the Front Desk Receptionist, on 05/19/2021 at 4:50 PM, revealed she was the receptionist at the front desk the day Resident #1 eloped. She said she did not see the resident sitting in the lobby around the time of the elopement, adding, she was very busy that day screening visitors and people coming in the front door because visitation had opened up to families. In addition, she revealed she let Resident #1 out the front door all the time, adding, to her knowledge the resident had privileges to go outside alone and sit on the front porch. Further, she stated the receptionists could see the resident from their window, and he/she let them know by knocking on the window when he/she wanted to come back inside. Observation of the elopement route the resident took, on 05/19/2021 at 11:10 AM, revealed Resident #1 would have exited the front door in his/her wheelchair, turned right, propelled down the ramp, traveled around the building, and was found about thirty (30) feet from the roadway. The State Survey Agency (SSA) Surveyor, accompanied by the Social Worker, walked the length of the parking lot where the resident allegedly traveled and was found. The estimated travel distance, as measured in foot distance by the SSA Surveyor, was approximately one hundred seventy-five (175) feet. Observation of the spot where the visitor stopped the resident and where staff located Resident #1 revealed a two-lane roadway about thirty (30) feet from the site. Interview with the Social Services Director (SSD), on 05/19/2021 at 11:10 AM, revealed the resident had made the statement several times before, I want to go home, but she was not aware he/she had made such a statement prior to the elopement. Interview with the Director of Nursing (DON), on 05/19/2021 at 1:45 PM, revealed someone visiting a resident in the Adult Day Care alerted the facility, at 2:15 PM on 05/05/2021, that Resident #1 was outside the facility and told the visitor he/she was going home. She stated she immediately exited the building and headed in the direction the caller said he saw the resident, and with the help of a few other staff, they returned the resident to the facility. The DON stated, in her interview with Licensed Practical Nurse (LPN) #1, the nurse on the unit where Resident #1 resided, LPN #1 said it had been about two (2) hours since she last saw the resident. Telephone interview with LPN #1, on 05/19/2021 at 10:02 AM, revealed she was the nurse assigned to Resident #1 the day he/she eloped. She revealed the resident had not expressed any unusual concerns that day, no more than any other time. LPN #1 revealed Resident #1 was depressed and angry about being in the nursing home and constantly talked about going home. She revealed the resident always had hopes of going home, but when his/her Physician told the resident, about two (2) weeks before the elopement, that going home again was not possible, the resident became more irritated and agitated toward his/her roommate, expressing anger and displeasure with his/her roommate to his/her spouse. Per interview, the spouse would call the facility regarding Resident #1's alleged complaints toward the roommate. LPN #1 also revealed she was not aware that Resident #1 had made a prior attempt to leave the building, trying to go home. She said the resident was not on elopement precautions, and she was not aware the resident had ever been on elopement precautions before this elopement attempt, on 05/05/2021. Telephone interview with State Registered Nurse Aide (SRNA) #2, on 05/19/2021 at 10:48 AM, revealed she worked as needed (PRN) at the facility and was working Unit 3, the unit where Resident #1 resided, the day the resident eloped. SRNA #2 said she and another aide were providing care to a totally dependent resident, which took a while, when the incident happened. SRNA #2 revealed the resident had been more upset lately, often stating he/she wanted to go back home and talking lovingly about the spouse. Review of Resident #1's Primary Care Physician's Progress Notes and Orders, dated 04/25/2021, revealed it was a sad situation with the resident because he/she wanted to go home so badly, and it was hard for the resident to understand that he/she had issues that prevented returning home at the present time. The note stated these issues were related to instability on a walker, inability to dress independently, and concerns relating to bathing because there was only a tub at home, with no walk-in shower. Per the note, the Physician assessed the resident as depressed, very anxious to go home, and he would again speak with the resident's family. Review of Resident #1's medical record revealed the facility admitted the resident, on 01/10/2020, with multiple diagnoses that included History of Falls, Personal History of Mental and Behavioral Disorders, and Generalized Muscle Weakness. The record stated Resident #1 required a manual wheelchair for mobility. Continued review of Resident #1's medical record revealed the resident had a history of exit seeking and verbalizing he/she wanted to go home. On 06/28/2020 at 3:30 PM, Resident #1 was found in the main lobby attempting to exit the front door and saying he/she was going home. An Elopement Risk Assessment was done, and the resident was determined to be at risk for elopement. Again, on 11/18/2020, documentation in the medical record progress notes revealed the nurse spoke to Resident #1, and he/she was angry and said he/she wanted to leave the facility. Per the notes, staff placed the resident on every fifteen (15) minute monitoring for forty-eight (48) hours; but an Elopement Risk Assessment was not done. Review of Resident #1's Comprehensive Care Plan (CCP), initiated on 01/10/2020, did not reveal an elopement risk focus or any interventions put in place to prevent elopement, even after the incidents on 06/28/2020 and 11/18/2020. Additional interview with the DON, on 05/20/2021 at 2:00 PM, revealed elopement assessments were conducted on all residents on admission, when there was an event, or when nursing judgment warranted it, as per policy. In addition, the DON stated she expected staff to observe the residents closely, listen when they talked to them, and act on their concerns; and doing these things were crucial to keeping residents safe. Interview with the Interim Administrator, on 05/20/2021 at 2:34 PM, revealed he was not aware of Resident #1's prior attempt to exit the facility, and he said if the staff was not aware of Resident #1's prior exit attempt, that was a concern because staff could have kept a closer watch on the resident. Further interview revealed if the resident was expecting to go home and was told he/she would never go home again, that would be devastating. The Administrator stated it was important for the staff to pay attention to all concerns and keep residents safe. Review of the facility's IJ Removal Plan revealed the facility implemented the following: 1. On 05/05/2021 and 05/06/2021, licensed nursing staff performed Elopement Risk Assessments on all residents to determine risk of elopement. 2. Nurses and State Registered Nurse Aides (SRNAs) will check for bracelet placement each shift and for function every week. Nurses will document this on the Treatment Administration Record (TAR) and SRNAs will document in the electronic health record (EHR). 3. A list of residents assessed as at risk of elopement will be kept in the Elopement Binder at the nursing stations and on the Elopement boards. 4. Residents identified as at risk for elopement will wear bracelets that will activate the door alarm as appropriate. If a resident refused to wear the secure care bracelet, other interventions to include one-on-one (1:1) care, care bracelets placed on wheelchairs per the manufacturer's recommendation, fifteen (15) minute monitoring, compassionate care visits with family, or psychiatric consults were other options. 5. Residents will be assessed by licensed nursing staff for risk of elopement upon admission, on a quarterly basis, and with significant changes in resident condition. 6. On 05/05/2021, the Quality Assurance (QA) Director began educating all staff on the elopement policy, including the location of the Elopement Binders and Boards; completing education on 05/07/2021. Currently 146 employees plus seven (7) therapy staff (153 total staff) received education on the elopement risk process and policy. One hundred percent (100 %) of staff were educated by 05/07/2021. 7. The QA Director or designee will in-service new staff and agency staff on the Elopement Policy as part of new employee orientation. Agency staff will be educated prior to beginning their first shift. 8. On 05/05/2021, the Maintenance Director checked all door alarms in the exit doors for proper functioning. All doors were functioning properly. Maintenance Department personnel will check doors on a weekly basis and will document checks in the Preventative Maintenance Log. Defective doors will be repaired immediately and/or staffed 24/7 until repaired. 9. On 05/24/2021, the Maintenance Director held an Elopement Drill on day shift. Elopement drills will be held monthly going forward. There were no issues identified during the 05/24/2021 drill. 10. On 05/06/2021, the MDS Assistant reviewed the care plans of all residents assessed to be at risk for elopement with no revisions indicated. On 05/24/2021, the MDS Coordinator reviewed these care plans again with one (1) revision on one (1) care plan. 11. All residents who are assessed to be at risk for elopement will be supervised by staff outside the facility. The new policy for outdoor time for all residents who desire to go out will be 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with staff supervision. Education for staff was started, on 05/06/2021, and completed, on 05/28/2021, by the QA Director and Admissions Coordinator. One hundred fifty three (153) staff were educated on this for 100 % completion. The QA Director or designee will educate Agency and new hires before the start of their shift. 12. The front entrance will be staffed from 8:00 AM to 4:30 PM each day. The front entrance will be locked during all other hours, except for emergency purposes. 13. On 05/07/2021, the Admissions Coordinator modified the Admission packet to include information related to resident movement in and outside of the facility for residents. It reflected the times of outdoor visits. The times are 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with staff supervision. 14. On 05/05/2021, the MDS Assistant reviewed and modified Resident #1's CCP to reflect the resident's individualized needs related to his/her assessed risk of elopement. CCP modifications included a psychological evaluation with medication adjustments, compassionate care visits, the need to provide staff supervision when the resident is outside the facility, one-to-one (1:1) supervision until the resident's need for supervision lessened, and counseling. The Social Services Director set up the psychiatric consult on 05/10/2021, and the APRN recommended therapy sessions; therapy session scheduled for 06/08/2021. The QA Director educated fifty-three (53) of ninety-three (93) nursing and activity staff on 05/06/2021. The remaining forty (40) staff were educated by the QA Director, on 05/27/2021, for one hundred percent (100 %) of staff educated. 15. On 05/06/2021, the MDS Assistant reviewed the care plans of all residents assessed to be at risk of elopement with no revisions indicated and again, on 05/24/2021 by the MDS Coordinator, with one (1) revision on one (1) care plan done. The QA Director started elopement education on 05/06/2021 and completed the education on 05/07/2021. One hundred and fifty three (153) staff were educated for 100 %. The QA Director or designee will educate any agency or new hire staff on this policy before they begin their shift. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Elopement Risk Assessments performed on 05/05/2021 and completed on 05/06/2021 revealed licensed nursing staff assessed eighty (80) residents for elopement risk. Review of eight (8) residents' medical record, assessed by nursing staff to be at risk for elopement, (Residents #1, #3, #4, #5, #6, #7, #8, and #9) revealed documentation the residents all wore Secure Care Alarm bracelets. Observation of Residents #1, #3, #4, #5, #6, #7, #8, and #9, on 06/02/2021, revealed all were wearing Secure Care Alarm Bracelets. 2. Review of the Elopement Policy, dated 05/2021, revealed Secure Care Alarm bracelets will be checked for placement every shift and tested on ce weekly for proper functioning. Review of documentation in Residents #1, #3, #4, #5, #6, #7, #8, and #9 medical records revealed daily and weekly documentation by nurses and SRNAs of Secure Care Alarm bracelet's placement and functioning. Interview with LPN #4, SRNA #7, LPN #5, RN #1, and LPN #6, on 06/02/2021, at 11:15 AM, 11:22 AM, 11:25 AM, 11:30 AM, and 11:35 AM, respectively, all revealed they checked each resident's Secure Care Alarm bracelets daily and weekly for placement and functionality. 3. Observation of the Elopement Binders and the Elopement Boards in Unit #1, #2, and #3 identified Resident #1, #3, #4, #5, #6, #7, #8, and #9 as an elopement risk and each are identified with a picture and a personal profile. Review of significant change in resident status revealed the facility followed the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) process for significant change, declines, or improvements in a resident's status. Review of education provided staff revealed staff received education regarding what constituted the definition of a significant change in resident status. 4. On 06/02/2021, observation of all residents assessed as at risk for elopement (Residents #1, #3, #4, #5, #6, #7, #8, and #9) were wearing Secure Care Alarm bracelets. There was no documented evidence residents at risk for elopement refused to wear the secure bracelets. Interview with the DON, on 06/02/2021 at 12:16 PM, revealed residents who refused to wear a Secure Care Alarm bracelet would be monitored closer for their whereabouts and placed on one-to-one (1:1) monitoring. In addition, per the manufacturer's recommendation, the secure care device was effective when placed on wheelchairs. 5. Review of the elopement policy, dated 5/2021, revealed elopement risk assessments will be performed upon admission, quarterly, and with significant changes in a resident's condition. Review of the Significant Change in Resident Status document, undated, revealed the facility followed the CMS RAI process for significant declines or improvements in a resident's status. Interview with the QA Director and DON, on 06/02/2021 at 11:03 AM and 12:16 PM respectively, revealed staff was educated on what constituted a change in a resident's condition during the elopement assessment policy education, on 05/05/2021 through 05/07/2021. 6. Review of the facility's document Type of In-Service-Elopement Policies, with attached rosters, signed by the QA Director, on 05/05/2021, revealed education was presented to Nursing, Activities, Dietary, Therapy/Social Services, Day Care, Front Office, and Housekeeping staff between 05/05/2021 and 05/07/2021. Staff not in attendance was phone in-serviced on the new policy guidelines. Review of phone in-service rosters revealed staff was called by the QA Director and informed of the new elopement policy changes and processes. One hundred percent (100 %) of staff received the education. Interview with LPN #4, Courtesy Aide #6, SRNA #7, LPN #5, RN #1, and LPN #6, and the Front Desk Attendant on 06/02/2021, at 11:15 AM, 11:20 AM, 11:22 AM, 11:25 AM, 11:30 AM, 11:51 AM, and 12:07 PM respectively, revealed they received education and training on the elopement policy, residents at risk for elopement, and location of the Elopement Binders and the Elopement Boards on the units from the QA Director and the DON. Interview with the QA Director, on 06/02/2021 at 11:03 AM, and the DON, on 06/02/2021 at 12:16 PM, revealed they both participated in making changes in the elopement assessment policy and in new guidelines for residents' outdoor time allotment. In addition, they both worked together to educate all staff on the elopement policy; elopement risk assessment guidelines for the assessment to occur on admission, quarterly, and if there is a change in condition or behavior; new guidelines around residents outdoor time; and locations of Elopement Binders, Elopement Boards, and Secure Care Alarm bracelets. Education rosters provided, between 05/05/2021 and 05/07/2021, showed one hundred percent (100 %) of the staff received the education. 7. Interview with the QA Director, on 06/02/2021 at 11:03 AM, revealed she provides elopement policy education to Agency staff and new hires before they begin their shift. Observation of the Agency and new hire binder revealed education and training material included in the orientation process. 8. Review of the exit doors alarm audit tool, titled Weekly Secure Care System Check & Egress, dated from 10/23/2019 through 05/13/2021, revealed the Maintenance Director checked nine (9) exit door alarms and egresses for proper functioning weekly. No issues were identified. Interview with the Director of Maintenance, on 06/02/2021 at 11:38 AM, revealed he checked all door alarms and egresses weekly, on Fridays, and documented the checks in the Preventative Maintenance Log. He stated he checked the door alarms, on 05/05/2021, the day Resident #1 eloped, and all alarms functioned properly. Also, he stated identified issues were repaired immediately or monitored until repaired. 9. Review of the facility's document Elopement Drill, with attached roster, signed by the QA Director, revealed an elopement drill was conducted, on 05/24/2021 at 12:15 PM, with staff from all departments participating. Interview with the QA Director, on 06/02/2021 at 11:03 AM, and the Maintenance Director, on 06/02/2021 at 11:38 AM, revealed they conducted and/or participated in an elopement drill, on 05/24/2021 at 12:15 PM. They both stated staff from all departments participated in the mock drill. 10. Review of the care plans of eight (8) residents at risk for elopement revealed all eight (8) residents had care plans that had been reviewed by the MDS Assistant on 05/06/2021. Interview with the MDS Assistant and MDS Coordinator, on 06/02/2021 at 11:51 AM, revealed the MDS Assistant reviewed all care plans of residents at risk for elopement on 05/06/2021. The MDS Coordinator reviewed the residents at risk for elopement care plans again, on 05/24/2021, and revised one (1) of the care plans. 11. Review of the new facility's policy titled, Schedule for Outdoor Time, dated 05/07/2021, with attached roster, revealed all residents who desired to go outside would be supervised by staff at the designated times of 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM. The QA Director and DON provided the education to all staff. Interview with LPN #4, Courtesy Aide #6, SRNA #7, LPN #5, RN #1, and LPN #6, and the Front Desk Attendant, on 06/02/2021 at 11:15 AM, 11:20 AM, 11:22 AM, 11:25 AM, 11:30 AM, 11:51 AM, and 12:07 PM respectively, revealed all staff interviewed received education and training on the Outdoor Time policy by the QA Director and the DON. Interview with the QA Director, on 06/02/2021 at 11:03 AM, revealed she provided the majority of the education to staff, with help from the DON, on 05/07/2021, regarding the new policy titled, Schedule for Outdoor Time, which would apply to residents at risk for elopement. Per the interview, all agency and new hires will be educated before the start of their shift. Review of a document in the AOC binder, dated 05/06/2021 and 05/07/2021, with attached resident roster, and signed by the SSD, revealed the SSD went to each resident and asked him/her not to go off the floor unless he/she informed staff of their location. The interview revealed the SSD instructed each resident they must be accompanied by staff when outside for their safety. On 06/02/2021, review of documentation in department notes of residents' medical records revealed the SSD educated residents to let staff know if they were going off the unit, and if going outside, staff must accompany them. Interview with the SSD, on 06/02/2021 at 10:50 AM, revealed she went room-to-room and informed all residents of the new rule to notify staff when leaving the unit and the need for staff to accompany them when going outside the facility. 12. Observation of the front entrance, on 06/01/2021 at 11:00 AM, and again, on 06/02/2021 at 8:48 AM, revealed a receptionist positioned at a desk in the front lobby. Interview with the Front Desk Attendant, on 06/02/2021 at 12:07 PM, revealed the Maintenance Director moved her work desk to the front lobby about two (2) weeks ago to allow her a higher visibility of who was entering and exiting the front door of the facility. The attendant stated staff monitored the front entrance, from 8:00 AM to 4:30 PM, seven (7) days a week. Interview with the Maintenance Director, on 06/02/2021 at 11:03 AM, revealed the front door was locked from 4:30 PM until 8:00 AM, except for emergency purposes. He stated, on 05/24/2021, parameters were set to prevent the doors from opening with an acc [TRUNCATED]

Based on interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure the development and implementation of a person-centered comprehensive care plan related to adequate supervision and monitoring to prevent elopement for one (1) of ten (10) sampled residents, Resident #1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/05/2021, at approximately 2:15 PM, Resident #1 exited the building in a wheelchair, without staff knowledge, and was headed toward the highway to go home, when a visitor stopped him/her. Record review revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of Resident #1's Comprehensive Care Plan (CCP) did not reflect an elopement risk focus or interventions to prevent a future elopement and keep the resident safe. The facility's failure to develop a comprehensive individualized care plan and implement interventions to address Resident #1's assessed needs related to supervision and monitoring to ensure a safe environment and prevent elopement has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/21/2021 and was determined to exist on 05/05/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/01/2021, with the facility alleging removal of the Immediate Jeopardy on 05/25/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/25/2021, prior to exit on 06/02/2021, with the remaining non-compliance at a Scope and Severity 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 Policy, dated 12/2014, revealed care plans were communication tools containing information about the resident so there would be continuity of care; therefore, all persons involved with the resident's care were made aware of and encouraged to make changes as they occurred. In addition, CCP updates and changes were the responsibility of all MDS nurses, activities staff, social services staff, and dining services staff. The policy stated CCP's were utilized to inform all staff of the needs and changes for all of the residents, and all problems, with interventions in place, should be included in the CCP, and a care plan note put in the chart for State Registered Nurse Aides (SRNA) to be updated. Review of the policy revealed CCP's must be accurate to reflect current conditions and changes with the residents, and changes and interventions were to be made as soon as possible (ASAP), with staff notified regarding the changes. Review of the facility's policy titled, Supervise: To Oversee, dated 10/2014, revealed it was the duty of the employees to provide supervision for the residents at all times to make sure the residents were safe and not in any danger. Also, the policy stated that some residents needed to be supervised more closely than others, and this information could be found on the resident's CCP and received directly from supervisors. Review of the facility's Investigative Accident/Incident Report, dated 05/07/2021, revealed a visitor reported, at approximately 2:15 PM on 05/05/2021, he noticed Resident #1 rolling his/her wheelchair on the north side of the building in the rear parking lot and heading towards the highway. Review of Resident #1's medical record revealed the facility admitted the resident, on 01/10/2020, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #1 required a manual wheelchair for mobility. Review of Resident #1's Admission Comprehensive MDS Assessment, Section C, dated 01/17/2020, completed by the MDS Coordinator, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), indicating moderate cognitive impairment. Review of Section E of the Admission Assessment revealed the resident low risk for elopement. Further review of Resident #1's medical record revealed the resident exhibited exit seeking behaviors and/or verbalized wanted to go home. Review of the medical record revealed, on 06/28/2020 at 3:30 PM, revealed Resident #1 was found in the main lobby attempting to exit the front door and saying he/she was going home. An Elopement Risk Assessment was completed, and the resident was determined to be at risk for elopement. Review of the Quarterly MDS Assessment, Section E, Behavior-Wandering, dated 07/02/2020, completed by the MDS Coordinator, revealed the facility assessed Resident #1 as exhibiting wandering behavior one (1) to three (3) days during the quarter ending 06/30/2020. However, review the resident's CCP revealed that after the exit attempt on 06/28/2020 and the quarterly MDS Assessment completed on 07/02/2020, a care plan was not developed to reflect an elopement risk focus with interventions. Interview with the MDS Assistant, on 05/19/2021 at 10:45 AM, revealed she conducted Resident #1's Admission MDS assessment. She revealed the resident had no behaviors assessed at that time, including wandering or exit-seeking. She stated in June 2020, the resident had an episode where he/she tried to get out the front door, and during that time, the resident was placed on fifteen (15) minute monitoring; however, she stated she was responsible but did not update the CCP to include supervision, monitoring for whereabouts, and the elopement risk. Continued interview with the MDS Assistant revealed the care plan should have been updated by her, and she did not know why it was not, on 06/28/2020, when Resident #1 demonstrated exit-seeking behavior. Continued review of the medical record revealed on 11/18/2020, a nurse documented Resident #1 was angry and stated he/she wanted to leave the facility. Per the notes, staff placed the resident on every fifteen (15) minute monitoring for forty-eight (48) hours. However, review of the medical record revealed an Elopement Risk Assessment was not completed nor was a care plan developed to address the resident wanting to leave the facility with interventions to keep the resident safe. Continued interview with the MDS Assistant, on 05/19/2021 at 10:45 AM, revealed again the care plan should have been updated by her, and she did not know why it was not, on 11/18/2020, when Resident #1 demonstrated exit-seeking behavior. Telephone interview with LPN #1, on 05/19/2021 at 10:02 AM, revealed she was the nurse assigned to Resident #1 the day he/she eloped. She revealed the resident had not expressed any unusual concerns that day, no more than any other time. He/She always talked about going home. She added that Resident #1 always had hopes of going home. However, the Physician told the resident, about two (2) weeks ago, that going home again was not a reality. LPN #1 said, after hearing this, Resident #1 was irritated and agitated toward his/her roommate, and expressed anger and displeasure about the roommate to his/her spouse. LPN #1 stated there was no indication Resident #1's CCP was updated to address his/her emotional status or change in behavior. LPN #1 also stated she was not aware that Resident #1 had made a prior attempt to leave the building and go home, and she was not aware the resident was ever on elopement precautions before this elopement attempt. Telephone interview with SRNA #2, on 05/19/2020 at 10:48 AM, revealed she worked as needed (PRN) and was working on Unit 3, where Resident #1 resided, the day the resident got out of the building. SRNA #2 stated the resident had been more upset lately, often stating he/she wanted to go home and talking a lot about his/her spouse. SRNA #2 stated she did not know that Resident #1 attempted to leave the facility through the front door in the past, nor was Resident #1 care planned as an elopement risk. Interview with the Social Services Director (SSD), on 05/19/2021 at 11:10 AM, revealed she frequently visited Resident #1, and she had heard the resident make the statement several times before, I want to go home, but she was not aware the resident had made a prior attempt to elope. However, per Resident #1's medical record, he/she was not care planned as an elopement risk. Interview with the Director of Nursing (DON), on 05/19/2021 at 1:45 PM, and again, on 05/20/2021 at 2:00 PM, revealed Resident #1 was placed on fifteen (15) minute monitoring after the first exit-seeking behavior attempt on 06/28/2020. The frequent monitoring was discontinued on 08/17/2020 because the resident informed staff when he/she left the unit and had made no attempts to leave/exit the building. The DON stated her expectation was that care plans were updated based on individualized care needs. She stated to make sure these care needs were current and accurate, staff needed to observe the residents closely, to listen when they talked about their concerns, and to develop interventions if individualized care needs were required to be added or modified. The DON stated doing this was very important to keep residents safe. However, per Resident #1's medical record, he/she did not have an Elopement Risk assessment done, and he/she was not care planned as an elopement risk. Interview with the Administrator, on 05/ 1 at 2:34 PM, revealed he was not aware of Resident #1's prior attempt to exit the facility and probably would not have done anything differently if this had been an isolated incident. However, he stated he was finding out the resident had prior exit-seeking behavior. In addition, if the staff was not aware of the resident's prior exit attempt, this was a concern. Per the interview, it would have been good for the staff to know this history to keep a closer watch on the resident. Likewise, he stated updating and implementing the care plan was important to reflect the resident's current conditions and changes, and all staff must be aware of the care plan and changes. Review of the facility's IJ Removal Plan revealed the facility implemented the following: 1. On 05/05/2021 and 05/06/2021, licensed nursing staff performed Elopement Risk Assessments on all residents to determine risk of elopement. 2. Nurses and State Registered Nurse Aides (SRNAs) will check for bracelet placement each shift and for function every week. Nurses will document this on the Treatment Administration Record (TAR) and SRNAs will document in the electronic health record (EHR). 3. A list of residents assessed as at risk of elopement will be kept in the Elopement Binder at the nursing stations and on the Elopement boards. 4. Residents identified as at risk for elopement will wear bracelets that will activate the door alarm as appropriate. If a resident refused to wear the secure care bracelet, other interventions to include one-on-one (1:1) care, care bracelets placed on wheelchairs per the manufacturer's recommendation, fifteen (15) minute monitoring, compassionate care visits with family, or psychiatric consults were other options. 5. Residents will be assessed by licensed nursing staff for risk of elopement upon admission, on a quarterly basis, and with significant changes in resident condition. 6. On 05/05/2021, the Quality Assurance (QA) Director began educating all staff on the elopement policy, including the location of the Elopement Binders and Boards; completing education on 05/07/2021. Currently 146 employees plus seven (7) therapy staff (153 total staff) received education on the elopement risk process and policy. One hundred percent (100 %) of staff were educated by 05/07/2021. 7. The QA Director or designee will in-service new staff and agency staff on the Elopement Policy as part of new employee orientation. Agency staff will be educated prior to beginning their first shift. 8. On 05/05/2021, the Maintenance Director checked all door alarms in the exit doors for proper functioning. All doors were functioning properly. Maintenance Department personnel will check doors on a weekly basis and will document checks in the Preventative Maintenance Log. Defective doors will be repaired immediately and/or staffed 24/7 until repaired. 9. On 05/24/2021, the Maintenance Director held an Elopement Drill on day shift. Elopement drills will be held monthly going forward. There were no issues identified during the 05/24/2021 drill. 10. On 05/06/2021, the MDS Assistant reviewed the care plans of all residents assessed to be at risk for elopement with no revisions indicated. On 05/24/2021, the MDS Coordinator reviewed these care plans again with one (1) revision on one (1) care plan. 11. All residents who are assessed to be at risk for elopement will be supervised by staff outside the facility. The new policy for outdoor time for all residents who desire to go out will be 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with staff supervision. Education for staff was started, on 05/06/2021, and completed, on 05/28/2021, by the QA Director and Admissions Coordinator. One hundred fifty three (153) staff were educated on this for 100 % completion. The QA Director or designee will educate Agency and new hires before the start of their shift. 12. The front entrance will be staffed from 8:00 AM to 4:30 PM each day. The front entrance will be locked during all other hours, except for emergency purposes. 13. On 05/07/2021, the Admissions Coordinator modified the Admission packet to include information related to resident movement in and outside of the facility for residents. It reflected the times of outdoor visits. The times are 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM with staff supervision. 14. On 05/05/2021, the MDS Assistant reviewed and modified Resident #1's CCP to reflect the resident's individualized needs related to his/her assessed risk of elopement. CCP modifications included a psychological evaluation with medication adjustments, compassionate care visits, the need to provide staff supervision when the resident is outside the facility, one-to-one (1:1) supervision until the resident's need for supervision lessened, and counseling. The Social Services Director set up the psychiatric consult on 05/10/2021, and the APRN recommended therapy sessions; therapy session scheduled for 06/08/2021. The QA Director educated fifty-three (53) of ninety-three (93) nursing and activity staff on 05/06/2021. The remaining forty (40) staff were educated by the QA Director, on 05/27/2021, for one hundred percent (100 %) of staff educated. 15. On 05/06/2021, the MDS Assistant reviewed the care plans of all residents assessed to be at risk of elopement with no revisions indicated and again, on 05/24/2021 by the MDS Coordinator, with one (1) revision on one (1) care plan done. The QA Director started elopement education on 05/06/2021 and completed the education on 05/07/2021. One hundred and fifty three (153) staff were educated for 100 %. The QA Director or designee will educate any agency or new hire staff on this policy before they begin their shift. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Elopement Risk Assessments performed on 05/05/2021 and completed on 05/06/2021 revealed licensed nursing staff assessed eighty (80) residents for elopement risk. Review of eight (8) residents' medical record, assessed by nursing staff to be at risk for elopement, (Residents #1, #3, #4, #5, #6, #7, #8, and #9) revealed documentation the residents all wore Secure Care Alarm bracelets. Observation of Residents #1, #3, #4, #5, #6, #7, #8, and #9, on 06/02/2021, revealed all were wearing Secure Care Alarm Bracelets. 2. Review of the Elopement Policy, dated 05/2021, revealed Secure Care Alarm bracelets will be checked for placement every shift and tested on ce weekly for proper functioning. Review of documentation in Residents #1, #3, #4, #5, #6, #7, #8, and #9 medical records revealed daily and weekly documentation by nurses and SRNAs of Secure Care Alarm bracelet's placement and functioning. Interview with LPN #4, SRNA #7, LPN #5, RN #1, and LPN #6, on 06/02/2021, at 11:15 AM, 11:22 AM, 11:25 AM, 11:30 AM, and 11:35 AM, respectively, all revealed they checked each resident's Secure Care Alarm bracelets daily and weekly for placement and functionality. 3. Observation of the Elopement Binders and the Elopement Boards in Unit #1, #2, and #3 identified Resident #1, #3, #4, #5, #6, #7, #8, and #9 as an elopement risk and each are identified with a picture and a personal profile. Review of significant change in resident status revealed the facility followed the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) process for significant change, declines, or improvements in a resident's status. Review of education provided staff revealed staff received education regarding what constituted the definition of a significant change in resident status. 4. On 06/02/2021, observation of all residents assessed as at risk for elopement (Residents #1, #3, #4, #5, #6, #7, #8, and #9) were wearing Secure Care Alarm bracelets. There was no documented evidence residents at risk for elopement refused to wear the secure bracelets. Interview with the DON, on 06/02/2021 at 12:16 PM, revealed residents who refused to wear a Secure Care Alarm bracelet would be monitored closer for their whereabouts and placed on one-to-one (1:1) monitoring. In addition, per the manufacturer's recommendation, the secure care device was effective when placed on wheelchairs. 5. Review of the elopement policy, dated 5/2021, revealed elopement risk assessments will be performed upon admission, quarterly, and with significant changes in a resident's condition. Review of the Significant Change in Resident Status document, undated, revealed the facility followed the CMS RAI process for significant declines or improvements in a resident's status. Interview with the QA Director and DON, on 06/02/2021 at 11:03 AM and 12:16 PM respectively, revealed staff was educated on what constituted a change in a resident's condition during the elopement assessment policy education, on 05/05/2021 through 05/07/2021. 6. Review of the facility's document Type of In-Service-Elopement Policies, with attached rosters, signed by the QA Director, on 05/05/2021, revealed education was presented to Nursing, Activities, Dietary, Therapy/Social Services, Day Care, Front Office, and Housekeeping staff between 05/05/2021 and 05/07/2021. Staff not in attendance was phone in-serviced on the new policy guidelines. Review of phone in-service rosters revealed staff was called by the QA Director and informed of the new elopement policy changes and processes. One hundred percent (100 %) of staff received the education. Interview with LPN #4, Courtesy Aide #6, SRNA #7, LPN #5, RN #1, and LPN #6, and the Front Desk Attendant on 06/02/2021, at 11:15 AM, 11:20 AM, 11:22 AM, 11:25 AM, 11:30 AM, 11:51 AM, and 12:07 PM respectively, revealed they received education and training on the elopement policy, residents at risk for elopement, and location of the Elopement Binders and the Elopement Boards on the units from the QA Director and the DON. Interview with the QA Director, on 06/02/2021 at 11:03 AM, and the DON, on 06/02/2021 at 12:16 PM, revealed they both participated in making changes in the elopement assessment policy and in new guidelines for residents' outdoor time allotment. In addition, they both worked together to educate all staff on the elopement policy; elopement risk assessment guidelines for the assessment to occur on admission, quarterly, and if there is a change in condition or behavior; new guidelines around residents outdoor time; and locations of Elopement Binders, Elopement Boards, and Secure Care Alarm bracelets. Education rosters provided, between 05/05/2021 and 05/07/2021, showed one hundred percent (100 %) of the staff received the education. 7. Interview with the QA Director, on 06/02/2021 at 11:03 AM, revealed she provides elopement policy education to Agency staff and new hires before they begin their shift. Observation of the Agency and new hire binder revealed education and training material included in the orientation process. 8. Review of the exit doors alarm audit tool, titled Weekly Secure Care System Check & Egress, dated from 10/23/2019 through 05/13/2021, revealed the Maintenance Director checked nine (9) exit door alarms and egresses for proper functioning weekly. No issues were identified. Interview with the Director of Maintenance, on 06/02/2021 at 11:38 AM, revealed he checked all door alarms and egresses weekly, on Fridays, and documented the checks in the Preventative Maintenance Log. He stated he checked the door alarms, on 05/05/2021, the day Resident #1 eloped, and all alarms functioned properly. Also, he stated identified issues were repaired immediately or monitored until repaired. 9. Review of the facility's document Elopement Drill, with attached roster, signed by the QA Director, revealed an elopement drill was conducted, on 05/24/2021 at 12:15 PM, with staff from all departments participating. Interview with the QA Director, on 06/02/2021 at 11:03 AM, and the Maintenance Director, on 06/02/2021 at 11:38 AM, revealed they conducted and/or participated in an elopement drill, on 05/24/2021 at 12:15 PM. They both stated staff from all departments participated in the mock drill. 10. Review of the care plans of eight (8) residents at risk for elopement revealed all eight (8) residents had care plans that had been reviewed by the MDS Assistant on 05/06/2021. Interview with the MDS Assistant and MDS Coordinator, on 06/02/2021 at 11:51 AM, revealed the MDS Assistant reviewed all care plans of residents at risk for elopement on 05/06/2021. The MDS Coordinator reviewed the residents at risk for elopement care plans again, on 05/24/2021, and revised one (1) of the care plans. 11. Review of the new facility's policy titled, Schedule for Outdoor Time, dated 05/07/2021, with attached roster, revealed all residents who desired to go outside would be supervised by staff at the designated times of 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM. The QA Director and DON provided the education to all staff. Interview with LPN #4, Courtesy Aide #6, SRNA #7, LPN #5, RN #1, and LPN #6, and the Front Desk Attendant, on 06/02/2021 at 11:15 AM, 11:20 AM, 11:22 AM, 11:25 AM, 11:30 AM, 11:51 AM, and 12:07 PM respectively, revealed all staff interviewed received education and training on the Outdoor Time policy by the QA Director and the DON. Interview with the QA Director, on 06/02/2021 at 11:03 AM, revealed she provided the majority of the education to staff, with help from the DON, on 05/07/2021, regarding the new policy titled, Schedule for Outdoor Time, which would apply to residents at risk for elopement. Per the interview, all agency and new hires will be educated before the start of their shift. Review of a document in the AOC binder, dated 05/06/2021 and 05/07/2021, with attached resident roster, and signed by the SSD, revealed the SSD went to each resident and asked him/her not to go off the floor unless he/she informed staff of their location. The interview revealed the SSD instructed each resident they must be accompanied by staff when outside for their safety. On 06/02/2021, review of documentation in department notes of residents' medical records revealed the SSD educated residents to let staff know if they were going off the unit, and if going outside, staff must accompany them. Interview with the SSD, on 06/02/2021 at 10:50 AM, revealed she went room-to-room and informed all residents of the new rule to notify staff when leaving the unit and the need for staff to accompany them when going outside the facility. 12. Observation of the front entrance, on 06/01/2021 at 11:00 AM, and again, on 06/02/2021 at 8:48 AM, revealed a receptionist positioned at a desk in the front lobby. Interview with the Front Desk Attendant, on 06/02/2021 at 12:07 PM, revealed the Maintenance Director moved her work desk to the front lobby about two (2) weeks ago to allow her a higher visibility of who was entering and exiting the front door of the facility. The attendant stated staff monitored the front entrance, from 8:00 AM to 4:30 PM, seven (7) days a week. Interview with the Maintenance Director, on 06/02/2021 at 11:03 AM, revealed the front door was locked from 4:30 PM until 8:00 AM, except for emergency purposes. He stated, on 05/24/2021, parameters were set to prevent the doors from opening with an access card after 4:30 PM and before 8:00 AM. He stated he canceled cards of past employees and previous resident/apartment family members who no longer were at the facility, and the facility notified families and residents of the change. 13. Review of an Admission document, revised on 05/07/2021, by the Admissions Coordinator, revealed a statement, If you need to leave your unit/floor, please notify your charge nurse of this. As well, if your loved one wishes to take you off the unit or outdoors, please notify the charge nurse upon leaving and returning to the unit. Outdoor times that we offer with staff supervision is 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM. Interview with the DON, on 06/02/2021 at 12:16 PM, revealed the admission information was given to all residents and families upon admission to the facility. 14. Review of Resident #1's CCP, revised 05/05/2021, revealed the MDS Assistant, based on identified needs of the elopement risk assessment, individualized Resident#1's CCP. This revision included a behavior-monitoring sheet, a symbol of a running person placed on the resident door, fifteen (15) minute monitoring, supervision when outside the facility, a Secure Care Alert bracelet to be worn, medications as ordered, compassionate care visits, and a Psychiatric consult. Interview with the MDS Assistant, on 06/02/2021 at 11:51 AM, revealed she assessed and updated Resident #1's care plan on 05/05/2021 to include individualized elopement risk interventions. She stated the MDS Coordinator reviewed the residents at risk for elopement care plans again, on 05/24/2021, and revised one (1) of the care plans. Interview with RN #1, Unit #3, on 06/02/2021 at 11:30 AM, revealed Resident #1 resided on Unit #3. Per the interview, she was aware of Resident #1's care plan revisions, to include frequent monitoring, compassionate care visits by spouse, wearing of the Secure Care Alarm bracelet, and the Psychiatric consult. She stated she also received education and training on the Elopement Policy and the Outdoor Time policy, by the QA Director and the DON. 15. Review of all eight (8) residents' care plans, assessed as at risk for elopement, contained interventions related to elopement risk. Interview with the MDS Assistant and the MDS Coordinator, on 06/02/2021 at 11:51 AM, revealed they reviewed care plans of residents at risk for elopement on 05/06/2021, and again on 05/24/2021, and revised one (1) care plan. Interview with the QA Director, on 06/02/2021 at 11:03 AM, revealed she provided the majority of the education to staff, on 05/07/2021, regarding the new schedule for outdoor time and the elopement policy updates. Per the interview, all agency and new hires will be educated before the start of their shift. Interview with LPN #4, Courtesy Aide #6, SRNA #7, LPN #5, RN #1, and LPN #6, and the Front Desk Attendant on 06/02/2021, at 11:15 AM, 11:20 AM, 11:22 AM, 11:25 AM, 11:30 AM, 11:51 AM, and 12:07 PM respectively revealed all staff interviewed revealed they received education and training on the Elopement Policy and Outdoor Time Policy by the QA Director and the DON.

Based on observation, interview, review of the facility's policies, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement the comprehensive person-centered care plan for each resident related to maintaining the resident's comfort and dignity as evidenced by staff posting unauthorized pictures and videos on social media, which would cause humiliation to a reasonable person in a similar situation, for two (2) of seven (7) sampled residents (Resident #1 and Resident #2). Residents #2's Comprehensive Care Plan (CCP), dated [DATE], revealed an intervention to maintain the resident's comfort and dignity while in the Long Term Care (LTC) setting. However, on [DATE], State Registered Nurse Aide (SRNA) #1 posted to Snapchat (a social media app where users can post short videos with captions), a short video showing Resident #2's face while he/she was in bed with a caption stating,[***] got up on me. Interview with Resident #2's Power of Attorney (POA), revealed this resident was a very private person and this would be embarrassing to the resident, and also this was an invasion of the resident's privacy and confidentiality. Furthermore, Resident #1's CCP, dated [DATE], revealed an intervention to maintain the resident's comfort and dignity while in the LTC setting. However, on [DATE], SRNA #1 posted a picture of Resident #1 while the resident was actively dying on Facebook (social media). Interview with Resident #1's representative revealed Resident #1 was a private person who had requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the active state of dying on social media. (Refer to F-583, F-600, and F-610) The findings include: Review of the facility Policy titled, Care Plan Development undated, revealed the facility must develop and implement a comprehensive person-centered care plan for each resident. Further review revealed the purpose of the Care Plan was to attain or maintain the resident's highest practicable physical, mental, and psychological well-being Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Resident #2's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed this resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #2's Comprehensive Care Plan (CCP), dated [DATE], revealed the resident wished to remain in the LTC facility, with a goal stating the resident would be comfortable and dignity maintained. Interventions included re-evaluate discharge plan quarterly and maintain the resident's comfort and dignity while in the LTC setting. Review of the recorded video of the post made to the social media app Snapchat by SRNA #1 on [DATE], revealed the video showed the face of Resident #2 while he/she was in bed and the caption stated,Asshole got up on me. Interview on [DATE] at 12:24 PM, with Resident #2's Power of Attorney (POA), revealed the facility notified him on [DATE], that a video of his relative was posted on a social media site. However, he stated the facility did not make him aware of the nature of the video, or the caption on the video. Upon being informed of the nature of the video and the caption, by the Surveyor, he stated Resident #2 would never want anything like that posted as he/she was a very private person. Further interview revealed this video and caption was very demeaning, and embarrassing to the resident. He further stated, posting this video on social media was an invasion of the resident's privacy and confidentiality. The Surveyor attempted an interview with Resident #2 on [DATE] at 2:00 PM; however, he/she was unable to answer questions related to his/her cognitive status. Interview on [DATE] at 2:11 PM, with SRNA #2, revealed she was unaware SRNA #1 had taken a video of Resident #2 until she saw the video posted that night at approximately 10:00 PM while at home. SRNA #2 confirmed the video of Resident #2 was posted on SRNA #1's Snapchat account. 2. Resident #1's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated [DATE] revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), indicating the resident was unable to finish the interview; and also assessed the resident as receiving Hospice Care. Additional review of the medical record revealed Resident #1 expired at the facility on [DATE]. Review of Resident #1's Comprehensive Care Plan (CCP), dated [DATE], revealed the resident wished to remain in the LTC facility, with a goal stating the resident would be comfortable and dignity maintained. Interventions included re-evaluate discharge plan quarterly and maintain the resident's comfort and dignity while in the LTC setting. SRNA #1 posted a picture of Resident #1 while he/she was actively dying, to the Facebook social media site on the evening of [DATE] (see interviews below). The Surveyor was unable to view the picture as it had been deleted from Facebook. Interview on [DATE] at 11:50 AM, with Resident #1's representative, revealed he was unaware of anyone in the family being informed that a picture of Resident #1 had been posted to a social media site during his/her last hours. Upon learning of the posting by the Surveyor, he stated Resident #1 was a private person and had requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the state of actively dying, as on [DATE]. Further interview revealed posting this picture on social media was an invasion of the resident's privacy and confidentiality. Phone interview on [DATE] at 2:24 PM, with SRNA #1, revealed she had been employed at the facility for approximately two (2) months, but had since been terminated. She admitted she posted a picture of Resident #1 to her Facebook account on [DATE] at approximately 9:00 PM while the resident was lying in bed with blankets over him/her. Further interview revealed she was sad about Resident #1's state, which was the reason for the posting, and she had already deleted the picture from her account. However, she denied posting a video of Resident #2 on Snapchat. Continued interview with SRNA #1, revealed it would be a privacy and dignity issue to post a video to Snapchat of Resident #2 in bed with the caption,Asshole got up on me; or to post a picture of Resident #1 while the resident was in bed. Interview on [DATE] at 3:00 PM, with the Dietary Manager, revealed on [DATE], at approximately 9:55 PM, her daughter (former employee of the facility), informed her SRNA #1 had posted the video of Resident #2 on Snapchat and her daughter went ahead and sent the video to her (Dietary Manager) via phone. Further interview revealed she then went to the Administrator's house on [DATE] at approximately 10:30 PM, and showed her the video. Additional interview revealed she did not know anything about a picture being taken of Resident #1 and placed on social media. The Dietary Manager acknowledged unauthorized postings of residents on social media was an invasion of their privacy, and confidentiality and was a dignity issue. Interview on [DATE] at 9:35 AM, with the Social Service Director (SSD), revealed the Administrator informed her via phone call on [DATE] at approximately 10:35 PM, that SRNA #1 had posted a video of Resident #2 on Snapchat. Further interview revealed she later learned that SRNA #1 had also posted a picture of Resident #1 on Facebook. Further interview revealed it would be considered abuse and a violation of the residents' privacy and confidentiality as well as a dignity issue to have unauthorized videos and pictures posted on social media. Further, it was her expectation CCPs be implemented for all residents. Interview on [DATE] at 10:44 AM, with the Director of Nursing (DON), revealed posting unauthorized pictures and videos of residents to a social media site was inappropriate and certainly a a violation of resident rights and privacy. Further interview revealed it was her expectation staff implement the CCPs in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being as per regulation. She stated Resident #1 and Resident #2's CCPs should have been implemented related to maintaining the resident's comfort and dignity while in the LTC setting. Interview on [DATE] at 11:07 AM, with the Administrator, revealed during the interview with SRNA #1 on [DATE], she denied posting the video of Resident #2, but the Dietary Manager's daughter who sent the video to the Dietary Manager, and also SRNA #2 was able to confirm the video of Resident #2 was posted to SRNA #1's Snapchat account. Further interview revealed SRNA #1 did confess to posting a picture of Resident #1 on Facebook. She stated it was a violation of resident rights related to privacy and confidentiality to post unauthorized pictures or videos of residents to social media. Additional interview revealed the CCP dictated the care a resident was to receive and it was her expectation staff implement the residents' CCPs in order to ensure residents receive necessary care and services. She stated Resident #1 and Resident #2's CCPs should have been implemented related to maintaining the resident's comfort and dignity.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure residents are free from abuse for two (2) of seven (7) sampled residents who had unauthorized pictures and videos posted on social media, which would cause humiliation to a reasonable person in a similar situation (Resident #1 and Resident #2). On 10/24/19, State Registered Nurse Aide (SRNA) #1 posted to Snapchat (a social media app where users can post short videos with captions), a short video showing the face of Resident #2 while he/she was in bed. The caption stated,[***] got up on me. Interview with Resident #2's Power of Attorney (POA), revealed the resident would never want anything like that posted as he/she was a very private person and this was very demeaning, and would be embarrassing to the resident. In addition, on 10/24/19, SRNA #1 posted a picture of Resident #1 as he/she was actively dying on Facebook (social media). Interview with Resident #1's representative revealed Resident #1 had requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the state of actively dying, as he/she was on 10/24/19. (Refer to F-583, F-610, and F-656) The finding include: Review of the facility's Abuse, Neglect, and Exploitation Policy and Procedure Policy, dated 11/2016, revealed it is the policy of the facility to prohibit and prevent abuse, neglect, and exploitation of residents. Further review revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse to residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Continued review revealed mental abuse included abuse facilitated or enabled through the use of technology. Review of the facility's Social Media Policy, undated, revealed employees are not to publish, post or release any information that is considered confidential. Review of the facility's Employee Cellular Telephone Usage, Policy, dated 06/2009, revealed it is the standard of the facility to ensure respect and protect the privacy of the residents. Further review revealed cellular phones are not to be used in any residential care areas. Continued review revealed under no circumstances are camera cellular phones to be used to take pictures of the residents or staff. Review of the facility's Bourbon Heights Inc. Confidentiality Agreement, dated 09/2013, revealed the facility will make all reasonable efforts to secure all resident information in a confidential manner. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 08/07/19 with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 10/09/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as requiring extensive assistance of two (02) staff for transfers and bed mobility. Review of the recorded video of the post made to the social media app Snapchat by SRNA #1 on 10/24/19, revealed a short video showing the face of Resident #2 while he/she was in bed with the caption,Asshole got up on me. Interview on 10/30/19 at 12:24 PM, with Resident #2's Power of Attorney (POA), revealed he was notified by the facility on 10/25/19 that a video of his relative was posted to a social media site. He stated he was not aware of the nature of the video, nor was he aware of the caption on the video. Upon being informed of the nature of the video by the Surveyor, he stated his relative would never want anything like that posted as he/she was a very private person and this would greatly upset him/her. Further interview revealed this was very demeaning and would be embarrassing to the resident. He stated he was upset that a facility staff member posted the unauthorized video of his relative. Interview with Resident #2 was attempted on 10/29/19 at 2:00 PM; however, the resident was not able to answer questions asked due to cognitive status. 2. Review of Resident #1's closed medical record revealed the facility admitted the resident on 06/07/19 with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 passed away at the facility on 10/27/19. Review of Resident #1's Significant Change MDS Assessment, dated 10/11/19 revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), indicating the resident was unable to finish the interview used to determine the resident's mental status. Continued review revealed Resident #1 was receiving Hospice Care. SRNA #1 posted a picture of Resident #1 as he/she was actively dying on Facebook on the evening of 10/24/19 (see interviews below). The Surveyor was unable to view the picture as it had been deleted from Facebook. Interview on 10/30/19 at 11:50 AM, with Resident #1's representative, revealed to his knowledge no one in the family was informed that a picture of Resident #1 was posted to a social media site. After being informed of the posting by the Surveyor, he stated Resident #1 had requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the state of actively dying, as he/she was on 10/24/19. He further stated he was very upset that he or the family was not notified of this posting to social media. Review of the medical record revealed no documented evidence the resident's representative or family members were notified of the social media posting. Review of the facility Investigation, dated 10/28/19, signed by the Social Services Director (SSD), revealed a former employee reported to the Dietary Manager on 10/24/19, that SRNA #1 had placed a video of Resident #2 on Snap chat. The incident was reported to the Administrator, SSD, the Director of Nursing (DON) and the local police department. Per the Investigation, interviews were conducted with staff by the Administrator, SSD and DON on 10/24/19 and 10/25/19 and the police interviewed staff on 10/24/19 and 10/25/19 as well. Additional review of the Investigation, revealed the facility did substantiate the allegation as SRNA #1 did admit to placing a photo of another resident (Resident #1) on social media. Per the Investigation, although SRNA #1 did deny placing a video of Resident #2 on Snap chat, SRNA #2 did verify she had seen the video of Resident #2 on SRNA #1's Snap chat story. SRNA #1 was terminated. Per the Investigation, Resident #2 was unable to answer questions due to his/her cognition. Statements obtained by the facility from SRNA #7, #8, #9, #10, #11, and #12, dated 10/24/19 and 10/25/19, who worked on unit 2, where Resident #1 and Resident #2 resided, revealed they denied knowledge of pictures or videos of residents on social media. Review of the assignment sheet for unit 2, for the second shift (3:00 PM-11:00 PM), on 10/24/19, revealed Licensed Practical Nurse (LPN) #1, SRNA #3, SRNA #7 and SRNA #8 were working with SRNA #1 during the time of the social media postings of Resident #1 and Resident #2. Review of the Statement the facility obtained from SRNA #3, undated, revealed she had posted a picture of herself at the facility in the bathroom on Snap chat (date unknown) and she thought SRNA #1 posted a picture of she (SRNA #3) and SRNA #1 from a resident's room (date unknown). Interview on 10/29/19 at 2:16 PM, with SRNA #3, who worked with SRNA #1 on the evening of 10/24/19 on unit 2, revealed she had been employed at the facility for approximately three (3) weeks. She stated she was not aware that SRNA #1 had posted the picture of Resident #1 or video of Resident #2 while she was working on 10/24/19, with SRNA #1. She further stated she was aware SRNA #1 had taken pictures of herself in resident rooms and posted to social media in the past; however, she had not seen pictures of residents on SRNA #1's social media accounts. Interview on 10/30/19 at 9:11 AM with SRNA #7, and on 10/30/19 at 9:16 AM, with SRNA #8, revealed they both confirmed working with SRNA #1, on Unit 2 on 10/24/19, but denied being aware of SRNA #1 posting a picture of Resident #1 or a video of Resident #2 on social media. Review of the Statement the facility obtained from SRNA #2, undated, revealed she had seen the post on social media of Resident #2 while the resident was in bed, and the caption about the resident not staying in bed. Further review revealed SRNA #2 was questioned if she had ever posted anything related to the facility and she verified she had posted herself putting up her middle finger. Interview on 10/29/19 at 2:11 PM, with SRNA #2, revealed she had been employed at the facility for approximately three (3) years. Per interview, she was unaware SRNA #1 had taken a video of Resident #2 until she saw the video posted that night at approximately 10:00 PM while at home. SRNA #2 confirmed the video of Resident #2 was posted on SRNA #1's Snapchat account. Further interview revealed she did not know anything about a picture of Resident #1 being posted on social media. Post-survey phone interview on 11/19/19 at 11:29 AM, with LPN #1, revealed she received a call on 10/24/19 between 10:30 PM and 11:00 PM from the Administrator, and was told to remove SRNA #1 from the floor and not let the SRNA leave the facility. She stated she was unsure why SRNA #1 was to be removed from the floor. Further interview revealed she was not aware of any staff members posting pictures or videos of residents on social media, and unauthorized postings would be considered abuse and an invasion of privacy. Review of the Statement written by SRNA #1, undated, revealed the only interaction she had with Resident #2 on 10/24/19, was when she helped get the resident dressed after his/her shower which was before dinner, and when she was asked to take the resident to his/her room about 8:00 or 9:00 PM tonight. Phone interview on 10/29/19 at 2:24 PM, with SRNA #1, revealed she had been employed at the facility for approximately two (2) months. She stated she did post a picture of Resident #1 to her Facebook account on 10/24/19 at approximately 9:00 PM. Per interview, it was a picture of the resident lying in bed with blankets over him/her. She further stated Resident #1's condition upset her and she was scared that she would possibly need to perform post-mortem care for the resident. Further, she was sad about Resident #1's state, which was the reason she posted the picture. She stated she later deleted the picture from her account. Further interview with SRNA #1, revealed on 10/24/19, she was notified at approximately 10:45 PM by LPN #1 that she needed to come to the nurse's station and not return to the floor. She stated LPN #1 was not aware of the reasoning that she needed to stay at the nurse's station. Continued interview revealed shortly thereafter the Administrator came and escorted her to the DON's office for an interview. SRNA #1 stated she told the Administrator and the police about the picture she had taken of Resident #1 while being interviewed about the video of Resident #2. Additional interview with SRNA #1, revealed she did not post the video of Resident #2 to her Snapchat account and was unsure who could have posted the video. She further stated she told the Administrator and the police that she did not post the video of Resident #2 on Snapchat. Continued interview revealed she was not aware of the cell phone policy, nor was she aware of the social media policy or the confidentiality agreement until after the incident. SRNA #1 further stated she did receive training on abuse in orientation in (MONTH) 2019. When questioned if it would be abuse to post a video to Snapchat of Resident #2 in bed with the caption,Asshole got up on me; or to post a picture of Resident #1 while the resident was in bed, she stated she didn't think it was abuse, but it was a privacy and dignity issue. Continued interview revealed she no longer worked at the facility. Review of SRNA #1's personnel files revealed she signed an acknowledgement stating she read and received a copy of Resident Rights, Health Insurance Portability and Accountability Act (HIPPA), Confidentiality Agreement, cell phone usage policy, and the facility's Abuse policy. These documents were signed on 08/26/19, on SRNA #1's date of hire. Interview on 10/29/19 at 3:00 PM, with the Dietary Manager, revealed on 10/24/19, at approximately 9:55 PM, her daughter who was a former employee of the facility, made her aware that SRNA #1 had posted the video of Resident #2 on Snapchat and her daughter sent the video to her (Dietary Manager) via phone. She stated to her knowledge, the video was posted at approximately 9:00 PM. She further stated when she received the video she immediately went to the facility to verify that the video of Resident #2 was taken on 10/24/19. Per interview, she arrived at the facility at approximately 10:00 PM and verified the video was taken during the evening of 10/24/19 by matching the clothing Resident #2 was wearing. She stated after verifying the video was taken on 10/24/19, she texted the Administrator at 10:23 PM, asking if the Administrator would be awake and if she could go over to the Administrator's house. Additional interview with the Dietary Manager, revealed she arrived at the Administrator's home on 10/24/19 at approximately 10:30 PM, and she showed the video to the Administrator. She further stated at approximately 10:35 PM, the Administrator called the Social Services Director (SSD) and had her (Dietary Manager) explain the situation to the SSD. Per interview, once she had explained the situation to the SSD, the Administrator was advised to call the police by the SSD and to begin an investigation. The Dietary Manager stated at approximately 10:50 PM, she and the Administrator arrived back to the facility. Per interview, her daughter(former employee), who was sitting with a relative at the facility, showed the Administrator the videos upon their arrival. She stated at this time, she left the Administrator and went to sit in her relative's room for the remainder of the night. Further interview revealed she did not know anything about a picture being taken of Resident #1 and placed on social media. Per interview, the Dietary Manager's daughter (former employee) did not want to be interviewed or involved in this investigation, as she was attending high school with SRNA #1. Interview on 10/31/19 at 9:35 AM, with the SSD, revealed she was notified by the Administrator via phone call on 10/24/19 at approximately 10:35 PM, that there had been an incident involving a staff member posting a video of Resident #2 on Snapchat. She stated she advised the Administrator to call the police and begin an abuse investigation. Further interview revealed she later learned that SRNA #1 had posted a picture of Resident #1 on Facebook. Per interview, on 10/25/19, she notified Resident #1's family that an unauthorized picture was posted to social media and notified Resident #2's family that an unauthorized video was posted to social media. Additional interview revealed it would be considered abuse and a violation of the residents' privacy and confidentiality to have unauthorized videos and pictures posted on social media. Interview on 10/31/19 at 10:44 AM, with the Director of Nursing (DON), revealed on 10/24/19, the Administrator called her at approximately 10:45 PM to inform her SRNA #1 posted a video of Resident #2 on Snapchat. She stated when she arrived to the facility on [DATE], she viewed the video and was able to confirm it was Resident #2 in the video. Per interview, the Administrator then went to the nurse's station at approximately 10:55 PM, and brought SRNA #1 to the DON's office for an interview. She stated during the interview with SRNA #1, she denied posting the video of Resident #2, but stated she did post a picture of Resident #1 on Facebook on 10/24/19. Additional interview revealed once the police had finished questioning SRNA #1, she dismissed SRNA #1 from employment and escorted her out of the facility. Continued interview with the DON, revealed a staff member posting an unauthorized picture or video of a resident would be considered abuse and a violation of the residents' privacy and dignity. Per interview, SRNA #1 had received training on privacy, dignity, confidentiality, and abuse on hire. Further interview revealed there had been no residents to complain about staff using cell phones, and she was unaware of any issues related to staff using cell phones in resident care areas until this incident. Interview on 10/31/19 at 11:07 AM, with the Administrator, revealed she received a text message from the Dietary Manager on 10/24/19 at 10:23 PM, asking if she was awake and if the Dietary Manager could come over. She further stated when the Dietary Manager arrived at approximately 10:30 PM, she showed the Administrator the video of Resident #2 and informed her that a staff member had posted the video on 10/24/19 at approximately 9:00 PM. Per interview, she called LPN #1 at approximately 10:40 PM and instructed her to remove SRNA #1 off the floor until she arrived at the facility. She stated she then called the police at approximately 10:45 PM, while on the way to the facility and arrived at the facility with the Dietary Manager at approximately 10:50 PM. Further interview with the Administrator, revealed upon her arrival to the facility, the Dietary Manager's daughter, (former employee) showed her the video of Resident #2 and she clearly identified it was Resident #2 in the video. Further, at approximately 10:55 PM she escorted SRNA #1 from the Unit 2 nurse's station and brought her to the DON's office. She stated SRNA #1 was interviewed and denied posting the video of Resident #2 to social media, but did confess to posting a picture of Resident #1 to Facebook. The Administrator stated SRNA #2 and also the Dietary Manager's daughter (former employee) who sent the video to the Dietary Manager, were able to confirm that the video of Resident #2 was posted to SRNA #1's Snapchat account. Continued interview revealed it was abuse and a violation of a resident's rights to post pictures or videos of residents to social media. The Administrator stated it was her expectation staff only use their cell phones during their breaks, and not use their cell phones in resident care areas.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure resident rights related to privacy and confidentiality for two (2) of seven (7) sampled residents who had unauthorized pictures and videos posted on social media, which would cause humiliation to a reasonable person in a similar situation (Resident #1 and Resident #2). On 10/24/19, State Registered Nurse Aide (SRNA) #1 posted to Snapchat (a social media app where users can post short videos with captions), a short video showing the face of Resident #2 while he/she was in bed with a caption stating,[***] got up on me. Interview with Resident #2's Power of Attorney (POA), revealed the resident was a very private person and this would be embarrassing to the resident, and also this was an invasion of the resident's privacy and confidentiality. Furthermore, on 10/24/19, SRNA #1 posted a picture of Resident #1 while the resident was actively dying on Facebook (social media). Interview with Resident #1's representative revealed Resident #1 was a private person who requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the active state of dying on social media, and this was an invasion of the resident's privacy and confidentiality. (Refer to F-600, F-610, and F-656)) The findings include: Review of the facility's Bourbon Heights Inc. Confidentiality Agreement, dated 09/2013, revealed the facility will make all reasonable efforts to secure all resident information in a confidential manner. Review of the facility's Social Media Policy, undated, revealed employees are not to publish, post or release any information that is considered confidential. Review of the facility's Employee Cellular Telephone Usage, dated 06/2009, revealed it is the standard of the facility to ensure respect and protect the privacy of the residents. Further review revealed cellular phones are not to be used in any residential care areas. Continued review revealed under no circumstances are camera cellular phones to be used to take pictures of the residents or staff. Review of the facility's Resident Rights, Policy, dated 11/2016, revealed each resident has a right to a dignified existence. Further review revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life. 1. Resident #2's clinical record revealed the facility admitted the resident on 08/07/19 with [DIAGNOSES REDACTED]. Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 10/09/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating severe cognitive impairment. Review of the recorded video of the post made to the social media app Snapchat by SRNA #1 on 10/24/19, revealed the short video showed the face of Resident #2 while he/she was in bed with the caption,Asshole got up on me. Interview on 10/30/19 at 12:24 PM, with Resident #2's Power of Attorney (POA), revealed he was notified by the facility on 10/25/19, that a video of his relative was posted on a social media site. However, he stated he was not aware of the nature of the video, or the caption on the video. Upon being informed of the nature of the video by the Surveyor, he stated his relative would never want anything like that posted as Resident #2 was a very private person. Further interview revealed this was very demeaning, embarrassing to the resident, and was a breech of privacy and confidentiality. The Surveyor attempted an interview with Resident #2 on 10/29/19 at 2:00 PM; however, the resident was unable to answer questions related to his/her cognitive status. 2. Resident #1's closed clinical record revealed the facility admitted the resident on 06/07/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS Assessment, dated 10/11/19 revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), indicating the resident was unable to finish the interview. Additional review of the MDS Assessment revealed Resident #1 was receiving Hospice Care. Continued review of the medical record revealed Resident #1 passed away at the facility on 10/27/19. SRNA #1 posted a picture of Resident #1 while actively dying, to the Facebook social media site on the evening of 10/24/19 (see interviews below). The Surveyor was not able to view the picture as it had been deleted from Facebook. Interview on 10/30/19 at 11:50 AM, with Resident #1's representative, revealed he was unaware of anyone in the family being informed that a picture of Resident #1 was posted to a social media site. Upon learning of the posting by the Surveyor, he stated Resident #1 was a private person and had requested a closed casket funeral and would have been Incredibly upset if anyone saw him/her in the state of actively dying, as he/she was on 10/24/19. Further, posting this picture on social media was an invasion of the resident's privacy and confidentiality. Review of the assignment sheet for unit 2, for the second shift (3:00 PM-11:00 PM), on 10/24/19, revealed Licensed Practical Nurse (LPN) #1, SRNA #3, SRNA #7 and SRNA #8 were working on the unit with SRNA #1 during the time of the social media postings of Resident #1 and Resident #2. Interview on 10/29/19 at 2:16 PM, with SRNA #3, revealed she was not aware that SRNA #1 had posted the picture of Resident #1 or video of Resident #2 while she was working with the SRNA on the evening shift on 10/24/19. Additional interview revealed she had not seen pictures of residents on SRNA #1's social media accounts. Per interview, posting pictures of residents on social media was an invasion of their personal privacy and would be a dignity issue for the residents. Interview on 10/30/19 at 9:11 AM with SRNA #7, and on 10/30/19 at 9:16 AM, with SRNA #8, revealed they both verified working with SRNA #1, on Unit 2 on 10/24/19, but denied being aware of SRNA #1 posting a picture of Resident #1 or a video of Resident #2 on social media. Further interview with the SRNAs revealed it would be inappropriate to post pictures or videos of residents on social media as this was an invasion of the residents' privacy. Post-survey phone interview, on 11/19/19 at 11:29 AM, with LPN #1, revealed she was not aware of any staff members posting pictures or videos of residents on social media, which would be in appropriate and an invasion of the residents' privacy. Interview on 10/29/19 at 2:11 PM, with SRNA #2, revealed she was unaware SRNA #1 had taken a video of Resident #2 until she saw the video posted that night at approximately 10:00 PM while at home. SRNA #2 verified the video of Resident #2 was posted on SRNA #1's Snapchat account. Additional interview revealed she did not know anything about a picture of Resident #1 being posted on social media. Continued interview revealed posting unauthorized pictures of residents could be considered a confidentiality and privacy issue. Phone interview on 10/29/19 at 2:24 PM, with SRNA #1, verified she had been employed at the facility for approximately two (2) months, but had been terminated. She stated she did post a picture of Resident #1 to her Facebook account on 10/24/19 at approximately 9:00 PM while the resident was lying in bed with blankets over him/her. Per interview, she was sad about Resident #1's state, which was the reason for the posting. She stated had already deleted the picture from her account. Continued interview with SRNA #1, revealed on 10/24/19, she was escorted by the Administrator to the DON's office for an interview. SRNA #1 stated she was interviewed about a video of Resident #2, which she denied taking or posting to social media. Further, she did tell the Administrator and the police about the picture she had taken and posted to Facebook of Resident #1 while being interviewed. Further interview revealed she was not aware of the cell phone policy, nor was she aware of the social media policy or the confidentiality agreement until after the incident. SRNA #1 stated it would be a privacy and dignity issue to post a video to Snapchat of Resident #2 in bed with the caption,Asshole got up on me; or to post a picture of Resident #1 while the resident was in bed. Review of SRNA #1's personnel files revealed she signed an acknowledgement stating she read and received a copy of Resident Rights, Health Insurance Portability and Accountability Act (HIPPA), Confidentiality Agreement, and cell phone usage policy. These documents were signed by SRNA #1 on 08/26/19, her date of hire. Interview on 10/29/19 at 3:00 PM, with the Dietary Manager, revealed on 10/24/19, at approximately 9:55 PM, her daughter who was a former employee of the facility, informed her SRNA #1 had posted the video of Resident #2 on Snapchat and her daughter went ahead and sent it to her (Dietary Manager) via phone. Further, when she received the video she went to the facility, and verified the video was taken during the evening of 10/24/19 by matching the clothing Resident #2 was wearing. Continued interview revealed she then went to the Administrator's house on 10/24/19 at approximately 10:30 PM, and showed her the video. Additional interview revealed she did not know anything about a picture being taken of Resident #1 and placed on social media. The Dietary Manager acknowledged unauthorized postings of residents on social media was an invasion of their privacy and confidentiality. Interview on 10/31/19 at 9:35 AM, with the Social Service Director (SSD), revealed she was informed by the Administrator via phone call on 10/24/19 at approximately 10:35 PM, that a staff member posted a video of Resident #2 on Snapchat. Per interview, she advised the Administrator to call the police and begin an investigation. Further interview revealed she later learned that SRNA #1 had posted a picture of Resident #1 on Facebook. Continued interview revealed it would be considered abuse and a violation of the residents' privacy and confidentiality to have unauthorized videos and pictures posted on social media. Interview on 10/31/19 at 10:44 AM, with the Director of Nursing (DON), revealed she viewed the video of Resident #2 which was placed on the Snapchat site with the inappropriate caption, and acknowledged the resident could be clearly identified. Per interview, during the investigation, SRNA #1 denied posting the video of Resident #2; however, it was verified by SRNA #2, that the video was in fact posted to SRNA #1's Snapchat account. Further, during the investigation, SRNA #1 did admit to posting a picture of Resident #1 while he/she was actively dying on 10/24/19. Continued interview revealed posting unauthorized pictures and videos of to a social media site was inappropriate and certainly a a violation of resident rights and privacy. Interview on 10/31/19 at 11:07 AM, with the Administrator, revealed she viewed the video of Resident #2 which was posted on the Snapchat media site, and the resident could be clearly identified in the video. Further interview revealed during the interview with SRNA #1 on 10/24/19, she denied posting the video of Resident #2, but the Dietary Manager's daughter who sent the video to the Dietary Manager, and also SRNA #2 was able to confirm the video of Resident #2 was posted to SRNA #1's Snapchat account. Further, during the investigation, SRNA #1 did confess to posting a picture of Resident #1. Continued interview revealed it was a violation of resident rights related to privacy and confidentiality to post unauthorized pictures or videos of residents to social media.

Based on interview, record review, and review of the facility's policies, video surveillance footage, and manufacturer's guidelines, it was determined the facility failed to have an effective system in place to ensure a safe environment and adequate supervision for residents who had been assessed to be at risk for elopement, and who exhibited exit-seeking behavior, for one (1) of three (3) sampled residents (Resident #1). On 08/15/15, Resident #1 utilized his/her rolling walker to exit the front door of the facility without staff knowledge at approximately 3:18 PM. Even though the resident had a Secure Care Bracelet attached to his/her rolling walker, the alarm did not sound when the resident exited the facility. Resident #1 returned to the facility through the front door utilizing his/her rolling walker at approximately 3:25 PM, at which point the Secure Care Bracelet alarm did sound, alerting staff. State Registered Nursing Assistant (SRNA) #1 responded to the alarm, and found Resident #1 in the main lobby with the door closed, with no evidence Resident #1 had been outside. Although Resident #1 reported to SRNA #1 he/she had returned from outside, SRNA #1 did not alert nursing staff and Resident #1 was not placed on increased supervision as directed by the care plan. Later on 08/15/15, at approximately 6:01 PM, Resident #1 again exited the facility through the front door utilizing his/her rolling walker, and again the alarm did not sound. Off-duty staff found Resident #1 lying on the ground in the parking lot by the side of the building. Staff inside the facility were alerted to the resident's whereabouts by the off-duty staff at approximately 6:15 PM. In addition, Resident #1's Secure Care Bracelet was improperly placed on the walker instead of on the resident's ankle, per the manufacturer's guidelines. Therefore, the alarm was not triggered when the resident exited the building twice on 08/15/15 without staff knowledge. Staff interviews revealed they were not aware the bracelets were not to be secured to walkers. The facility's failure to have an effective system in place to ensure the proper utilization and functioning of the Secure Care system, and the failure to provide increased supervision to Resident #1 when exit-seeking behavior was exhibited, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/20/15 and was determined to exist on 08/15/15. An acceptable credible Allegation of Compliance (AOC) was received on 08/25/15 which alleged removal of the Immediate Jeopardy on 08/20/15. The Immediate Jeopardy was verified to be removed on 08/20/15 as alleged with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care (F-323) at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure care plans are followed to implement interventions to provide adequate supervision. The findings include: Review of the facility's Policy Guidelines for the Secure Care System, revised 09/2014, revealed the Secure Care Bracelet could be placed on a walker or wheelchair if a resident refused to have it placed on his/her ankle. Review of the Secure Care Transmitter User Guide, dated 02/25/15, revealed to ensure proper functioning, the Secure Care transmitter was to be placed on a resident's ankle, unless a resident was confined to a wheelchair with both legs elevated, in which case it could be applied to a rod above the wheel of the wheelchair. Interview with the Director of Nursing (DON) on 08/20/15 at 11:43 AM revealed prior to Resident #1's exiting the building twice on 08/15/15 without the alarm sounding, it was her understanding the Secure Care Bracelet could be placed on an assistive device such as a walker or wheelchair. She stated she was not aware of the manufacturers guidelines for the proper placement of the Secure Care Bracelets until the facility requested and received a copy of the guidelines from their supplier on 08/20/15. The DON further stated, following the incident, Resident #1's and one other resident's Secure Care Bracelets were removed from their walkers and placed on their ankles. A third resident (Resident #2) who refused to have his/her Secure Care Bracelet placed on his/her ankle was immediately placed on fifteen (15) minute checks, with the Secure Care Bracelet being ultimately removed from the resident on 08/20/15 as his/her circumstances had changed and he/she was no longer determined to be an elopement risk. Record review revealed the facility admitted Resident #1 on 12/08/10, with multiple [DIAGNOSES REDACTED].#1's son on 12/06/10. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/15, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #1 to ambulate independently with the assist of a walker. Review of Resident #1's Comprehensive Care Plan (CCP), dated 04/21/15, revealed Resident #1 was care planned for being at risk for elopement due to the [DIAGNOSES REDACTED].#1's wandering behavior; staff were to report any threats of leaving the facility to the charge nurse; and the resident would be placed on fifteen (15) minute monitoring or one-on-one (1:1) supervision when attempting to leave the facility unattended. The facility had a video security system which recorded video but not audio. Review of the facility's video surveillance footage for 08/15/15 revealed Resident #1 first exited the building at 3:18 PM through the front door, at which time the alarm did not function as there was no staff response observed. Further review of the video revealed when the resident re-entered the facility at 3:25 PM, also through the front door, SRNA #1 rushed to the door, clearly responding to an alarm. Resident #1 was observed to be back in the lobby with the doors closed in the time it took SRNA #1 to respond. Resident #1 again exited the facility at 6:01 PM through the front doors, again with no alarm sounding and no staff response was observed on the video. Interview with SRNA #1 on 08/19/15 at 10:47 AM and again at 2:38 PM revealed she responded to the Secure Care alarm at 3:25 PM, and found Resident #1 in the lobby at that time. SRNA #1 stated she asked Resident #1 if she had been on the porch, to which Resident #1 responded yes. SRNA #1 further stated she walked with Resident #1 back to the unit, and told Kentucky Medication Aide (KMA) #1 the resident reported having been outside. SRNA #1 revealed she did not see Registered Nurse (RN) #1 when she took Resident #1 back to the unit, or she would have reported what the resident had said to the nurse. SRNA #1 went on to reveal she thought Resident #1 was confused and had not really been outside, as she was unaware Resident #1 had exited the facility at 3:18 PM as no alarm had sounded. Interview with KMA #1 on 08/19/15 at 11:17 AM revealed she heard SRNA #1 tell her on the afternoon of 08/15/15 Resident #1 had been to the door; she stated she didn't understand Resident #1 had stated he/she was coming in from outside. KMA #1 further stated she informed RN #1 that Resident #1 had been to the door and set off the Secure Care alarm. Interview with RN #1 on 08/19/15 at 2:24 PM revealed she had been working on 08/15/15, and had heard from KMA #1 Resident #1 had gone to the door to look out and set off the alarm. She stated she was not told Resident #1 had stated he/she had been outside. RN #1 revealed when Resident #1 exited the building at 6:01 PM, no alarm sounded to alert staff of the resident's exit. Continued interview revealed RN #1 was made aware of the elopement when the unit received a call at 6:15 PM from off-duty staff who reported Resident #1 was outside in the parking lot. Further interview revealed RN #1 went outside in response to the call and found Resident #1 lying on his/her left side in the parking lot, and assessed the resident to have a skin tear to his/her left elbow. RN #1 stated she asked Resident #1 what she was doing outside, to which Resident #1 responded I don't know. RN #1 called Resident #1's doctor and received an order to send Resident #1 to the emergency room . RN #1 notified Emergency Medical Services (EMS) who arrived transported Resident #1 to the hospital at approximately 6:43 PM. Interview with Cook #1 on 08/19/15 at 3:12 PM revealed she was driving past the facility on 08/15/15 after 6:00 PM when she noticed someone on the ground in the side parking lot. Cook #1 stated she found Resident #1 lying on his/her left side across a speed bump with his/her walker lying on the ground nearby. Cook #1 further stated Resident #1 appeared to have some blood on the left elbow. Cook #1 called inside to Unit #1 where Resident #1 resided, and informed KMA #1 of the resident's location. Interview with the Maintenance Director revealed he was called in to the facility on the evening of 08/15/15 following the elopement. The Maintenance Director revealed he tested all of the facility exits, and also tested Resident #1's walker at the exits. He stated he discovered Resident #1's alarm did not sound every time when he took the walker, with the Secure Care Bracelet attached to it, through the exit door. He further stated he was previously aware of the problem. He explained due to the height of the Secure Care Bracelet on the walker, it did not consistently trigger the alarm at the exit door. The Maintenance Director reported he did not know the precise height at which the transmitter bracelet should be placed for consistent detection by the system, but determined it was a concern if the bracelet was not placed on the ankle as recommended by the manufacturer. Interview with the Administrator on 08/19/15 at 12:19 PM revealed she was called to the facility the evening of 08/15/15 after Resident #1 had eloped. She revealed, in her review of the video footage, it was clear the alarm did not trigger when Resident #1 exited the facility at 3:18 PM or 6:01 PM. She stated after testing Resident #1's walker at the front exit, it was determined it did not consistently trigger the alarm. Continued interview revealed although there was a problem with the placement of the Secure Care Bracelet which led to a failure to alert staff of the resident exiting the building, the facility also identified staff failed to implement the Care Plan for increased supervision after Resident #1 first exited the building at 3:18 PM. Interview with the DON on 08/20/15 at 11:43 AM revealed her expectation was for the Secure Care system to alert staff by alarming whenever a resident was in close proximity to a receiver or attempted to exit the facility. She acknowledged this could only be assured by proper placement of the bracelet on the resident's ankle. She further acknowledge, based on Resident #1's exit-seeking behavior on 08/15/15, staff should have implemented the Care Plan related to increased supervision. An attempt was made to interview Resident #1 on 08/20/15 at 11:35 AM, at which time the resident was sitting in his/her room in a recliner. Resident #1 was hard of hearing, and was very difficult to engage in conversation. The resident did not appear to recall exiting the facility on 08/15/15, although agreed to being able to move about the facility pretty well using the walker. Resident #1 had a Secure Care Bracelet on his/her left ankle during the interview. Observation on 08/19/15 of the area where Resident #1 was found on 08/15/15 revealed it was approximately one hundred and twenty-eight (128) feet from the entrance to the facility, on a speed bump in the parking lot by the side of the facility. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 08/25/15, which alleged removal of the Immediate Jeopardy (IJ) effective 08/20/15. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was sent to the hospital on the evening of 08/15/15 for evaluation in the emergency room (ER) and was discharged back to the facility the same night. Upon return to the facility, RN #1 performed a head to toe skin assessment. 2. Upon return from the hospital ER, Resident #1 was placed on fifteen (15) minute monitoring while asleep and one (1) on one (1) supervision while awake as directed by the Administrator upon Resident #1's return on 08/15/15. 3. The Secure Care system was checked by the Maintenance Director on 08/15/15 to identify the root cause of the accident. 4. Resident #1's Secure Care Bracelet was removed from his/her rolling walker, and a new Secure Care Bracelet was placed on his/her left ankle by KMA #1. 5. Two other residents with Secure Care Bracelet's on their walkers, Resident #2 and Resident #4, had Secure Care Bracelets removed from their walkers, with Resident #4's Secure Care Bracelet placed on his/her ankle the evening of 08/15/15. Resident #2 initially refused placement on his/her ankle, and was placed on fifteen (15) minute checks on the evening of 08/15/15. Resident #2 was determined by staff to no longer be an elopement risk on 08/20/15 with his/her Secure Care Bracelet's removed at that time and fifteen (15) minute checks discontinued at that time. 6. A video surveillance investigation was initiated on 08/15/15 by the Administrator to identify the source of Resident #1's exit from the facility. Further video investigation was conducted by the Administrator on 08/17/15. 7. An investigation of the events involving Resident #1 was initiated on 08/15/15 by the Social Services Director (SSD) and concluded on 08/18/15. 8. All Secure Care Bracelets in use were checked for functioning and placement by the unit charge nurse on duty on 08/15/15 and each shift for seventy-two (72) hours. This was in conjunction with a head count conducted every shift by the unit charge nurse on duty, also initiated on 08/15/15 and concluded on 08/18/15. 9. All residents were re-assessed utilizing the Elopement Risk Assessment (Decision Tree) on 08/17/15 by facility nursing staff with care plans updated as required. 10. All care signs for elopement were checked to be in place for seventeen (17) residents with Secure Care Bracelets on 08/17/15 by the Quality Assurance (QA) Assistant. Care signs were symbols placed above a resident's bed to alert staff providing care the resident was an elopement risk. Additionally, all Elopement Risk Boards were updated, with additional boards added to the Adult Day Care office and the Therapy Office. 11. The Secure Care Policy was updated to remove language pertaining to the allowance of the Secure Care Bracelet being placed on assistive devices on 08/19/15 by the DON. 12. Beginning on 08/17/15 and concluding 08/19/15, 150 of 152 current facility staff were in-serviced on elopement, behaviors, the facility's elopement policy and implementing care plan interventions. The remaining two (2) employees were to be educated prior to being scheduled for work. 13. Beginning on 08/17/15 and concluding 08/19/15, 150 of 152 current facility staff were in-serviced on reporting any inconsistencies in the Secure Care Bracelet alarm system or any failures immediately to the charge nurse. Only two (2) staff remaining to be educated prior to being assigned any work. 14. Daily rounds were made by the Administrator beginning on 08/17/15 and concluding on 08/20/15 to ensure staff understood the education they had received on elopement, behaviors, reporting, and implementing care plan interventions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of nursing notes for Resident #1 dated 08/15/15 revealed Resident #1 was sent to the hospital on the evening of 08/15/15. Review of ER nursing notes dated 08/15/15 revealed the hospital discharge impression was a contusion to the left elbow, a contusion to the left hip, and a concussion without loss of consciousness. Continued review of facility nursing notes dated 08/15/15 revealed upon return to the facility, RN #1 performed a head to toe skin assessment, revealing no additional areas of concern. Interview with the Medical Director (MD on 08/25/15 at 1:20 PM revealed he had been contacted on 08/15/15 when Resident #1 eloped, and the facility had reviewed it's Allegation of Compliance with him. The MD revealed he felt the underlying issue to be antibiotic medication Resident #1 was taking to combat a UTI. The MD stated it was an unfortunate situation which he hoped never happens again, but had supported the facility's efforts to correct it's problems. 2. Review of 15 Minute Monitoring Form documentation for Resident #1 revealed he/she was placed on fifteen (15) minute monitoring on 08/15/15 at 9:00 PM and was documented as ongoing at the time of the Extended Survey on 08/26/15. Staff was observed with Resident #1 in Resident #1's room on 08/19/15 at 8:15 AM; in Resident #1's room on 08/20/15 at 11:35 AM; and on 08/26/15 at 11:10 AM. Interview with SRNA #7 on 08/26/15 at 10:03 AM revealed she was responsible for scheduling the increased supervision for Resident #1. Interview with monitoring staff on 08/26/15, SRNA #8 at 10:12 AM, and SRNA #9 at 10:24 AM, all confirmed they had sat with Resident #1 on more than one occasion on twelve (12) hour shifts since the 08/15/15 elopement. These statements were corroborated by staff initials on the 15 Minute Monitoring Forms. 3. The Secure Care system was checked by the Maintenance Director on 08/15/15 to identify the root cause of the accident. Interview with the Maintenance Director on 08/19/15 at 12:08 PM revealed he was called in the night of 08/15/15 after Resident #1 had eloped, and he tested the Secure Care alarm system at that time. The Maintenance Director revealed, in testing the system, he determined the Secure Care system was inconsistent in alerting staff when placed on resident walkers due to the height of the bracelet. Follow up interview with the Maintenance Director on 08/26/15 at 11:13 AM confirmed there was a height cutoff on the alarm system that wasn't 100% effective in alarming when placed on resident walkers. The Maintenance Director went on to reveal, now that all residents with Secure Care Bracelets have them on their ankles, the alarms have been working consistently without exception. The Maintenance Director revealed, in addition to the staff testing that has been occurring since the elopement, in which staff escort residents with Secure Care Bracelets to a nearby receiver to ensure the receiver was triggered, maintenance routinely tests all of the exits on Friday to ensure they are functioning properly. 4. Interview with RN #1 on 08/20/15 at 1:15 PM confirmed Resident #1's Secure Care Bracelet was removed from his/her rolling walker, and a new Secure Care Bracelet was placed on his/her left ankle by KMA #1. Resident #1's Secure Care Bracelet was observed on his/her ankle by the State Survey Agency on 08/20/15 at 11:35 AM. 5. Two other residents with Secure Care Bracelet's on their walkers, Resident #2 and Resident #4, had Secure Care Bracelets removed from their walkers, with Resident #4's Secure Care Bracelet placed on his/her ankle the evening of 08/15/15. Resident #2 initially refused placement on his/her ankle, and was placed on fifteen (15) minute checks on the evening of 08/15/15. Fifteen (15) minute check sheets for Resident #2 were reviewed, and were current up to 08/20/15, when he/she was determined by facility staff to no longer be an elopement risk. Observation of both residents on 08/20/15 confirmed Secure Care Bracelets were no longer placed on walkers, with Resident #4 wearing his/her bracelet on his/her ankle. 6. Interview with the Administrator on 08/19/15 at 12:19 PM revealed a video surveillance investigation was initiated on 08/15/15 by the Administrator to identify the source of Resident #1's exit from the facility. Further video investigation was conducted by the Administrator on 08/17/15 and it was determined at that time Resident #1 had exited the facility earlier in the day on 08/15/15 and returned prior to the elopement at 6:01 PM. This video footage was reviewed by the State Survey Agency, with times identified in the facility investigation for Resident #1's exit(s) and return in the afternoon of 08/15/15 verified by the date/time stamp on the recording. 7. Interview with the Social Services Director (SSD) on 08/19/15 at 3:48 PM revealed she was called in the evening of 08/15/15 and began an initial investigation at that time. Continued interview revealed she completed her final investigation on 08/18/15. Review of the final investigation dated 08/18/15 revealed the SSD investigation further revealed Resident #1 had been to the nurses station and stated to RN #1 several times he/she was waiting on his/her daughter to come take her to pick beans. Interview with the SSD on 08/19/15 at 3:48 PM verified results of her investigation, and also verified she was involved in the planning process to address concerns and ensure the safety of residents. 8. Interview with RN #1 on 08/19/15 at 2:24 PM revealed, after Resident #1 eloped, she checked all Secure Care Bracelet's on Unit 1 for placement and functioning. This check, as well as checks completed by nursing staff on Unit 2 and Unit 3, were reviewed by the State Survey Agency on 08/25/15. Interview with the Assistant Director of Nursing (ADON) on 08/19/15 at 4:00 PM revealed these checks were completed again seventy-two (72) hours later on 08/18/15. This was also verified through documentation review by the State Survey Agency on 08/25/15. Interview with SRNA #8 on 08/26/15 at 10:12 AM verified nurse aides had been checking placement and functioning of Secure Care Bracelets every shift from 08/15/15 through 08/18/15. Review of Unit Shift Reports for each unit revealed Secure Care Bracelets were checked for functioning and placement each shift as well as a head count conducted on each unit, with no concerns identified. 9. Review of the Elopement Risk Assessment (Decision Tree) revealed all residents were re-assessed on 08/17/15 by facility nursing staff with care plans updated as required. No additional residents were identified as at risk for elopement, requiring no care plan updates at that time. All Elopement Risk Assessment (Decision Tree)s completed on 08/17/15 were reviewed with LPN #2 on 08/26/15 at 9:35 AM by the state Survey Agency. 10. All care signs for elopement were checked on 08/17/15 by the Quality Assurance (QA) Assistant. Per interview with the QA Assistant on 08/26/15 at 10:48 AM, Elopement Care Signs consisted of a running man stick figure at the head of each bed of residents identified as elopement risks. Additionally, all Elopement Risk Boards were updated, with additional boards added to the Adult Day Care office and the Therapy Office. The QA Assistant revealed some updated resident photos were taken. A facility tour with the QA Assistant on 08/26/15 confirmed current boards were in place on each unit nursing station and break room, as well as the front office, the maintenance office, the employee lounge, the Adult Day Care office, and the Therapy Office. 11. Review by the State Survey Agency on 08/25/15 of the Secure Care Transmitter User Guide, updated 02/25/15, and the facility's Policy Guidelines for the Secure Care System, updated 08/2015, revealed the facility policy no longer contained information contradictory to the User Guide. Interview on 08/25/15 at 10:37 AM with the Administrator revealed she had changed the policy, with the change consisting of the removal of information permitting staff to place a transmitter on a resident's walker or wheelchair. 12. Review of sign-in sheets for in-services revealed 150 of 152 current facility staff were in-serviced on elopement and behaviors from 08/15/15 through 08/19/15. Interview with the Administrator on 08/25/15 at 11:51 AM revealed the remaining two (2) employees were to be educated prior to being scheduled for work. Interview on 08/19/15 at 2:24 PM with RN #1, the charge nurse of Unit 1 from which Resident #1 eloped on 08/15/15, revealed she in-serviced all staff working at that time on the elopement policy, staff responsibilities, the use of the Secure Care Bracelets, and resident behaviors. Interview with SRNA #1 on 08/19/15 at 2:38 PM revealed she was in-serviced following the elopement on 08/151/5. SRNA #1 stated the in-service covered staff responsibilities during an elopement, as well as recognizing and documenting resident behaviors. SRNA #1 stated the importance of alerting the charge nurse of behaviors was stressed. Interview with SRNA #4 on 08/20/15 at 11:04 AM revealed she attended two in-services when she came in to work on 08/17/17, one of which was on elopement and resident behaviors. SRNA #4 was able to discuss resident behaviors and staff interventions in detail, and also noted the importance of alerting the charge nurse whenever a resident has behavioral issues or is exit seeking. Interview with SRNA #5 on 08/20/15 at 11:20 AM revealed she had attended in-services on elopement and resident behaviors. SRNA #5 stressed the importance of alerting nursing staff whenever a resident triggers a door alarm. Interview with LPN #4 on 08/20/15 at 2:02 PM revealed she had been in-serviced regarding the elopement policy and resident behaviors. LPN #4 discussed the importance of trying to determine resident needs and ensure their needs are met, ensuring their Secure Care Bracelet was functioning, and possibly increasing resident supervision if setting off exit alarms. Interview with SRNA #9 on 08/26/15 at 10:24 AM revealed she had been in-serviced on elopement and resident behaviors. SRNA #9 revealed the in-service covered how to respond if an elopement occurs, recognizing, documenting, and redirecting resident behaviors when possible, and the importance of keeping the charge nurse aware of the situation. Comparison of in-service signatures with employee listing confirmed 150 of 152 employees had been in-services as of State Survey Agency review on 08/26/15. 13. Review of in-service signatures and comparison with a comprehensive employee listing revealed 150 of 152 current facility staff were in-serviced on reporting any inconsistencies in the Secure Care Bracelet alarm system or any failures immediately to the charge nurse. The in-service was initiated on 08/15/15 and continued through 08/19/15. Interview with the Administrator on 08/25/15 at 11:51 AM revealed the two (2) staff remaining were to be educated prior to being assigned any work. Interview with SRNA #1 on 08/19/15 at 2:38 PM revealed she had been in-service on what to do if the Secure Care Bracelet system doesn't work, which was to redirect and supervise the resident involved and to alert the charge nurse immediately. Interview with Cook #1 on 08/19/15 at 3:12 PM confirmed she had been in-serviced on the importance of redirecting residents and reporting to her supervisor any time she witnessed a resident Secure Care Bracelet not functioning. Interview with SRNA #6 on 08/20/15 at 11:30 AM revealed she had attended an in-service, and stressed the importance of informing the charge nurse any time a resident Secure Care Bracelet did not function. Interview with KMA #2 on 08/26/15 at 11:29 AM revealed she had been in-serviced on the importance of redirecting residents and informing the charge nurse if a resident's Secure Care Bracelet does not alarm. Comparison of in-service signatures with employee listing confirmed 150 of 152 employees had been in-services as of State Survey Agency review on 08/26/15. 14. Interview with the Administrator on 08/25/15 at 10:37 AM revealed daily rounds were made by the Administrator beginning on 08/17/15 and concluding on 08/20/15 to ensure staff understood the education they had received on elopement, behaviors, reporting, and implementing care plan interventions. Review of the daily rounds sheets revealed rounds were recorded on Weekly Walk Thru sheets, with multiple staff interviewed regarding the elopement policy and the use of and what to do if Secure Care Bracelets were determined to not be functioning. Several staff had been interviewed each day, per review of the documentation, with staff consistently providing appropriate responses. Interview with KMA #2 on 08/25/15 at 11:29 AM revealed she had observed the QA Assistant on Unit 2 questioning staff about elopement procedure and Secure Care Bracelets, although she had not been questioned following the in-services.

Based on interview, record review, and review of the facility's policy, and video surveillance footage it was determined the facility failed to have an effective system in place to ensure services were provided in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). Interview and record review revealed Resident #1 had a history of [REDACTED].#1's Comprehensive Care Plan revealed staff were to perform fifteen (15) minute checks or one (1) on one (1) supervision if Resident #1 attempted to leave the facility unattended. On 08/15/15, Resident #1 utilized his/her rolling walker to exit the front door of the facility without staff knowledge at approximately 3:18 PM. Even though the resident had a Secure Care Bracelet attached to his/her rolling walker, the alarm did not sound when the resident exited the facility. Resident #1 returned to the facility through the front door utilizing his/her rolling walker at approximately 3:25 PM, at which point the Secure Care Bracelet alarm did sound, alerting staff. State Registered Nursing Assistant (SRNA) #1 responded to the alarm, and found Resident #1 in the main lobby with the door closed, with no evidence Resident #1 had been outside. Although Resident #1 reported to SRNA #1 he/she had returned from outside, SRNA #1 did not alert nursing staff and Resident #1 was not placed on increased supervision as directed by the care plan. Later on 08/15/15, at approximately 6:01 PM, Resident #1 again exited the facility through the front door utilizing his/her rolling walker, and again the alarm did not sound. Off-duty staff found Resident #1 lying on the ground in the parking lot by the side of the building. Staff inside the facility were alerted to the resident's whereabouts by the off-duty staff at approximately 6:15 PM. The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was followed related to providing increased supervision for at-risk residents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/20/15 and was determined to exist on 08/15/15. An acceptable credible Allegation of Compliance (AOC) was received on 08/25/15 which alleged removal of the Immediate Jeopardy on 08/19/15. The Immediate Jeopardy was verified to be removed on 08/26/15 as alleged with the remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment (F-282) at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure care plans are followed to implement interventions to provide adequate supervision. The findings include: Review of the facility's policy titled E.H.R. - Care Plans, dated December 2014, revealed the plan of care was used to inform staff of the needs of residents and included interventions for problems identified. Further review revealed care plans were communication tools to ensure continuity of care. Record review revealed the facility admitted Resident #1 on 12/08/10 with multiple [DIAGNOSES REDACTED].#1's son on 12/06/10. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/15, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate impairment. Further review of the MDS Assessment revealed the facility assessed Resident #1 to ambulate independently with the assist of a walker. Review of Resident #1's Comprehensive Care Plan (CCP), dated 04/21/15, revealed Resident #1 was care planned for being at risk for elopement due to the [DIAGNOSES REDACTED].#1's wandering behavior; staff were to report any threats of leaving the facility to the charge nurse; and the resident would be placed on fifteen (15) minute monitoring or one-on-one (1:1) supervision when attempting to leave the facility unattended. Review of facility video surveillance footage for 08/15/15 revealed Resident #1 exited the facility with his/her rolling walker at 3:18 PM, at which time no staff were observed responding alarm (the video footage did not have sound recording capability). When Resident #1 returned to the facility at 3:25 PM, SRNA #1 was observed rushing up the hall to the lobby, where Resident #1 was ambulating at the time with no evidence of having been outside. Continued video footage review revealed at 6:01 PM Resident #1 exited the facility a second time with her rolling walker, with no staff response observed at that time. Interview with State Registered Nurse Aide (SRNA) #1 on 08/19/15 at 10:47 AM revealed Resident #1 had been confused the morning of 08/15/15, and had been talking about seeing his/her mother in the hallway. SRNA #1 stated she questioned Kentucky Medication Aide (KMA) #1 about the resident's confusion and was told Resident #1 was recovering from a urinary tract infection which might explain the confusion. Continued interview revealed SRNA #1 responded to Resident #1's Secure Care alarm on 08/15/15 at approximately 3:25 PM and the resident reported having been outside. However, as SRNA #1 did not see the door open and the alarm had not sounded earlier when the resident reportedly went out the door, she thought Resident #1 was confused, and did not believe Resident #1 had really left or attempted to leave the facility at that time. SRNA #1 stated she told KMA #1 the resident reported having been outside. SRNA further revealed she should have informed the nurse of the alarm sounding, and the resident's comments about being outside. SRNA #1 stated, although she was uncertain what Resident #1's comprehensive care plan said, she felt Resident #1 warranted more attention, and attempted to keep a closer eye on Resident #1. Per interview, she encouraged the resident to eat dinner in the dining room so she could keep an eye on him/her, although Resident #1 refused, stating he/she was waiting on his/her sisters. Interview with KMA #1 on 08/19/15 at 11:17 AM revealed SRNA #1 had approached her in the afternoon of 08/15/15 and she understood SRNA #1 to state Resident #1 had been at the door, but did not recall being told Resident #1 stated she had been outside. KMA #1 stated she reported to the nurse Resident #1 had been seen at the door. Continued interview revealed Resident #1 did have an elopement care plan, and had she understood the resident reported having been outside, she would have passed that information to the nurse and the resident might have been placed on fifteen (15) minute checks or one-on-one supervision. Interview with Registered Nurse (RN) #1 on 08/19/15 at 2:24 PM revealed she did not witness any abnormal behavior from Resident #1 on 08/15/15. She stated Resident #1 liked to go to the door and look out, and when KMA #1 reported to her Resident #1 had been to the door that afternoon she did not consider it out of the ordinary, and did not think it was exit-seeking behavior. Continued interview revealed if it was exit-seeking behavior, she would have implemented Resident #1's CCP for fifteen (15) minute checks or one-on-one supervision. Interview with SRNA #4 on 08/20/15 at 11:04 AM revealed she had not heard of Resident #1 setting off the alarm prior to 08/15/15, although the resident did like to sit in the lobby and speak with other residents. She explained when a resident sets off an alarm, especially if it is unusual for the resident to do so, staff should keep a closer watch on the resident and inform the nurse. Continued interview revealed at times, the nurses put residents on fifteen (15) minute checks if a resident attempted to leave the facility. Interview with SRNA #6 on 08/20/15 at 11:30 AM revealed it was unusual for Resident #1 to go to the door and set off the Secure Care alarm; however, she reported the resident had been more confused in the past week and had been setting off the alarm. SRNA #6 stated the nurse aide care plan gave direction for the SRNAs to watch Resident #1 more closely if he/she set off an alarm by attempting to exit the building. SRNA #4 further stated she was responsible for ensuring the nurse was made aware of a resident's attempt to leave, or if the resident talked about leaving. Further interview with RN #1 on 08/20/15 at 1:15 PM revealed, even though the Secure Care alarm sounded at 3:25 PM, she wouldn't have necessarily done anything different if a nurse aide had informed her Resident #1 reported having been outside. She stated Resident #1 was confused, and unless she had evidence the resident had gone out of the building, or attempted to go out, she would not have implemented the care plan for increased supervision. Interview with the Director of Nursing (DON) on 08/20/15 at 11:43 AM revealed her expectation was for the SRNAs to inform their charge nurse whenever a resident triggered an exit alarm. She explained although going to the door in and of itself may not be exit-seeking, as residents like to look outside, going outside or saying they were returning from outside should have been considered exit-seeking for Resident #1 as it was unusual behavior. The DON stated she expected nursing to follow the CCP, and acknowledged they did not do so for Resident #1 on 08/15/15. Interview with the Administrator on 08/19/15 at 12:19 PM revealed her expectation on 08/15/15 would have been for SRNA #1 to report to the charge nurse, RN #1, if Resident #1 set off the alarm and mentioned having been outside. She stated she would then expect RN #1 to follow the interventions outlined in the care plan and alert Administration of Resident #1 being placed on fifteen (15) minute checks or 1:1 supervision. The Administrator acknowledged staff failed to follow Resident #1's CCP when he/she exhibited exit seeking behavior. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 08/25/15, which alleged removal of the Immediate Jeopardy (IJ) effective 08/19/15. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was sent to the hospital on the evening of 08/15/15 for evaluation in the emergency room (ER) and was discharged back to the facility the same night. Upon return to the facility, RN #1 performed a head to toe skin assessment. 2. Upon return from the hospital ER, Resident #1 was placed on fifteen (15) minute monitoring while asleep and one (1) on one (1) supervision while awake as directed by the Administrator upon Resident #1's return on 08/15/15. 3. The Secure Care system was checked by the Maintenance Director on 08/15/15 to identify the root cause of the accident. 4. Resident #1's Secure Care Bracelet was removed from his/her rolling walker, and a new Secure Care Bracelet was placed on his/her left ankle by KMA #1. 5. Two other residents with Secure Care Bracelet's on their walkers, Resident #2 and Resident #4, had Secure Care Bracelets removed from their walkers, with Resident #4's Secure Care Bracelet placed on his/her ankle the evening of 08/15/15. Resident #2 initially refused placement on his/her ankle, and was placed on fifteen (15) minute checks on the evening of 08/15/15. Resident #2 was determined by staff to no longer be an elopement risk on 08/20/15 with his/her Secure Care Bracelet's removed at that time and fifteen (15) minute checks discontinued at that time. 6. A video surveillance investigation was initiated on 08/15/15 by the Administrator to identify the source of Resident #1's exit from the facility. Further video investigation was conducted by the Administrator on 08/17/15. 7. An investigation of the events involving Resident #1 was initiated on 08/15/15 by the Social Services Director (SSD) and concluded on 08/18/15. 8. All Secure Care Bracelets in use were checked for functioning and placement by the unit charge nurse on duty on 08/15/15 and each shift for seventy-two (72) hours. This was in conjunction with a head count conducted every shift by the unit charge nurse on duty, also initiated on 08/15/15 and concluded on 08/18/15. 9. All residents were re-assessed utilizing the Elopement Risk Assessment (Decision Tree) on 08/17/15 by facility nursing staff with care plans updated as required. 10. All care signs for elopement were checked to be in place for seventeen (17) residents with Secure Care Bracelets on 08/17/15 by the Quality Assurance (QA) Assistant. Care signs were symbols placed above a resident's bed to alert staff providing care the resident was an elopement risk. Additionally, all Elopement Risk Boards were updated, with additional boards added to the Adult Day Care office and the Therapy Office. 11. The Secure Care Policy was updated to remove language pertaining to the allowance of the Secure Care Bracelet being placed on assistive devices on 08/19/15 by the DON. 12. Beginning on 08/17/15 and concluding 08/19/15, 150 of 152 current facility staff were in-serviced on elopement, behaviors, the facility's elopement policy and implementing care plan interventions. The remaining two (2) employees were to be educated prior to being scheduled for work. 13. Beginning on 08/17/15 and concluding 08/19/15, 150 of 152 current facility staff were in-serviced on reporting any inconsistencies in the Secure Care Bracelet alarm system or any failures immediately to the charge nurse. Only two (2) staff remaining to be educated prior to being assigned any work. 14. Daily rounds were made by the Administrator beginning on 08/17/15 and concluding on 08/20/15 to ensure staff understood the education they had received on elopement, behaviors, reporting, and implementing care plan interventions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of nursing notes for Resident #1 dated 08/15/15 revealed Resident #1 was sent to the hospital on the evening of 08/15/15. Review of ER nursing notes dated 08/15/15 revealed the hospital discharge impression was a contusion to the left elbow, a contusion to the left hip, and a concussion without loss of consciousness. Continued review of facility nursing notes dated 08/15/15 revealed upon return to the facility, RN #1 performed a head to toe skin assessment, revealing no additional areas of concern. Interview with the Medical Director (MD on 08/25/15 at 1:20 PM revealed he had been contacted on 08/15/15 when Resident #1 eloped, and the facility had reviewed it's Allegation of Compliance with him. The MD revealed he felt the underlying issue to be antibiotic medication Resident #1 was taking to combat a UTI. The MD stated it was an unfortunate situation which he hoped never happens again, but had supported the facility's efforts to correct it's problems. 2. Review of 15 Minute Monitoring Form documentation for Resident #1 revealed he/she was placed on fifteen (15) minute monitoring on 08/15/15 at 9:00 PM and was documented as ongoing at the time of the Extended Survey on 08/26/15. Staff was observed with Resident #1 in Resident #1's room on 08/19/15 at 8:15 AM; in Resident #1's room on 08/20/15 at 11:35 AM; and on 08/26/15 at 11:10 AM. Interview with SRNA #7 on 08/26/15 at 10:03 AM revealed she was responsible for scheduling the increased supervision for Resident #1. Interview with monitoring staff on 08/26/15, SRNA #8 at 10:12 AM, and SRNA #9 at 10:24 AM, all confirmed they had sat with Resident #1 on more than one occasion on twelve (12) hour shifts since the 08/15/15 elopement. These statements were corroborated by staff initials on the 15 Minute Monitoring Forms. 3. The Secure Care system was checked by the Maintenance Director on 08/15/15 to identify the root cause of the accident. Interview with the Maintenance Director on 08/19/15 at 12:08 PM revealed he was called in the night of 08/15/15 after Resident #1 had eloped, and he tested the Secure Care alarm system at that time. The Maintenance Director revealed, in testing the system, he determined the Secure Care system was inconsistent in alerting staff when placed on resident walkers due to the height of the bracelet. Follow up interview with the Maintenance Director on 08/26/15 at 11:13 AM confirmed there was a height cutoff on the alarm system that wasn't 100% effective in alarming when placed on resident walkers. The Maintenance Director went on to reveal, now that all residents with Secure Care Bracelets have them on their ankles, the alarms have been working consistently without exception. The Maintenance Director revealed, in addition to the staff testing that has been occurring since the elopement, in which staff escort residents with Secure Care Bracelets to a nearby receiver to ensure the receiver was triggered, maintenance routinely tests all of the exits on Friday to ensure they are functioning properly. 4. Interview with RN #1 on 08/20/15 at 1:15 PM confirmed Resident #1's Secure Care Bracelet was removed from his/her rolling walker, and a new Secure Care Bracelet was placed on his/her left ankle by KMA #1. Resident #1's Secure Care Bracelet was observed on his/her ankle by the State Survey Agency on 08/20/15 at 11:35 AM. 5. Two other residents with Secure Care Bracelet's on their walkers, Resident #2 and Resident #4, had Secure Care Bracelets removed from their walkers, with Resident #4's Secure Care Bracelet placed on his/her ankle the evening of 08/15/15. Resident #2 initially refused placement on his/her ankle, and was placed on fifteen (15) minute checks on the evening of 08/15/15. Fifteen (15) minute check sheets for Resident #2 were reviewed, and were current up to 08/20/15, when he/she was determined by facility staff to no longer be an elopement risk. Observation of both residents on 08/20/15 confirmed Secure Care Bracelets were no longer placed on walkers, with Resident #4 wearing his/her bracelet on his/her ankle. 6. Interview with the Administrator on 08/19/15 at 12:19 PM revealed a video surveillance investigation was initiated on 08/15/15 by the Administrator to identify the source of Resident #1's exit from the facility. Further video investigation was conducted by the Administrator on 08/17/15 and it was determined at that time Resident #1 had exited the facility earlier in the day on 08/15/15 and returned prior to the elopement at 6:01 PM. This video footage was reviewed by the State Survey Agency, with times identified in the facility investigation for Resident #1's exit(s) and return in the afternoon of 08/15/15 verified by the date/time stamp on the recording. 7. Interview with the Social Services Director (SSD) on 08/19/15 at 3:48 PM revealed she was called in the evening of 08/15/15 and began an initial investigation at that time. Continued interview revealed she completed her final investigation on 08/18/15. Review of the final investigation dated 08/18/15 revealed the SSD investigation further revealed Resident #1 had been to the nurses station and stated to RN #1 several times he/she was waiting on his/her daughter to come take her to pick beans. Interview with the SSD on 08/19/15 at 3:48 PM verified results of her investigation, and also verified she was involved in the planning process to address concerns and ensure the safety of residents. 8. Interview with RN #1 on 08/19/15 at 2:24 PM revealed, after Resident #1 eloped, she checked all Secure Care Bracelet's on Unit 1 for placement and functioning. This check, as well as checks completed by nursing staff on Unit 2 and Unit 3, were reviewed by the State Survey Agency on 08/25/15. Interview with the Assistant Director of Nursing (ADON) on 08/19/15 at 4:00 PM revealed these checks were completed again seventy-two (72) hours later on 08/18/15. This was also verified through documentation review by the State Survey Agency on 08/25/15. Interview with SRNA #8 on 08/26/15 at 10:12 AM verified nurse aides had been checking placement and functioning of Secure Care Bracelets every shift from 08/15/15 through 08/18/15. Review of Unit Shift Reports for each unit revealed Secure Care Bracelets were checked for functioning and placement each shift as well as a head count conducted on each unit, with no concerns identified. 9. Review of the Elopement Risk Assessment (Decision Tree) revealed all residents were re-assessed on 08/17/15 by facility nursing staff with care plans updated as required. No additional residents were identified as at risk for elopement, requiring no care plan updates at that time. All Elopement Risk Assessment (Decision Tree)s completed on 08/17/15 were reviewed with LPN #2 on 08/26/15 at 9:35 AM by the state Survey Agency. 10. All care signs for elopement were checked on 08/17/15 by the Quality Assurance (QA) Assistant. Per interview with the QA Assistant on 08/26/15 at 10:48 AM, Elopement Care Signs consisted of a running man stick figure at the head of each bed of residents identified as elopement risks. Additionally, all Elopement Risk Boards were updated, with additional boards added to the Adult Day Care office and the Therapy Office. The QA Assistant revealed some updated resident photos were taken. A facility tour with the QA Assistant on 08/26/15 confirmed current boards were in place on each unit nursing station and break room, as well as the front office, the maintenance office, the employee lounge, the Adult Day Care office, and the Therapy Office. 11. Review by the State Survey Agency on 08/25/15 of the Secure Care Transmitter User Guide, updated 02/25/15, and the facility's Policy Guidelines for the Secure Care System, updated 08/2015, revealed the facility policy no longer contained information contradictory to the User Guide. Interview on 08/25/15 at 10:37 AM with the Administrator revealed she had changed the policy, with the change consisting of the removal of information permitting staff to place a transmitter on a resident's walker or wheelchair. 12. Review of sign-in sheets for in-services revealed 150 of 152 current facility staff were in-serviced on elopement and behaviors from 08/15/15 through 08/19/15. Interview with the Administrator on 08/25/15 at 11:51 AM revealed the remaining two (2) employees were to be educated prior to being scheduled for work. Interview on 08/19/15 at 2:24 PM with RN #1, the charge nurse of Unit 1 from which Resident #1 eloped on 08/15/15, revealed she in-serviced all staff working at that time on the elopement policy, staff responsibilities, the use of the Secure Care Bracelets, and resident behaviors. Interview with SRNA #1 on 08/19/15 at 2:38 PM revealed she was in-serviced following the elopement on 08/151/5. SRNA #1 stated the in-service covered staff responsibilities during an elopement, as well as recognizing and documenting resident behaviors. SRNA #1 stated the importance of alerting the charge nurse of behaviors was stressed. Interview with SRNA #4 on 08/20/15 at 11:04 AM revealed she attended two in-services when she came in to work on 08/17/17, one of which was on elopement and resident behaviors. SRNA #4 was able to discuss resident behaviors and staff interventions in detail, and also noted the importance of alerting the charge nurse whenever a resident has behavioral issues or is exit seeking. Interview with SRNA #5 on 08/20/15 at 11:20 AM revealed she had attended in-services on elopement and resident behaviors. SRNA #5 stressed the importance of alerting nursing staff whenever a resident triggers a door alarm. Interview with LPN #4 on 08/20/15 at 2:02 PM revealed she had been in-serviced regarding the elopement policy and resident behaviors. LPN #4 discussed the importance of trying to determine resident needs and ensure their needs are met, ensuring their Secure Care Bracelet was functioning, and possibly increasing resident supervision if setting off exit alarms. Interview with SRNA #9 on 08/26/15 at 10:24 AM revealed she had been in-serviced on elopement and resident behaviors. SRNA #9 revealed the in-service covered how to respond if an elopement occurs, recognizing, documenting, and redirecting resident behaviors when possible, and the importance of keeping the charge nurse aware of the situation. Comparison of in-service signatures with employee listing confirmed 150 of 152 employees had been in-services as of State Survey Agency review on 08/26/15. 13. Review of in-service signatures and comparison with a comprehensive employee listing revealed 150 of 152 current facility staff were in-serviced on reporting any inconsistencies in the Secure Care Bracelet alarm system or any failures immediately to the charge nurse. The in-service was initiated on 08/15/15 and continued through 08/19/15. Interview with the Administrator on 08/25/15 at 11:51 AM revealed the two (2) staff remaining were to be educated prior to being assigned any work. Interview with SRNA #1 on 08/19/15 at 2:38 PM revealed she had been in-service on what to do if the Secure Care Bracelet system doesn't work, which was to redirect and supervise the resident involved and to alert the charge nurse immediately. Interview with Cook #1 on 08/19/15 at 3:12 PM confirmed she had been in-serviced on the importance of redirecting residents and reporting to her supervisor any time she witnessed a resident Secure Care Bracelet not functioning. Interview with SRNA #6 on 08/20/15 at 11:30 AM revealed she had attended an in-service, and stressed the importance of informing the charge nurse any time a resident Secure Care Bracelet did not function. Interview with KMA #2 on 08/26/15 at 11:29 AM revealed she had been in-serviced on the importance of redirecting residents and informing the charge nurse if a resident's Secure Care Bracelet does not alarm. Comparison of in-service signatures with employee listing confirmed 150 of 152 employees had been in-services as of State Survey Agency review on 08/26/15. 14. Interview with the Administrator on 08/25/15 at 10:37 AM revealed daily rounds were made by the Administrator beginning on 08/17/15 and concluding on 08/20/15 to ensure staff understood the education they had received on elopement, behaviors, reporting, and implementing care plan interventions. Review of the daily rounds sheets revealed rounds were recorded on Weekly Walk Thru sheets, with multiple staff interviewed regarding the elopement policy and the use of and what to do if Secure Care Bracelets were determined to not be functioning. Several staff had been interviewed each day, per review of the documentation, with staff consistently providing appropriate responses. Interview with KMA #2 on 08/25/15 at 11:29 AM revealed she had observed the QA Assistant on Unit 2 questioning staff about elopement procedure and Secure Care Bracelets, although she had not been questioned following the in-services.

Based on interview, record review, and review of the facility's policy, it was determined the facility's Administration failed to have an effective system in place to ensure policies and procedures were developed and/or implemented to provide quality resident care. The facility's Administration failed to develop written policies to ensure safety and supervision of residents assessed to have wandering/exit seeking behaviors. The facility's Administration failed to have an effective system in place to ensure residents were monitored for exit seeking behaviors to ensure their safety, and failed to ensure residents' Comprehensive Care Plans were updated and revised to reflect residents' needs. Resident #1 became upset on 09/21/14, when being re-directed by staff, obtained a six (6) inch paring knife to cut off his/her Secure Care Bracelet with, and at approximately 6:32 PM, the resident eloped from the facility without staff's knowledge. The police found Resident #1 at 7:01 PM, on a heavily traveled two (2) lane road which had no shoulder or sidewalk, almost three tenths of a mile from the facility. Resident #1 was taken back to the facility at approximately 7:10 PM and was not assessed for injury related to being upset. Interview and record review revealed Resident #1 had a history of [REDACTED]. on 05/08/14 after cutting his/her Secure Care Bracelet off. Even though interview with the Administrator revealed the facility's Administration was aware of the incident on 03/13/14, and Resident #1's elopement on 05/08/14, the facility's Administration failed to investigate and ensure the resident's care plan was updated and revised to include increased supervision and to ensure his/her safety. (Refer to F-280 and F-323) The facility's Administration's failure to an effective system in place to policies and procedures were developed and/or implemented to provide quality resident care and ensure the safety and supervision of residents was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 09/30/14, and determined to exist on 09/21/14. An acceptable credible Allegation of Compliance (AOC) was received on 10/07/14 which alleged removal of the Immediate Jeopardy on 10/07/14. The Immediate Jeopardy was verified to be removed on 10/07/14 as alleged with the remaining non-compliance at 42 CFR 483.75 Administration (F-490) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure implementation of policies and procedures to provide a safe environment and adequate supervision of residents. The findings include: Review of the facility's policy titled, "Wandering/Elopement Policy" dated 11/2010, revealed all residents with a [DIAGNOSES REDACTED]. Further review revealed, residents found to have a potential for wandering would be fitted with a secure care bracelet. Continued review revealed should a resident elope or attempt elopement, the resident would be monitored every 15 minutes for seventy-two (72) hours then assessed for any needed changes/interventions. Interview with the Administrator on 09/26/14 at 12:38 PM, revealed the facility did not have an elopement screening tool. Review of the facility's policy titled, "Care Management" dated 08/20/12, revealed the plan of care should be continuously updated to reflect current resident needs at all times. Further review revealed updating the Plan of Care was the responsibility of all involved staff. Resident #1 was admitted by the facility on 12/27/13 and assessed at the time of admission to be at risk for wander/exit seeking behaviors with placement of a Secure Care Bracelet at that time. Record review revealed Resident #1 had a history of [REDACTED]. However, there was no documented evidence Resident #1's care plan was updated or revised to address the need for increased supervision. On 05/08/14, Resident #1 cut the Secure Care Bracelet off, exited the the facility without staff knowledge and was found on the facility's property by staff leaving the facility. However, there was no documented evidence Resident #1's care plan was updated or revised to address the need for increased supervision or monitoring. On 09/21/14, Resident #1 cut the Secure Care Bracelet off with a paring knife and eloped from the facility without staff's knowledge. Resident #1 was found by police walking with his/her walker on a heavily traveled roadway with no shoulder or sidewalk approximately three tenths of a mile from the facility. However, there was no documented evidence Resident #1's care plan was updated or revised to address the need for increased supervision or monitoring until 09/22/14. Interviews with direct care staff revealed not all of them were aware of Resident #1's history of elopement or behaviors which potentially lead up to unsupervised exit seeking behaviors. Interview with the Director of Nursing (DON), on 09/30/14 at 4:20 PM, revealed the facility did not have a wandering/elopement risk screening tool for nurses to utilize. She stated when a resident was admitted and family or the transferring facility reported a history of wandering/elopement risk the facility staff "just would put one on" (Secure Care Bracelet) the newly admitted resident. Interview with the Administrator, on 09/30/14 at 1:17 PM, revealed prior to 09/21/14, she was aware Resident #1 had verbally threatened to cut the Secure Care Bracelet off and leave the facility on 03/08/14. Per interview she was also aware Resident #1 had cut the Secure Care Bracelet off and left the facility without staff knowledge on 05/14/14. Further interview revealed the facility should have performed and completed an investigation for the incident of 05/14/14; however, she stated she did not perceive this to be an elopement due to the resident being found on the facility property. Further interview revealed the care plan should have been updated and revised to accurately reflect the needs of the resident to ensure safe supervision and monitoring of the resident. Additionally, the Administrator reported the facility had a wandering/elopement policy requiring residents to be screened for wandering/elopement risks; however, the facility did not have a wandering/elopement risk screening tool or specific policy on when the screenings should occur. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/06/14, which alleged removal of the Immediate Jeopardy (IJ), effective 10/07/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on fifteen (15) minute observations on 09/21/14. Resident #1's room was searched for other objects that could be utilized to remove secure care bracelet or be utilized to harm self or others by staff on duty on 09/21/14 and then searched again on 09/25/14 by the Quality Assurance Director (QA) with a set of nail clippers removed from the closet area. A tamper resistant secure care bracelet was ordered by the Housekeeping Supervisor on 09/22/14. Resident #1 then went on a Leave of Absence from the facility with his/her son from 09/22/14 through 09/25/14. 2. All thirteen (13) residents, that had Secure Care Bracelets were reviewed for risk to ensure Secure Care Bracelets were in place, functioning properly, and were care planned appropriately with no changes or updates required by the Assistant Director of Nursing (ADON) on 09/22/14. 3. A 3:00 PM to 11:00 PM House Supervisor position was added, effective 09/24/14, with the role to help supervise and to investigate or review any resident information as directed by the Director of Nursing (DON). 4. On 09/30/14, all 107 residents were assessed for risk for elopement and four (4) care plans for the residents identified were updated to accurately reflect the needs of the resident by the MDS Coordinator, MDS Assistant, DON, QA Director, and the ADON. A screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. The Elopement Risk Assessment Decision Tree was implemented and completed, on 10/04/14 and 10/05/14, on all residents with no new residents identified to be at risk for elopement and was completed by the Infection Control Nurse, the Wound Care Nurse, and another Licensed Practical Nurse (LPN). 5. The DON, QA Director, and the Administrator created a monitoring policy and criteria for secure care bracelet placement to include monitoring would not be discontinued until review by the Quality Assurance Committee or Physician recommendation. The monitoring policy was created on 09/30/08. Implementation and Education of the new monitoring policy was completed by the QA Director, the Infection Control Nurse, and the Quality Assurance Assistant on 10/06/14. 6. All areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. 7. Boards for identification of residents at risk for elopement were placed in the nursing stations on 10/02/14. Additional boards for identification of residents at risk for elopement were placed in the break rooms, including the area by the time clock, and at the front office, on 10/03/14 by the QA Assistant, to help all staff to identify residents at risk for elopement. 8. Education regarding leaving offices unattended or tools/supplies unsecured when out of offices and to ensure sharp objects are placed inside desk was given to Kitchen staff, Maintenance Department, Activities Department, front office staff, Social Services Department, Therapy Department, Quality Assurance Department, and the Nursing office staff starting 10/01/14 and completed on 10/03/14 and was given by Department Supervisors. 9. Resident #1's Comprehensive Care Plan was updated to include a new Elopement Care Plan by the Minimum Data Set (MDS) Coordinator on 10/01/14. 10. Employees were scheduled by the Scheduling Coordinator, on 10/02/14, to be responsible for a minimum of fifteen (15) minute monitoring for Resident #1 while in his/her room and one on one (1:1) supervision with Resident #1 while out of room with his/her spouse whom was also a resident of the facility. Also, one on one (1:1) supervision was to be done if Resident #1 was wanting to go off the unit until otherwise directed. 11. All care plans were reviewed to ensure updates had been completed for any new orders received in the last thirty (30) days with any issues identified and corrected at the time of the audit, starting on 10/03/14 and completed on 10/06/14, and was completed by the Infection Control Nurse, the Wound Care Nurse, the second shift House Supervisor, the ADON, and another LPN. 12. Resident Care signs located in each resident's room were updated to include risk for elopement on 10/01/14 and education on the Resident Care signs was given to all facility by the QA Director, the Infection Control Nurse and by the DON from 10/01/14 through 10/06/14. 13. A new tamper resistant secure care bracelet was placed on Resident #1, on 10/06/14, by the Maintenance Director and QA Director. 14. An in-service training was given to all staff on elopement to include the procedures on a Golden Alert announcement when an elopement occurs or is attempted by residents. In addition, all staff were given in-service training on behaviors and reporting and documentation of behaviors, supervision, new Resident Care signs for residents with elopement risk, and updating care plans for resident changes. All in-service training were completed by 10/06/14 by the QA Director, QA Assistant, and the Infection Control Nurse. All staff will also be receiving these in-service training annually. 15. The facility included education on elopement, monitoring behaviors, care plans, and supervision in the new employee orientation program by 10/06/14. The QA Director and QA Assistant will incorporate into their current check off of new employees during orientation to determine understanding of the policies on elopement, care plans, potential behaviors, reporting of behaviors, and supervision of residents. 16. The facility implemented plans to monitor its performance to ensure the residents' environment remain as free from accident hazards as possible and that adequate supervision is in place by monitoring through the Quality Assurance Committee weekly walk through on an ongoing basis to identify areas of potential hazards and inadequate supervision. The Medical Director will have an on-going role in the monitoring of these solutions as both the medical director and as the personal physician for Resident #1. The facility's QA Committee members will review daily reports and investigations from each unit to identify potential accident hazards for tracking and trending purposes and report their findings during the daily QA Committee meeting and to the Quarterly QA Committee which includes the Medical Director. Any areas of potential harm identified will be reported to the Administrator for immediate attention. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the "fifteen (15) minute monitoring form", on 09/21/14 revealed, Resident #1 was on one to one supervision with the Administrator upon return to the facility from 7:30 PM until 8:45 PM and fifteen (15) minute monitoring began at 8:45 PM on 09/21/14. Resident #1 remained on fifteen minute monitoring until 09/22/14 at 5:30 PM when he/she left the faciity on a Leave of Absence with his/her son. Interview with Kentucky Medication Aide (KMA) #1, on 09/29/14 at 3:00 PM, revealed he searched Resident #1's room on 09/21/14 for objects that could be used to remove the secure care band but was not able to find anything in Resident #1's room other than the Secure Care Bracelet that he/she removed prior to eloping from the facility, which was found in Resident #1's trash can. Interview with the QA Director, on 09/29/14 at 11:22 AM revealed she did a follow-up search of Resident #1's room. A late entry Nurses' Note written by the MDS Assistant, on 09/26/14 at 8:09 AM revealed Resident #1 returned to the facility on [DATE] at 6:00 PM and the Nurses' Note revealed staff was present when Resident #1 unpacked his/her belongings and there were no objects in the belongings to cut the Secure Care Bracelet off. Review of the "fifteen (15) minute monitoring form" revealed fifteen (15) minute monitoring resumed on 09/25/14 at 6:00 PM upon Resident #1's return to the facility and would continue fifteen (15) minute monitoring until the Administrator and QA team deemed unnecessary. Review of the purchase order revealed a tamper resistant Secure Care Bracelet was ordered on [DATE] by the Housekeeping Director. 2. The check off sheet the ADON completed, on 09/22/14, regarding her review of all thirteen (13) residents with Secure Care Bracelets to ensure placement, proper functioning, and to ensure they were appropriately care planned was reviewed and a copy of the check off sheet was obtained. An interview with the ADON, on 10/01/14 at 10:50 AM, revealed she did complete a review of all thirteen (13) residents with Secure Care Bracelets to ensure placement and proper functioning was completed and all thirteen (13) residents with Secure Care Bracelets had care plans on 09/22/14. 3. Review of the facility's staff schedule of Registered Nurse (RN) #1 revealed a House Supervisor position for 3:00 PM to 11:00 PM had been added and a copy of the schedule was obtained. A copy of the "Job Description" for the Nursing Supervisor position was also obtained and reviewed. Interviews, on 10/09/14, with the Infection Control Nurse at 9:00 AM, State Registered Nursing Assistant (SRNA) #8 at 9:30 AM, Unit Coordinator #1 at 10:48 AM, Unit Coordinator #2 at 12:55 PM, KMA #17 at 1:12 PM, SRNA #18 at 1:28 PM, and SRNA #16 at 1:50 PM confirmed that a House Supervisor position for 3:00 PM to 11:00 PM had been added and RN #1 was assigned to the position. 4. Reviewed the screening tool, Elopement Risk Assessment Decision Tree instructions sheet, dated 10/2014, revealed the new screening tool was to be completed upon admission, quarterly, and with any significant change in condition/mental health status. Review of the facility's Elopement Risk Assessments revealed they were completed for the sampled and unsampled residents reviewed. Interview with the MDS Coordinator on 10/09/14 at 2:20 PM, the DON on 10/09/14 at 3:15 PM and the QA Director on 10/09/14 at 3:30 PM revealed the screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. They reported all one hundred and seven (107) residents were assessed for risk for elopement through use of the new screening tool with no residents determined to be at risk except the previous residents determined to be at risk. Four (4) residents' care plans required updating to accurately reflect the needs of the resident. 5. Obtained and reviewed copies of the facility's new monitoring policy with the criteria for placement of the Secure Care Bracelet. Obtained and reviewed copies of the education provided to staff regarding the new policy with signatures. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education regarding the new policy. 6. Review of the facility's maps provided by the Administrator revealed all areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. Interview on 10/09/14, with the Infection Control Nurse at 9:00 AM and with the MDS Coordinator on 10/09/14 at 2:20 PM revealed they were involved in the facility wide search for hazardous items. 7. Observation on 10/09/14 in the employee break room, time clock area, front office and nurses station revealed elopement boards in place as per the Allegation of Compliance. Further observation revealed the elopement boards included pictures of residents at risk for elopement, with the residents' room numbers. 8. Obtained and reviewed a copy of education given to staff related to leaving offices unattended or tools/supplies unsecured with copies of signatures of staff in attendance completed on 10/03/14. Interview on 10/09/14 with Maintenance Director at 2:52 PM; House Keeping #18 at 2:58 PM; Maintenance #19 at 3:04 PM; Dietary #20 at 3:12 PM; and Dietary #21 at 3:17 PM revealed they all reported receiving the education. 9. Review of Resident #1's care plan for potential for unsupervised exits from the facility revealed his/her care plan had been updated and a new care plan for potential for elopement had been added by the MDS Coordinator on 10/01/14 and included Resident #1's history of elopement. A copy of both the previous and new care plan related to elopement were obtained. 10. Review of the "sitter schedule" from 10/02/14 through 10/21/14 for Resident #1 revealed an extra staff member was assigned to Resident #1 between the hours of 7:00 AM and 12:00 AM through those dates. Further review of Resident #1's sitter instruction sheet revealed the sitter must monitor Resident #1 for a minimum of fifteen (15) minute monitoring while Resident #1 was in his/her room and one to one (1:1) supervision while Resident #1 was out of his/her room. A copy of the "sitter schedule" and sitter instructions for monitoring sheet were obtained. 11. Reviewed MD orders and care plan updates for the previous thirty (30) days to verify updates had been completed by 10/06/14 for seventeen (17) residents. 12. Observation on 10/09/14, of the facility's identified elopement risk residents revealed the appropriate Resident Care signs in place in their room on the communication board or on the door to their room. The facility's Elopement Risk/Resident Care Sign Education was reviewed with copies obtained to include signatures of staff in attendance. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education. 13. Observations of Resident #1, on 10/09/14 revealed a Secure Care Bracelet on the right ankle. Obtained a copy of the facility's Purchase Order # and dated 09/22/14 that the tamper resistant Secure Care product had been ordered. Interview with the Administrator on 10/09/14 at 3:30 PM revealed Resident #1's Secure Care Bracelet had been replaced, a tamper resistant bracelet had been ordered and would be placed on the resident when available. 14. Reviewed the "Golden Alert" in-service given to staff with copies obtained to include signature of staff in attendance. Copy of in-service related to behaviors, reporting and documentation of behaviors, supervision, new care signs for elopement risk and updating care plans for resident changes was obtained with signatures of staff in attendance and completed by 10/06/14. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education related to the facility's "Golden Alert". Interview on 10/09/14 with Maintenance Director at 2:52 PM; House Keeping #18 at 2:58 PM; Maintenance #19 at 3:04 PM; Dietary #20 at 3:12 PM; and Dietary #21 at 3:17 PM revealed they all reported receiving the education related to the facility's "Golden Alert". 15. New employee education packet was reviewed with copies obtained. Education included elopement, monitoring and reporting of behaviors, care plans, and supervision of residents. 16. Reviewed audits completed by QA committee members from weekly walk through with new areas identified on audit tool. Reviewed minutes of daily QA meeting that included areas of potential hazard and supervision issues. Interview with the Medical Director on 10/09/14, revealed the facility did report the elopement to him on the night of the incident. Further interview revealed he took an active role in the daily care of the residents and the facility kept him well informed. Further interview revealed he was fully participating in the decision making process of the facility. Interview with the Administrator on 10/09/14, revealed she was actively participating in the audits as well as reviewing the data from the audits and would continue to review audits making changes as needed based on the data and the needs of the residents of the facility.

Based on record review, interview and review of the facility's policies, Incident Reports, Investigations and Security Footage document, it was determined the facility failed to have an effective system in place to ensure a safe environment and adequate supervision for residents who had been assessed at risk for wandering and/or exit seeking behaviors for one (1) of twelve (12) sampled residents residents (Resident #1). On 09/21/14, Resident #1 was agitated with staff's redirection, and at approximately 6:32 PM, Resident #1 cut off his/her Secure Care Bracelet with a six (6) inch paring knife and eloped from the facility without staff's knowledge. Resident #1 was found by police at 7:01 PM, approximately three tenths of a mile from the facility, walking with a walker on a heavily traveled two (2) lane road, without a sidewalk or a shoulder, and escorted back into the facility by staff at approximately 7:10 PM. Interview and record review revealed Resident #1 had a history of [REDACTED]. On 03/13/14, Resident #1 became upset and told the Social Worker (SW) he/she was going to remove the Secure Care Bracelet and leave the facility. On 05/08/14, Resident #1 became upset when informed he/she would require supervision in the courtyard with his/her spouse. Approximately one (1) hour and twenty (20) minutes later, staff leaving the facility found Resident #1 in the parking lot outside the facility, without his/her Secure Care Bracelet in place. The Secure Care Bracelet was found in Resident #1's room in the trash can with a plastic knife present also. However, there was no documented evidence the facility investigated the successful elopement incident on 05/08/14, and no documented evidence the facility increased supervision of Resident #1 prior to the resident eloping from the facility again on 09/21/14 without staff's knowledge. (Refer to F-280) The facility's failure to have an effective system in place to ensure a safe environment and adequate supervision has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/14 and was determined to exit on 09/21/14. An acceptable credible Allegation of Compliance (AOC) was received on 10/07/14 which alleged removal of the Immediate Jeopardy on 10/07/14. The Immediate Jeopardy was verified to be removed on 10/07/14 as alleged with the remaining non-compliance at 42 CFR 483.25 Quality of Care (F-323) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure a safe environment and adequate supervision of residents. The findings include: Review of the facility's policy titled, "Wandering/Elopement Policy" dated 11/2010, revealed all residents with a [DIAGNOSES REDACTED]. Further review revealed residents found to have a potential for wandering would be fitted with a Secure Care Bracelet. Continued review revealed should a resident elope or attempt elopement, the resident would be monitored every fifteen (15) minutes for seventy-two (72) hours then assessed for any "needed changes/interventions". The State Survey Agency requested the tool utilized by staff upon admission and anytime nursing judgement warranted for screening residents as risk for wandering or elopement as per the facility's Wandering/Elopement Policy. However, interview with the Administrator on 09/26/14 at 12:38 PM, and the Director of Nursing (DON), on 09/30/14 at 1:53 PM, revealed the facility did not have an elopement screening tool. Record review revealed the facility admitted Resident #1 on 12/27/13, with multiple [DIAGNOSES REDACTED].#1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Continued review of the MDS Assessments revealed the facility assessed Resident #1 to ambulate independently with the assistance of a walker. Further review of the Admission and Quarterly MDS Assessments revealed no documented evidence the facility assessed Resident #1 to be at risk for wandering. Review of the Comprehensive Care Plan (CCP), dated 01/10/14, for Resident #1 revealed the facility care planned the resident for the potential for unsupervised exits from the facility due to his/her [DIAGNOSES REDACTED].#1 left the facility; if he/she was observed to be wandering away from unit, staff were to stay with the resident approaching him/her in a calm and accepting manner, staying with the resident while conversing with him/her and gently persuading him/her to return to the designated area of the facility. Further review of the CCP revealed the facility care planned Resident #1 to ambulate independently with a "Jazzy" walker. Continued record review revealed a consent authorizing the use of the Secure Care Bracelet to "promote the safety" of Resident #1, signed by Resident #1's son on 12/27/13. Additionally, record review revealed no documented evidence Resident #1 was screened on admission or at any other time prior to 09/21/14 for his/her wandering and elopement risk. Review of the facility's self-reported "Final Report" Incident Letter, dated 09/24/14, revealed on 09/21/14, Resident #1 had been redirected by staff during the evening meal, for "being inappropriate towards his/her spouse" (also a resident). Review of the letter revealed Resident #1 removed his/her Secure Care Bracelet and left the facility without staff knowledge. Further review revealed the facility was notified by an off duty staff person. Continued review revealed the facility was unable to determine how long Resident #1 was out of the facility. Further review revealed Resident #1 was escorted back to the facility where a search of Resident #1's belongings revealed a small knife found hidden in the tissue box in the basket attached to the resident's "Jazzy" walker. Further review revealed Resident #1 was placed on every fifteen (15) minute checks while in his/her room and 1:1 while out of his/her room. Review of the facility's document, "Review of Security Footage" of the Administrator's and Accounting Clerk's observation of the facility's video surveillance dated 10/07/14, revealed on 09/21/14 at 5:45 PM, Resident #1 went to his/her room with the Secure Care Bracelet in place. Review of the document revealed at 5:53 PM, Resident #1 exited his/her room with the Secure Care Bracelet in place, went to the Personal Care elevator where he/she entered the elevator and went upstairs. At 6:00 PM review revealed Resident #1 ambulated through the double doors leading to the apartment section of the facility and at 6:17 PM, Resident #1 returned from the apartments, through the double doors and returned to his/her room at 6:22 PM. Continued review revealed at 6:29 PM, Resident #1 exited his/her room with a laptop computer on top of the seat on the rolling walker and ambulated by the Unit One Nurse's Station at 6:31 PM. Further review revealed Resident #1 exited out the front doors in the lobby area of the facility at 6:32 PM and was escorted by staff back into the building at 7:10 PM, thirty-eight (38) minutes later. Review of the police department Master Call Table revealed, on 09/21/14 at 6:54 PM, an unknown caller reported an elderly person with a walker in traffic. Continued review revealed a police officer was dispatched to the area and arrived at 7:01 PM to find an elderly person in a black robe with a walker in traffic. Further review revealed the facility staff to arrive on scene at 7:05 PM. Additional review revealed the police officer to be enroute back to the facility at 7:09 PM. Observation on 09/29/14, of the area Resident #1 was found on 09/21/14, revealed it was approximately three tenths of a mile from the facility on a heavily traveled roadway which had no sidewalk or shoulder. Interview with Assistant Feeder (AF) #11, on 09/30/14 at 12:56 PM, revealed she was in the dining room on 09/21/14 during the evening meal. AF #11 revealed around 5:30 PM or 5:45 PM, she had served Resident #1 and his/her spouse their meal trays and was monitoring the residents. Continued interview revealed she witnessed Resident #1 become upset with his/her spouse when the spouse did not move closer to the table and dropped food onto the floor. Per interview AF #11 redirected Resident #1 and reported her observations to the resident's nurse. Further interview revealed she returned to the dining room around 6:30 PM, at which time Resident #1 had already left the dining area. Interview, on 09/29/14 at 3:26 PM, with Licensed Practical Nurse (LPN) #1, responsible for Resident #1's care, revealed the resident had been observed becoming upset with his/her spouse during the evening meal in the dining room prior to his/her elopement from the facility. Continued interview revealed LPN #1 redirected Resident #1 by whispering to Resident #1 the facility could not "have that here". LPN #1 reported Resident #1 was quiet and didn't say anything more. Interview with Housekeeper (HK) #5, on 09/29/14 at 10:53 AM, revealed she was traveling home around 7:00 PM and saw Resident #1 with a walker on the roadway. HK #5 reported she immediately phoned the facility to advise of the elopement. Further interview revealed by the time she turned her vehicle around to go back to Resident #1, the police were already with the resident and directing traffic around him/her. Continued interview, on 09/29/14 at 3:26 PM with, LPN #1 revealed she was unaware Resident #1 was out of the facility until she received a call from an off duty staff person. LPN #1 reported when she went to pick Resident #1 up, police were on the side of the road with the resident. LPN #1 revealed upon return to the facility she did not conduct a head to toe assessment for injury of Resident #1 due to his/her being upset. However, interview with the DON, on 09/30/14 at 1:53 PM, revealed Resident #1 should have been assessed for injury after the elopement. Interview, on 09/29/14 at 10:15 AM, with Resident #1 revealed he/she did not advise staff of the intent to leave the facility on 09/21/14. Resident #1 revealed he/she was not upset prior to leaving the facility. Continued interview revealed Resident #1 reported he/she "stole" a knife from a resident's room outside the "nursing unit" (indicating an apartment) and cut his/her Secure Care Bracelet off with it. Per interview, prior to leaving the facility, Resident #1 called his/her brother to request a ride to another brother's house. Resident #1 stated the brother he/she called did not "get here fast enough" so the resident left the facility walking with his/her "Jazzy" walker, lap top computer and cell phone. Resident #1 further reported, he/she had "planned to leave that day and had no plans on coming back but only to visit" his/her spouse. Review of the Nurse's Notes revealed on 09/21/14 at 6:55 PM, the facility received a call from an off duty staff reporting Resident #1 had eloped from the facility. Further review revealed three (3) staff members left the facility to look for and retrieve Resident #1. Continued review revealed Resident #1 was transported back to the facility in a staff's personal vehicle and during transport, while stopped, Resident #1 attempted to unbuckle the seat belt. Further review revealed the SSD, Administrator, Resident #1's son and Physician were notified of the elopement. Interview with the SSD, on 09/26/14 at 10:45 AM, revealed she was not at the facility when Resident #1 eloped on 09/21/14. She stated staff called her to come back to the facility and she arrived around 7:30 PM to initiate the investigation. Continued interview revealed she requested written statements from staff who retrieved Resident #1 and talked with Resident #1 regarding the knife found in the basket attached to the walker. She stated Resident #1 was placed on one on one (1:1) monitoring until approximately 10:00 PM then on every fifteen (15) minute monitoring. Continued interview revealed on 09/21/14, she did not interview other residents, assess other residents for the risk of elopement or ensure other residents with Secure Care Bracelets had the bracelets in place as she "didn't see a need" to have done those things after Resident #1's elopement. Further interview on 09/29/14 at 3:26 PM with, LPN #1 revealed the facility did not assess other residents at risk for wandering or elopement to ensure placement of their Secure Care Bracelets or complete a formal resident count to ensure no other residents had eloped until 09/22/14. Interview with the Administrator, on 09/26/14 at 12:38 PM, revealed she was notified by the facility on 09/21/14 of Resident #1's elopement. The Administrator revealed she came to the facility and talked with Resident #1 and initiated the investigation for the elopement. Continued interview revealed Resident #1's personal belongings and room were searched with a knife found in the basket of the "Jazzy" walker and the Secure Care Bracelet found in the trash can in the room. Resident #1 was placed on one on one (1:1) monitoring until approximately 10:00 PM then on every fifteen (15) minute monitoring. Interview and record review revealed Resident #1 had a history of [REDACTED]. Record review of the Nurse's Notes, dated 03/13/14, revealed Resident #1 became upset over a conversation between the resident and the Social Worker and verbally threatened to remove the Secure Care Bracelet and leave the facility. Resident #1 was unable to be re-directed by staff. Continued review revealed on 05/08/14, Resident #1 became upset when informed he/she would require supervision in the courtyard with his/her spouse. Review revealed approximately one (1) hour and twenty (20) minutes after Resident #1 became upset, he/she was found outside the facility, in the parking lot, without the Secure Care Bracelet in place, by an off duty staff person leaving the facility. Continued review revealed Resident #1 refused to come back into the facility and remained outside the facility with staff for approximately three and one-half (3.5) hours before agreeing to return to the facility. Further review revealed the Secure Care Bracelet was found in Resident #1's room in the trash can with a plastic knife. However, even though the facility initiated every fifteen (15) minute checks of Resident #1 for seventy-two (72) hours after each of these incidents, there was no documented evidence the resident's CCP was updated or revised after the incidents, and no documented evidence the facility investigated the resident's elopement on 05/08/14. Interview with Unit Coordinator #1, on 10/01/14 at 11:23 AM, revealed she was aware Resident #1 was care planned for unsupervised exit seeking behaviors. However, she stated she was not aware Resident #1 had previously threatened to remove the Secure Care Bracelet and leave the facility or had actually cut the Secure Care Bracelet off and left the facility prior to the incident on 09/21/14. Continued interview, on 09/30/14 at 10:52 PM with the SSD, revealed she was aware Resident #1 had an elopement history of verbal threats to remove the Secure Care Bracelet and leave the facility and had a history of [REDACTED]. She revealed she did not investigate the incident on 05/08/14 when Resident #1 cut the Secure Care Bracelet off and exited the facility as Resident #1 did not get off the facility property. Further interview revealed she was unaware of any interventions implemented by the facility at that time, except the replacement of his/her Secure Care Bracelet. Continued interview with the DON, on 09/30/14 at 1:53 PM, revealed she was aware prior to 09/21/14, Resident #1 had a history of [REDACTED]. She stated Resident #1's eloped from the facility on 05/08/14, but this was not investigated as the resident did not get off the facility property. Further interview revealed however, Resident #1's care plan should have been updated and revised at that time to accurately reflect the resident's history of unsupervised exit seeking behaviors with interventions implemented and education given to staff for monitoring and increased supervision. Further interview with the Administrator, on 09/30/14 at 1:17 PM, revealed she was aware in March of 2014, Resident #1 had previously threatened to remove the Secure Care Bracelet and leave the facility. Per interview, she was aware in May, 2014, Resident #1 had cut the Secure Care Bracelet off and exited the facility without staff's knowledge. The Administrator revealed however, Resident #1's successful elopement on 05/08/14 was not investigated as the resident did not get off the facility property. Continued interview revealed Resident #1's care plan should have been updated and revised to reflect the resident's threats/attempts to remove the Secure Care Bracelet, or actual removal of the Secure Care Bracelet to alert staff to monitor him/her for this behavior with interventions implemented for increased monitoring of behaviors related to the unsupervised exit seeking behaviors. Further interview revealed the facility did not have an elopement screening tool nor a policy related to frequency of screening for wandering/elopement; however, her expectation was for staff to continuously screen residents based on behaviors and document the findings including updating and revising the care plan to accurately reflect the resident's needs. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/06/14, which alleged removal of the Immediate Jeopardy (IJ), effective 10/07/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on fifteen (15) minute observations on 09/21/14. Resident #1's room was searched for other objects that could be utilized to remove secure care bracelet or be utilized to harm self or others by staff on duty on 09/21/14 and then searched again on 09/25/14 by the Quality Assurance Director (QA) with a set of nail clippers removed from the closet area. A tamper resistant secure care bracelet was ordered by the Housekeeping Supervisor on 09/22/14. Resident #1 then went on a Leave of Absence from the facility with his/her son from 09/22/14 through 09/25/14. 2. All thirteen (13) residents, that had Secure Care Bracelets were reviewed for risk to ensure Secure Care Bracelets were in place, functioning properly, and were care planned appropriately with no changes or updates required by the Assistant Director of Nursing (ADON) on 09/22/14. 3. A 3:00 PM to 11:00 PM House Supervisor position was added, effective 09/24/14, with the role to help supervise and to investigate or review any resident information as directed by the Director of Nursing (DON). 4. On 09/30/14, all 107 residents were assessed for risk for elopement and four (4) care plans for the residents identified were updated to accurately reflect the needs of the resident by the MDS Coordinator, MDS Assistant, DON, QA Director, and the ADON. A screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. The Elopement Risk Assessment Decision Tree was implemented and completed, on 10/04/14 and 10/05/14, on all residents with no new residents identified to be at risk for elopement and was completed by the Infection Control Nurse, the Wound Care Nurse, and another Licensed Practical Nurse (LPN). 5. The DON, QA Director, and the Administrator created a monitoring policy and criteria for secure care bracelet placement to include monitoring would not be discontinued until review by the Quality Assurance Committee or Physician recommendation. The monitoring policy was created on 09/30/08. Implementation and Education of the new monitoring policy was completed by the QA Director, the Infection Control Nurse, and the Quality Assurance Assistant on 10/06/14. 6. All areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. 7. Boards for identification of residents at risk for elopement were placed in the nursing stations on 10/02/14. Additional boards for identification of residents at risk for elopement were placed in the break rooms, including the area by the time clock, and at the front office, on 10/03/14 by the QA Assistant, to help all staff to identify residents at risk for elopement. 8. Education regarding leaving offices unattended or tools/supplies unsecured when out of offices and to ensure sharp objects are placed inside desk was given to Kitchen staff, Maintenance Department, Activities Department, front office staff, Social Services Department, Therapy Department, Quality Assurance Department, and the Nursing office staff starting 10/01/14 and completed on 10/03/14 and was given by Department Supervisors. 9. Resident #1's Comprehensive Care Plan was updated to include a new Elopement Care Plan by the Minimum Data Set (MDS) Coordinator on 10/01/14. 10. Employees were scheduled by the Scheduling Coordinator, on 10/02/14, to be responsible for a minimum of fifteen (15) minute monitoring for Resident #1 while in his/her room and one on one (1:1) supervision with Resident #1 while out of room with his/her spouse whom was also a resident of the facility. Also, one on one (1:1) supervision was to be done if Resident #1 was wanting to go off the unit until otherwise directed. 11. All care plans were reviewed to ensure updates had been completed for any new orders received in the last thirty (30) days with any issues identified and corrected at the time of the audit, starting on 10/03/14 and completed on 10/06/14, and was completed by the Infection Control Nurse, the Wound Care Nurse, the second shift House Supervisor, the ADON, and another LPN. 12. Resident Care signs located in each resident's room were updated to include risk for elopement on 10/01/14 and education on the Resident Care signs was given to all facility by the QA Director, the Infection Control Nurse and by the DON from 10/01/14 through 10/06/14. 13. A new tamper resistant secure care bracelet was placed on Resident #1, on 10/06/14, by the Maintenance Director and QA Director. 14. An in-service training was given to all staff on elopement to include the procedures on a Golden Alert announcement when an elopement occurs or is attempted by residents. In addition, all staff were given in-service training on behaviors and reporting and documentation of behaviors, supervision, new Resident Care signs for residents with elopement risk, and updating care plans for resident changes. All in-service training were completed by 10/06/14 by the QA Director, QA Assistant, and the Infection Control Nurse. All staff will also be receiving these in-service training annually. 15. The facility included education on elopement, monitoring behaviors, care plans, and supervision in the new employee orientation program by 10/06/14. The QA Director and QA Assistant will incorporate into their current check off of new employees during orientation to determine understanding of the policies on elopement, care plans, potential behaviors, reporting of behaviors, and supervision of residents. 16. The facility implemented plans to monitor its performance to ensure the residents' environment remain as free from accident hazards as possible and that adequate supervision is in place by monitoring through the Quality Assurance Committee weekly walk through on an ongoing basis to identify areas of potential hazards and inadequate supervision. The Medical Director will have an on-going role in the monitoring of these solutions as both the medical director and as the personal physician for Resident #1. The facility's QA Committee members will review daily reports and investigations from each unit to identify potential accident hazards for tracking and trending purposes and report their findings during the daily QA Committee meeting and to the Quarterly QA Committee which includes the Medical Director. Any areas of potential harm identified will be reported to the Administrator for immediate attention. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the "fifteen (15) minute monitoring form", on 09/21/14 revealed, Resident #1 was on one to one supervision with the Administrator upon return to the facility from 7:30 PM until 8:45 PM and fifteen (15) minute monitoring began at 8:45 PM on 09/21/14. Resident #1 remained on fifteen minute monitoring until 09/22/14 at 5:30 PM when he/she left the faciity on a Leave of Absence with his/her son. Interview with Kentucky Medication Aide (KMA) #1, on 09/29/14 at 3:00 PM, revealed he searched Resident #1's room on 09/21/14 for objects that could be used to remove the secure care band but was not able to find anything in Resident #1's room other than the Secure Care Bracelet that he/she removed prior to eloping from the facility, which was found in Resident #1's trash can. Interview with the QA Director, on 09/29/14 at 11:22 AM revealed she did a follow-up search of Resident #1's room. A late entry Nurses' Note written by the MDS Assistant, on 09/26/14 at 8:09 AM revealed Resident #1 returned to the facility on [DATE] at 6:00 PM and the Nurses' Note revealed staff was present when Resident #1 unpacked his/her belongings and there were no objects in the belongings to cut the Secure Care Bracelet off. Review of the "fifteen (15) minute monitoring form" revealed fifteen (15) minute monitoring resumed on 09/25/14 at 6:00 PM upon Resident #1's return to the facility and would continue fifteen (15) minute monitoring until the Administrator and QA team deemed unnecessary. Review of the purchase order revealed a tamper resistant Secure Care Bracelet was ordered on [DATE] by the Housekeeping Director. 2. The check off sheet the ADON completed, on 09/22/14, regarding her review of all thirteen (13) residents with Secure Care Bracelets to ensure placement, proper functioning, and to ensure they were appropriately care planned was reviewed and a copy of the check off sheet was obtained. An interview with the ADON, on 10/01/14 at 10:50 AM, revealed she did complete a review of all thirteen (13) residents with Secure Care Bracelets to ensure placement and proper functioning was completed and all thirteen (13) residents with Secure Care Bracelets had care plans on 09/22/14. 3. Review of the facility's staff schedule of Registered Nurse (RN) #1 revealed a House Supervisor position for 3:00 PM to 11:00 PM had been added and a copy of the schedule was obtained. A copy of the "Job Description" for the Nursing Supervisor position was also obtained and reviewed. Interviews, on 10/09/14, with the Infection Control Nurse at 9:00 AM, State Registered Nursing Assistant (SRNA) #8 at 9:30 AM, Unit Coordinator #1 at 10:48 AM, Unit Coordinator #2 at 12:55 PM, KMA #17 at 1:12 PM, SRNA #18 at 1:28 PM, and SRNA #16 at 1:50 PM confirmed that a House Supervisor position for 3:00 PM to 11:00 PM had been added and RN #1 was assigned to the position. 4. Reviewed the screening tool, Elopement Risk Assessment Decision Tree instructions sheet, dated 10/2014, revealed the new screening tool was to be completed upon admission, quarterly, and with any significant change in condition/mental health status. Review of the facility's Elopement Risk Assessments revealed they were completed for the sampled and unsampled residents reviewed. Interview with the MDS Coordinator on 10/09/14 at 2:20 PM, the DON on 10/09/14 at 3:15 PM and the QA Director on 10/09/14 at 3:30 PM revealed the screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. They reported all one hundred and seven (107) residents were assessed for risk for elopement through use of the new screening tool with no residents determined to be at risk except the previous residents determined to be at risk. Four (4) residents' care plans required updating to accurately reflect the needs of the resident. 5. Obtained and reviewed copies of the facility's new monitoring policy with the criteria for placement of the Secure Care Bracelet. Obtained and reviewed copies of the education provided to staff regarding the new policy with signatures. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education regarding the new policy. 6. Review of the facility's maps provided by the Administrator revealed all areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. Interview on 10/09/14, with the Infection Control Nurse at 9:00 AM and with the MDS Coordinator on 10/09/14 at 2:20 PM revealed they were involved in the facility wide search for hazardous items. 7. Observation on 10/09/14 in the employee break room, time clock area, front office and nurses station revealed elopement boards in place as per the Allegation of Compliance. Further observation revealed the elopement boards included pictures of residents at risk for elopement, with the residents' room numbers. 8. Obtained and reviewed a copy of education given to staff related to leaving offices unattended or tools/supplies unsecured with copies of signatures of staff in attendance completed on 10/03/14. Interview on 10/09/14 with Maintenance Director at 2:52 PM; House Keeping #18 at 2:58 PM; Maintenance #19 at 3:04 PM; Dietary #20 at 3:12 PM; and Dietary #21 at 3:17 PM revealed they all reported receiving the education. 9. Review of Resident #1's care plan for potential for unsupervised exits from the facility revealed his/her care plan had been updated and a new care plan for potential for elopement had been added by the MDS Coordinator on 10/01/14 and included Resident #1's history of elopement. A copy of both the previous and new care plan related to elopement were obtained. 10. Review of the "sitter schedule" from 10/02/14 through 10/21/14 for Resident #1 revealed an extra staff member was assigned to Resident #1 between the hours of 7:00 AM and 12:00 AM through those dates. Further review of Resident #1's sitter instruction sheet revealed the sitter must monitor Resident #1 for a minimum of fifteen (15) minute monitoring while Resident #1 was in his/her room and one to one (1:1) supervision while Resident #1 was out of his/her room. A copy of the "sitter schedule" and sitter instructions for monitoring sheet were obtained. 11. Reviewed MD orders and care plan updates for the previous thirty (30) days to verify updates had been completed by 10/06/14 for seventeen (17) residents. 12. Observation on 10/09/14, of the facility's identified elopement risk residents revealed the appropriate Resident Care signs in place in their room on the commu

Based on 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' Comprehensive Care Plans were reviewed and revised to implement interventions to provide adequate supervision for one (1) of twelve (12) sampled residents (Resident #1) who had a known history of wandering and exit seeking behaviors. On 09/21/14, Resident #1 became agitated at the evening meal, obtained a six (6) inch paring knife from elsewhere in the facility, and at approximately 6:32 PM, successfully eloped from the facility without staff's knowledge. Resident #1 was found by police at 7:01 PM, approximately three tenths of a mile from the facility, on a two (2) lane heavily traveled road which had no sidewalk or shoulder. Staff escorted Resident #1 back to the facility at approximately 7:10 PM. Resident #1 was not assessed for injury after his/her return to the facility due to being "upset". Interview and record review revealed Resident #1 had a history of [REDACTED]. On 03/13/14, Resident #1 became upset over a conversation between the resident and the Social Worker and verbally threatened to remove his/her Secure Care Bracelet and leave the facility. Also, on 05/08/14, Resident #1 became upset after being informed he/she would require supervision in the courtyard with his/her spouse. Resident #1 was found approximately one (1) hour and twenty (20) minutes later that day by an off duty staff person, outside the facility in the parking lot without his/her Secure Care Bracelet in place. Staff found Resident #1's Secure Care Bracelet in the trash can in his/her room with a plastic knife. Although Resident #1 was placed on every fifteen (15) minute checks for seventy-two (72) hours following these incidents; there was no documented evidence the Comprehensive Care Plan was updated and revised regarding these incidents to ensure adequate supervision of the resident. (Refer to F-323) The facility's failure to have an effective system in place to ensure residents' Comprehensive Care Plans were reviewed and revised to implement interventions to provide adequate supervision was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/30/14 and was determined to exit on 09/21/14. An acceptable credible Allegation of Compliance (AOC) was received on 10/07/14 which alleged removal of the Immediate Jeopardy on 10/07/14. The Immediate Jeopardy was verified to be removed on 10/07/14 as alleged with the remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment (F-280) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure care plans are reviewed and revised to implement interventions to provide adequate supervision. The findings include: Review of the facility's policy titled, "Care Management" dated August 2012, revealed the plan of care should be continuously updated to reflect current resident needs at all times. Further review revealed updating the Plan of Care was the responsibility of all involved staff. Record review revealed the facility admitted Resident #1 on 12/27/13, with multiple [DIAGNOSES REDACTED].#1's son on 12/27/13. Review of the Admission Minimum Data Set (MDS) Assessment, dated 01/06/14 and the Quarterly MDS Assessment, dated 08/27/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate impairment. Further review of the MDS Assessments revealed the facility assessed Resident #1 to ambulate independently with the assist of a walker. Review of Resident #1's Comprehensive Care Plan (CCP), dated 01/10/14, revealed Resident #1 was care planned for being at risk for wandering/unsupervised exit seeking behaviors due to the [DIAGNOSES REDACTED]. Review of the care plan revealed interventions which included placement of a monitoring device on the resident that would sound an alarm when the resident left the building, to alert staff to Resident #1's wandering behavior, observe resident for wandering away from unit, approach resident in a calm and accepting manner, and directed staff to stay with the resident, converse and gently persuade Resident #1 to walk back to designated area. Review of Resident #1's Nurse's Notes, dated 03/13/14, revealed Resident #1 became upset over a conversation between the resident and the Social Worker and he/she verbally threatened to remove the Secure Care Bracelet and leave the facility. Resident #1 was unable to be re-directed by staff and was placed on every fifteen (15) minute checks; however, review of the CCP revealed no documented evidence it was updated, revised and interventions implemented to reflect the behavior. Interview, on 09/29/14 at 3:26 PM, with Licensed Practical Nurse (LPN) #1, who was assigned to Resident #1, revealed she was not aware of the incident on 03/13/14 where Resident #1 had threatened to remove his/her Secure Care Bracelet and leave the facility. LPN #1 revealed Resident #1's care plan should have been updated and revised to implement additional interventions related to monitoring Resident #1. Interview with the Minimum Data Set (MDS) Coordinator, on 10/01/14 at 9:58 AM, revealed there were "set" interventions which were implemented for elopement risk residents; however, Resident #1's care plan should have been updated and revised for the incident on 03/13/14 to ensure the interventions were appropriate to provide adequate supervision of the resident. Continued review of the Nurse's Note revealed on 05/08/14, Resident #1 became upset when informed he/she would require supervision in the courtyard with his/her spouse. Approximately one (1) hour and twenty (20) minutes after Resident #1 became upset, he/she was found outside the facility, in the parking lot, without the Secure Care Bracelet, by off duty staff leaving the facility. Further review revealed Resident #1 refused to come back into the facility. Review of the Note revealed the Physician was notified and medications were ordered for agitation. Further review revealed the Secure Care Bracelet was found in Resident #1's room in the trash can with a plastic knife. However, review of the Comprehensive Care Plan revealed no documented evidence the Care Plan was updated or revised with interventions for this behavior. Interview on 09/30/14 with State Registered Nursing Assistant (SRNA) #3 at 4:30 PM, with SRNA #6 at 4:57 PM, and on 10/01/14 with SRNA #8 revealed they all knew Resident #1; however, were not aware of Resident #1 threatening to cut off his/her Secure Care Bracelet, or of the resident threatening to leave the facility or of him/her exiting the facility previously. Further interview on 09/29/14 at 3:26 PM, with LPN #1 revealed she had not been aware of the incident on 05/08/14 where Resident #1 had cut his/her Secure Care Bracelet off and eloped from the facility. She stated Resident #1's care plan should have been updated and revised to implement additional interventions for increased supervision and monitoring of Resident #1. Continued interview with the MDS Coordinator, on 10/01/14 at 9:58 AM, revealed Resident #1's care plan should have been updated and revised for the 05/08/14 incident to ensure the interventions were providing adequate supervision of the resident. Further review of the Nurse's Notes revealed on 09/21/14 at 6:55 PM, the facility received a call from an off duty staff person reporting Resident #1's elopement. Per the Note the Social Services Director, Administrator, Resident #1's son and Physician were notified of the elopement. Review of the facility's self-reported "Final Report" Incident Letter, dated 09/24/14, revealed on 09/21/14, Resident #1 had removed his/her Secure Care Bracelet and exited the facility without staff's knowledge. Further review revealed Resident #1 was placed on every fifteen (15) minute checks while in his/her room and one on one (1:1) while out of his/her room. However, continued review of the CCP revealed no documented evidence the care plan was updated and revised to include Resident #1's successful elopement from the facility on 09/21/14. Review revealed no documented evidence of the interventions implemented for increased supervision of Resident #1 for every fifteen (15) minute checks while in his/her room and one on one (1:1) while out of his/her room until 09/22/14. Further interview, on 09/29/14 at 3:26 PM, with LPN #1 revealed Resident #1 was returned to the facility and one on one (1:1) supervision was implemented, then every fifteen (15) minute checks were implemented. However, review of the CCP revealed no documented evidence of the increased supervision of Resident #1 through one on one (1:1) supervision or every fifteen (15) minute checks until 09/22/14. Further interview with the MDS Coordinator, on 10/01/14 at 9:58 AM, revealed all staff was responsible for updating and revising the care plans. Per interview, the care plan was the tool utilized for the care a resident was to receive and if the care plan was not revised and updated to reflect a resident's current needs the facility was unable to ensure the resident received the care they needed and required. Interview with the Director of Nursing (DON), on 09/30/14 at 1:53 PM, revealed all nurses were responsible for updating and revising residents' care plans. She stated Resident #1's care plan should have been updated and revised with each of the incidents of threatening to cut off the Secure Care Bracelet and when he/she exited the facility without staff's knowledge on 05/08/14 and communicated to staff; however, this was not done. She indicated after the 09/21/14 elopement the care plan should have been updated and revised to include the every fifteen (15) minute checks which had been implemented upon Resident #1's return to the facility; however, this had not been done until 09/22/14. Interview with the Administrator, on 09/30/14 at 1:17 PM, revealed she was aware of Resident #1's previous threats to remove the Secure Care Bracelet and of his/her unsupervised exit from the facility in May, 2014. Per interview, every fifteen (15) minute checks were implemented after each of these incidents for a seventy-two (72) hour period. According to the Administrator, Resident #1's care plan should have been updated and revised on 03/13/14 and 05/08/14 to reflect the incidents in order to implement interventions to ensure the resident's safety. The Administrator indicated Resident #1's care plan should have been updated and revised on 09/21/14 after the resident's elopement, but this was not done until 09/22/14. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/06/14, which alleged removal of the Immediate Jeopardy (IJ), effective 10/07/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on fifteen (15) minute observations on 09/21/14. Resident #1's room was searched for other objects that could be utilized to remove secure care bracelet or be utilized to harm self or others by staff on duty on 09/21/14 and then searched again on 09/25/14 by the Quality Assurance Director (QA) with a set of nail clippers removed from the closet area. A tamper resistant secure care bracelet was ordered by the Housekeeping Supervisor on 09/22/14. Resident #1 then went on a Leave of Absence from the facility with his/her son from 09/22/14 through 09/25/14. 2. All thirteen (13) residents, that had Secure Care Bracelets were reviewed for risk to ensure Secure Care Bracelets were in place, functioning properly, and were care planned appropriately with no changes or updates required by the Assistant Director of Nursing (ADON) on 09/22/14. 3. A 3:00 PM to 11:00 PM House Supervisor position was added, effective 09/24/14, with the role to help supervise and to investigate or review any resident information as directed by the Director of Nursing (DON). 4. On 09/30/14, all 107 residents were assessed for risk for elopement and four (4) care plans for the residents identified were updated to accurately reflect the needs of the resident by the MDS Coordinator, MDS Assistant, DON, QA Director, and the ADON. A screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. The Elopement Risk Assessment Decision Tree was implemented and completed, on 10/04/14 and 10/05/14, on all residents with no new residents identified to be at risk for elopement and was completed by the Infection Control Nurse, the Wound Care Nurse, and another Licensed Practical Nurse (LPN). 5. The DON, QA Director, and the Administrator created a monitoring policy and criteria for secure care bracelet placement to include monitoring would not be discontinued until review by the Quality Assurance Committee or Physician recommendation. The monitoring policy was created on 09/30/08. Implementation and Education of the new monitoring policy was completed by the QA Director, the Infection Control Nurse, and the Quality Assurance Assistant on 10/06/14. 6. All areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. 7. Boards for identification of residents at risk for elopement were placed in the nursing stations on 10/02/14. Additional boards for identification of residents at risk for elopement were placed in the break rooms, including the area by the time clock, and at the front office, on 10/03/14 by the QA Assistant, to help all staff to identify residents at risk for elopement. 8. Education regarding leaving offices unattended or tools/supplies unsecured when out of offices and to ensure sharp objects are placed inside desk was given to Kitchen staff, Maintenance Department, Activities Department, front office staff, Social Services Department, Therapy Department, Quality Assurance Department, and the Nursing office staff starting 10/01/14 and completed on 10/03/14 and was given by Department Supervisors. 9. Resident #1's Comprehensive Care Plan was updated to include a new Elopement Care Plan by the Minimum Data Set (MDS) Coordinator on 10/01/14. 10. Employees were scheduled by the Scheduling Coordinator, on 10/02/14, to be responsible for a minimum of fifteen (15) minute monitoring for Resident #1 while in his/her room and one on one (1:1) supervision with Resident #1 while out of room with his/her spouse whom was also a resident of the facility. Also, one on one (1:1) supervision was to be done if Resident #1 was wanting to go off the unit until otherwise directed. 11. All care plans were reviewed to ensure updates had been completed for any new orders received in the last thirty (30) days with any issues identified and corrected at the time of the audit, starting on 10/03/14 and completed on 10/06/14, and was completed by the Infection Control Nurse, the Wound Care Nurse, the second shift House Supervisor, the ADON, and another LPN. 12. Resident Care signs located in each resident's room were updated to include risk for elopement on 10/01/14 and education on the Resident Care signs was given to all facility by the QA Director, the Infection Control Nurse and by the DON from 10/01/14 through 10/06/14. 13. A new tamper resistant secure care bracelet was placed on Resident #1, on 10/06/14, by the Maintenance Director and QA Director. 14. An in-service training was given to all staff on elopement to include the procedures on a Golden Alert announcement when an elopement occurs or is attempted by residents. In addition, all staff were given in-service training on behaviors and reporting and documentation of behaviors, supervision, new Resident Care signs for residents with elopement risk, and updating care plans for resident changes. All in-service training were completed by 10/06/14 by the QA Director, QA Assistant, and the Infection Control Nurse. All staff will also be receiving these in-service training annually. 15. The facility included education on elopement, monitoring behaviors, care plans, and supervision in the new employee orientation program by 10/06/14. The QA Director and QA Assistant will incorporate into their current check off of new employees during orientation to determine understanding of the policies on elopement, care plans, potential behaviors, reporting of behaviors, and supervision of residents. 16. The facility implemented plans to monitor its performance to ensure the residents' environment remain as free from accident hazards as possible and that adequate supervision is in place by monitoring through the Quality Assurance Committee weekly walk through on an ongoing basis to identify areas of potential hazards and inadequate supervision. The Medical Director will have an on-going role in the monitoring of these solutions as both the medical director and as the personal physician for Resident #1. The facility's QA Committee members will review daily reports and investigations from each unit to identify potential accident hazards for tracking and trending purposes and report their findings during the daily QA Committee meeting and to the Quarterly QA Committee which includes the Medical Director. Any areas of potential harm identified will be reported to the Administrator for immediate attention. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the "fifteen (15) minute monitoring form", on 09/21/14 revealed, Resident #1 was on one to one supervision with the Administrator upon return to the facility from 7:30 PM until 8:45 PM and fifteen (15) minute monitoring began at 8:45 PM on 09/21/14. Resident #1 remained on fifteen minute monitoring until 09/22/14 at 5:30 PM when he/she left the faciity on a Leave of Absence with his/her son. Interview with Kentucky Medication Aide (KMA) #1, on 09/29/14 at 3:00 PM, revealed he searched Resident #1's room on 09/21/14 for objects that could be used to remove the secure care band but was not able to find anything in Resident #1's room other than the Secure Care Bracelet that he/she removed prior to eloping from the facility, which was found in Resident #1's trash can. Interview with the QA Director, on 09/29/14 at 11:22 AM revealed she did a follow-up search of Resident #1's room. A late entry Nurses' Note written by the MDS Assistant, on 09/26/14 at 8:09 AM revealed Resident #1 returned to the facility on [DATE] at 6:00 PM and the Nurses' Note revealed staff was present when Resident #1 unpacked his/her belongings and there were no objects in the belongings to cut the Secure Care Bracelet off. Review of the "fifteen (15) minute monitoring form" revealed fifteen (15) minute monitoring resumed on 09/25/14 at 6:00 PM upon Resident #1's return to the facility and would continue fifteen (15) minute monitoring until the Administrator and QA team deemed unnecessary. Review of the purchase order revealed a tamper resistant Secure Care Bracelet was ordered on [DATE] by the Housekeeping Director. 2. The check off sheet the ADON completed, on 09/22/14, regarding her review of all thirteen (13) residents with Secure Care Bracelets to ensure placement, proper functioning, and to ensure they were appropriately care planned was reviewed and a copy of the check off sheet was obtained. An interview with the ADON, on 10/01/14 at 10:50 AM, revealed she did complete a review of all thirteen (13) residents with Secure Care Bracelets to ensure placement and proper functioning was completed and all thirteen (13) residents with Secure Care Bracelets had care plans on 09/22/14. 3. Review of the facility's staff schedule of Registered Nurse (RN) #1 revealed a House Supervisor position for 3:00 PM to 11:00 PM had been added and a copy of the schedule was obtained. A copy of the "Job Description" for the Nursing Supervisor position was also obtained and reviewed. Interviews, on 10/09/14, with the Infection Control Nurse at 9:00 AM, State Registered Nursing Assistant (SRNA) #8 at 9:30 AM, Unit Coordinator #1 at 10:48 AM, Unit Coordinator #2 at 12:55 PM, KMA #17 at 1:12 PM, SRNA #18 at 1:28 PM, and SRNA #16 at 1:50 PM confirmed that a House Supervisor position for 3:00 PM to 11:00 PM had been added and RN #1 was assigned to the position. 4. Reviewed the screening tool, Elopement Risk Assessment Decision Tree instructions sheet, dated 10/2014, revealed the new screening tool was to be completed upon admission, quarterly, and with any significant change in condition/mental health status. Review of the facility's Elopement Risk Assessments revealed they were completed for the sampled and unsampled residents reviewed. Interview with the MDS Coordinator on 10/09/14 at 2:20 PM, the DON on 10/09/14 at 3:15 PM and the QA Director on 10/09/14 at 3:30 PM revealed the screening tool, Elopement Risk Assessment Decision Tree, was developed to identify residents at risk for elopement on 10/02/14 by the DON and the QA Director. They reported all one hundred and seven (107) residents were assessed for risk for elopement through use of the new screening tool with no residents determined to be at risk except the previous residents determined to be at risk. Four (4) residents' care plans required updating to accurately reflect the needs of the resident. 5. Obtained and reviewed copies of the facility's new monitoring policy with the criteria for placement of the Secure Care Bracelet. Obtained and reviewed copies of the education provided to staff regarding the new policy with signatures. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education regarding the new policy. 6. Review of the facility's maps provided by the Administrator revealed all areas of the facility covered by the Secure Care System were searched for hazardous items which started on 10/01/14 and was completed on 10/03/14, by staff which included the QA Nurse, Housekeeping Director and MDS Coordinator. Interview on 10/09/14, with the Infection Control Nurse at 9:00 AM and with the MDS Coordinator on 10/09/14 at 2:20 PM revealed they were involved in the facility wide search for hazardous items. 7. Observation on 10/09/14 in the employee break room, time clock area, front office and nurses station revealed elopement boards in place as per the Allegation of Compliance. Further observation revealed the elopement boards included pictures of residents at risk for elopement, with the residents' room numbers. 8. Obtained and reviewed a copy of education given to staff related to leaving offices unattended or tools/supplies unsecured with copies of signatures of staff in attendance completed on 10/03/14. Interview on 10/09/14 with Maintenance Director at 2:52 PM; House Keeping #18 at 2:58 PM; Maintenance #19 at 3:04 PM; Dietary #20 at 3:12 PM; and Dietary #21 at 3:17 PM revealed they all reported receiving the education. 9. Review of Resident #1's care plan for potential for unsupervised exits from the facility revealed his/her care plan had been updated and a new care plan for potential for elopement had been added by the MDS Coordinator on 10/01/14 and included Resident #1's history of elopement. A copy of both the previous and new care plan related to elopement were obtained. 10. Review of the "sitter schedule" from 10/02/14 through 10/21/14 for Resident #1 revealed an extra staff member was assigned to Resident #1 between the hours of 7:00 AM and 12:00 AM through those dates. Further review of Resident #1's sitter instruction sheet revealed the sitter must monitor Resident #1 for a minimum of fifteen (15) minute monitoring while Resident #1 was in his/her room and one to one (1:1) supervision while Resident #1 was out of his/her room. A copy of the "sitter schedule" and sitter instructions for monitoring sheet were obtained. 11. Reviewed MD orders and care plan updates for the previous thirty (30) days to verify updates had been completed by 10/06/14 for seventeen (17) residents. 12. Observation on 10/09/14, of the facility's identified elopement risk residents revealed the appropriate Resident Care signs in place in their room on the communication board or on the door to their room. The facility's Elopement Risk/Resident Care Sign Education was reviewed with copies obtained to include signatures of staff in attendance. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education. 13. Observations of Resident #1, on 10/09/14 revealed a Secure Care Bracelet on the right ankle. Obtained a copy of the facility's Purchase Order # and dated 09/22/14 that the tamper resistant Secure Care product had been ordered. Interview with the Administrator on 10/09/14 at 3:30 PM revealed Resident #1's Secure Care Bracelet had been replaced, a tamper resistant bracelet had been ordered and would be placed on the resident when available. 14. Reviewed the "Golden Alert" in-service given to staff with copies obtained to include signature of staff in attendance. Copy of in-service related to behaviors, reporting and documentation of behaviors, supervision, new care signs for elopement risk and updating care plans for resident changes was obtained with signatures of staff in attendance and completed by 10/06/14. Interview on 10/09/14 with LPN #15 at 9:00 AM; LPN #8 at 9:20 AM; SRNA #8 at 9:30 AM; Unit Coordinator #1 at 10:48 AM; SRNA #12 at 11:05 AM; Unit Coordinator #2 at 12:55 PM; KMA #17 at 1:12 PM; SRNA #18 at 1:28 AM; SRNA #16 at 1:50 PM; Unit Coordinator #3 at 3:35 PM; SRNA #19 at 3:50 PM; SRNA #20 at 4:10 PM; KMA #21 at 4:27 PM; and SRNA #22 at 4:35 PM revealed they all reported receiving the education related to the facility's "Golden Alert". Interview on 10/09/14 with Maintenance Director at 2:52 PM; House Keeping #18 at 2:58 PM; Maintenance #19 at 3:04 PM; Dietary #20 at 3:12 PM; and Dietary #21 at 3:17 PM revealed they all reported receiving the education related to the facility's "Golden Alert". 15. New employee education packet was reviewed with copies obtained. Education included elopement, monitoring and reporting of behaviors, care plans, and supervision of residents. 16. Reviewed audits completed by QA committee members from weekly walk through with new areas identified on audit tool. Reviewed minutes of daily QA meeting that included areas of potential hazard and supervision issues. Interview with the Medical Director on 10/09/14, revealed the facility did report the elopement to him on the night of the incident. Further interview revealed he took an active role in the daily care of the residents and the facility kept him well informed. Further interview revealed he was fully participating in the decision making process of the facility. Interview with the Administrator on 10/09/14, revealed she was actively participating in the audits as well as reviewing the data from the audits and would continue to review audits making changes as needed based on the data and the needs of the residents of the facility.

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 received appropriate treatment to prevent Urinary Tract Infections (UTI's) for one (1) of eight (8) sampled residents (Resident #1). Resident #1 was noted to experience signs and symptoms of a UTI which included increased confusion, dark amber colored urine, and an increased temperature from 07/09/12 through 07/20/12 and documentation revealed the Physician was notified. However, there was no documented evidence the Physician responded with orders to further evaluate these signs and symptoms except for a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) on 07/10/12. Resident #1 presented to the emergency room (ER) on 07/20/12 with [DIAGNOSES REDACTED]. The resident was admitted to the hospital, a Peripherally Inserted Central Catheter (PICC) was placed, and Resident #1 received Intravenous (IV) antibiotics related to the UTI. The resident was readmitted to the facility on [DATE] and continued to receive IV antibiotics. The findings include: Review of the facility's policy and procedure entitled, "Urinary Tract Infection", undated, revealed to decrease the risk of Urinary Tract Infections (UTI's), observe for fever and/or chills, Dysuria (painful urination), Urinary frequency and/ or urgency, flank or supra pubic pain or tenderness, change in character of urine (visual or smell), change in mental status; including new or worse incontinence, and increase in confusion. Review of Resident #1's clinical record revealed the facility admitted the resident on 02/13/10 with [DIAGNOSES REDACTED]. The end of the ileum is brought out through an opening in the abdominal wall to drain the urine gathered in the reservoir. This opening is called a stoma. The patient wears a bag over the stoma to collect the urine. The bag adheres to the body, over the stoma using an adhesive disk). Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 03/07/12, and Quarterly MDS Assessment, dated 05/23/12 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicating the resident was cognitively intact. Review of the Comprehensive Plan of Care, dated 05/24/12, revealed the resident had an alteration in urinary elimination related to a [MEDICATION NAME]/ileal conduit with a goal that no complication related to the [MEDICATION NAME] would go undetected. The interventions included observing for signs and symptoms of a UTI such as foul smelling urine, dark colored urine, sediment in urine, complaints of back or flank pain, elevated temperature, and notify physician if observed, and medications and labs per order. Review of the Nurse's Notes, dated 07/9/12 at 1:35 PM, revealed the resident complained of right side pain, had amber colored urine in the catheter bag, and vital signs were Temperature (T)- 98.5, Pulse (P) 70, Respirations (R) -22 Blood Pressure (B/P)-102/82. The Physician was called and a message was left. Review of the Condition Change Form, dated 07/10/12, with no time noted, revealed the resident was observed several times twisting the catheter tubing, appeared confused, and the Physician was notified of the confusion and dark urine which was amber colored, and a new order was received. Review of the physician's orders [REDACTED]. Interview with the Unit Manager who completed the Nurse's Notes, dated 07/09/10, revealed the resident started showing increased confusion on 07/09/12 and twisting the [MEDICATION NAME] which was out of character for her/him and she had specifically asked the aides to keep a closer eye on her/him. She stated, at the time she obtained the lab order, the attending Physician told her he did not want to order a urinalysis because the resident had a [MEDICATION NAME] which would always show bacteria. Continued interview revealed when this resident was treated for [REDACTED]. Review of the laboratory data drawn on 07/10/12, revealed the Complete blood Count (CBC) indicated the White Blood Cells (WBC) was high at 11.7 (reference range- 4.5-10.5) and the Basic Metabolic Panel (BMP) indicated all normal levels. Review of the Nurse's Notes, dated 07/13/12 at 8:30 PM, revealed the resident was having increased confusion, had bothered the ostomy supplies and was unable to do ostomy care. Further review revealed the resident threw away a box of supplies stating it made her/him sick. Review of the Nurse's Notes, dated 07/13/12 at 10:15 PM, revealed the nurse was called to the resident's room per the State Registered Nursing Assistant (SRNA), and two (2) SRNAs were turning the resident to change linens and saw a bed pan under Resident #1. Further review revealed the resident showed increased confusion, was totally unaware she/he was on the bed pan, and the resident's bottom and thighs had multiple skin problems. The Note stated, at 10:55 PM, the attending Physician was paged, and at 11:00 PM the attending Physician called the facility and was informed of the resident's increased confusion, routine of putting self on bedpan and ringing for assistance, resident being unaware she/he was on the bed pan, and when staff changed linens related to her/him bothering the ostomy, the resident was found on the bedpan, and her/his skin was in poor condition with bruising, redness and blisters. Further review revealed the attending Physician informed the nurse that the Unit Manager had called him earlier this week and labs were done. Interview, on 07/28/12 at 5:30 PM, with LPN #3, who wrote the Note, dated 07/13/12 at 10:15 PM, revealed the resident was never as confused as she/he was on 07/14/12 when the bed pan was found under her/him. Continued interview revealed she called the attending Physician and impressed upon him about the resident's confusion and how the resident liked to do everything herself/himself and how it was not like the resident to leave the bedpan under herself/himself. Further interview revealed she felt the Physician should have come to the facility to see the resident related to the wound and the confusion and stated she expressed her concerns to the Physician; however, no orders were obtained. She further stated she told the oncoming nurse, Registered Nurse (RN) #1 she felt the resident could be getting septic. Review of the Nurse's Notes, dated 07/14/12 at 3:50 AM, revealed the resident had a temperature of 100.5 and received Tylenol 500 milligrams (mg's) for the increased temperature. Interview, on 07/28/12 at 6:25 PM, with RN #1 who completed the Note, dated 07/14/12 at 3:50 AM, revealed the attending Physician was notified several times prior to 07/13/12 related to the resident possibly having a UTI. She stated she felt the Physician should have prescribed something for the resident or referred the resident to her/his urologist and she was concerned the resident could be getting septic as was the concern of all the nursing staff. (In a signed Affidavit dated 07/30/12, by RN #1, she stated her statement regarding her concern for Resident #1 becoming septic was not an individualized statement concerning Resident #1 but a general statement that any elderly person with these particular symptoms could become septic and had she felt Resident #1 was septic and needed more care, she would have notified the Director of Nursing.) Review of the Nurse's Notes, dated 07/14/12 at 6:30 AM, revealed the resident was alert and verbal, and her/his urine was dark amber in color. An entry, dated 07/14/12 at 8:00 AM, revealed the resident was alert and oriented, conveyed needs, and temperature was 100.5. Review of the Nurse's Note, dated 7/14/12 at 10:00 AM, revealed the attending Physician was notified of a temperature of 100.5 this AM and 99.5 at this time, the resident's lungs were clear to auscultation, and the resident was in no respiratory distress. Further review, revealed at 2:30 PM the attending Physician returned the call and was aware of the resident's confusion at times, temperature of 100.5 this AM, with no new orders. Review of the Nurse's Note, dated 07/14/12 at 9:40 PM, revealed a temperature at 4:00 PM of 100.9 and 102.2 axillary (AX) at 6:30 PM. Tylenol was administered. Further review revealed the resident's temperature at 8:30 PM was 100.5 AX. Interview, on 07/31/12 at 4:55 PM, with RN #2, who wrote the entry 07/14/12 at 9:40 PM, revealed she was aware the resident was having an increased temperature and increased confusion. She stated she would have anticipated the Physician would have ordered an urinalysis; however, she did not bring this to the Physician's attention and administered Tylenol for the fever. Review of the Nurse's Note, dated 07/16/12 at 9:25 AM, revealed the resident was refusing to feed self and when staff attempted to help resident with breakfast she/he refused and stated she/he would not be spoon fed. Review of the Condition Change Form, dated 07/16/12, revealed the physician was updated related to the resident's buttocks surrounding tissue, the resident not eating, and the resident refusing staff to feed her/him. Review of the Nurse's Notes, dated 07/16/12 at 9:00 PM, revealed the resident refused to let staff give a bath this PM, stated would take in AM due to being exhausted, required a lot of encouragement to take medications, fluids were encouraged, and dark amber urine was noted in the bag and tubing. Review of the Nurse's Note, dated 7/18/12 at 8:00 AM, revealed the attending Physician was there to examine the area around the resident's buttocks, and the Physician was aware of the reported temperature of 101.8 last night, difficulty taking medications and periods of increased confusion at times. The Note stated, the Physician wanted to wait on treatment for [REDACTED]. The next entry, dated 07/18/12 at 4:45 PM, revealed the nurse spoke with the attending Physician's office, vital signs were reported and no new orders were received. Review of the Nurse's Notes, dated 07/18/12 at 9:00 PM, revealed the resident continued to have some increased confusion and required a lot of encouragement to take medications. An entry, dated 07/18/12 at 10:10 PM, revealed the resident's temperature was 99.5, Tylenol was given, and the urine in the catheter bag was dark amber color with a foul odor. Review of the Nurse's Notes, dated 07/19/12 at 8:20 AM, revealed a temperature of 100.0, the resident was awake with confusion and angry with conversation, staff attempted to feed, resident would not eat, attempted to have resident on bed pan with no results at this time. An addendum, at 9:50 AM, revealed the resident had been on the bed pan several times and no bowel movement was noted. The Note stated, the attending Physician was paged related to temperature and intermittent confusion. Review of the Condition Change Form, dated 07/19/12, revealed a temperature of 100.0 and a fleets enema was given per physician's orders [REDACTED]. Review of the Nurse's Notes, dated 07/20/12 at 7:25 AM, revealed the resident's urine was tea colored, the resident was alert and would answer questions, was slightly lethargic with conversation, and the attending Physician was paged. The Condition Change Form, dated 07/20/12 at 7:30 AM, revealed the resident's vital signs were; B/P -136/74, P-100,R-24, T-101.8, and the resident's urine was tea colored. According to the Form, the attending Physician was notified of the resident being diaphoretic, and new orders were received to send the resident to the emergency room for evaluation. Further interview, on 07/30/12 at 6:40 PM, with the Unit Manager, revealed she had written the Note, dated 07/20/12 at 7:25 AM, and had called the Physician and informed him of the resident's increased temperature. She stated Resident #1 was diaphoretic with beads of sweat on her/his nose. She stated, the Physician "could hear it in my voice", she/he needed to go out. Interview, on 07/29/12 at 2:30 PM and 07/30/12 at 5:30 PM, with the Director of Nursing (DON), revealed the nurses were to call the Physician if there was a concern and it was up to the Physician to respond with orders. She stated she went unit to unit and received verbal report from the nurses as well as read the shift report and reviewed new physician's orders [REDACTED]. She stated there was a morning meeting held Monday through Friday where changes in residents' conditions were discussed and she remembered discussing this resident regarding the pressure sore related to the bedpan, the low grade temperature, and the increased confusion. When asked if she felt the attending Physician responded effectively during the ten (10) day period from 07/09/12 through 07/20/12 when the resident was having increased temperature, increased confusion, and discolored urine, she stated it was the Physician's recourse to write physician's orders [REDACTED]. Interview, on 07/31/12 at 11:10 AM, with the attending Physician, revealed he felt the nurses kept him informed of the resident's condition and he was the on-call Physician consistently from 07/09/12 through 07/20/12. He stated he had ordered labs for a CBC and a BMP to check for infection on 07/10/12 and the white blood cells were only slightly elevated and the electrolytes were normal. He further stated a urine specimen from an ileal conduit would not give accurate information because bacteria already had access to the ileal conduit; however, he would have ordered a urine if the resident's white blood cells had been elevated. Per interview, it would be feasible to obtain a urine specimen on a resident with an ileal conduit if the resident showed signs and symptoms [MEDICAL CONDITION] which would include fever and confusion. Continued interview revealed he was aware Resident #1 was having dark urine, fever, and confusion which continued after the labs were drawn; however, the symptoms were intermittent. He further stated, if he had seen a persistent temperature of 101 for forty-eight (48) hours he would consider the resident may have an infection. He stated if there was evidence of persistent fever, and confusion or an increase in white blood cells, or an electrolyte abnormality, he would treat for a UTI. Further interview revealed he was careful in prescribing antibiotics for a resident with an ilial conduit because of multi-drug resistant organisms. When questioned about the Nurse's Note written on 07/18/12 regarding a possible evaluation at the emergency room , he stated the resident was having difficulty taking medications, was having fever, and confusion and he had checked the resident that day and asked staff to contact him later in the day with an update on the resident's condition. He stated later in the day the resident was afebrile. However, he stated he gave orders to send to the emergency roiagnom on [DATE] due to a clinical status change with the resident having diaphoresis and [MEDICAL CONDITION] Continued interview revealed the resident's [DIAGNOSES REDACTED]. Interview, on 07/31/12 at 12:00 PM, with the Medical Director revealed a resident with an ileal conduit would always show organisms in the urine. He stated the resident was showing signs and symptoms of a UTI from 07/09/12 through 07/20/12 and some Physicians would have treated the resident earlier. Further interview revealed his criteria to treat would be a mild temperature elevation and an elevation of white blood cells of 10,000 to 10,200; however, he generally treated his resident's early for signs and symptoms of a UTI. He further stated, some Physicians were more conservative related to controversy over starting antibiotics when not needed due to multi-resistant drug organisms. In a follow up interview, on 08/01/12 at 4:45 PM, with the Medical Director, he stated he had reviewed current literature which indicated dark and malodorous urine was not indicative of a UTI just as clear urine did not indicate there was an absence of infection. He further stated bacteria in the urine would clear itself four (4) out of five (5) times and if treated when not necessary, could lead to a resistive infection. He further stated the criteria needed to treat a UTI would be a positive urine culture or signs of being septic or near septic, or a white blood count of 15,000 or more. Continued interview revealed with an ileal conduit, a urologist would need to obtain a specimen from the ureter for it to be an accurate specimen. However, record review revealed no documented evidence the urologist was contacted from 07/09/12 through 07/20/12. Review of the Hospital Discharge Summary, dated 07/23/12, revealed the resident was admitted to the hospital on [DATE] with a history of fever, lassitude, and somnolence for a week and also with altered mental status by way of confusion. Upon evaluation , the patient was noted to have a significant white blood count of 27,000 and a Urinary Tract Infection as the source. The hospital course included [MEDICATION NAME] (antibiotic therapy), PICC line placement and continued antibiotic therapy. The Summary stated, the patient presented with [MEDICAL CONDITION] or Dementia that was undoubtedly due to the infection and had resolved and the patient was back to baseline. The discharge [DIAGNOSES REDACTED]. Further review revealed the resident was to continue on intravenous antibiotic therapy for twelve (12) more days. Interview, on 07/29/12 at 12:30 PM, with the Attending Physician at the hospital, revealed the resident presented to the emergency room with fever, altered mental status and a UTI. She stated patients who showed symptoms of a UTI such as fever, dark urine and confusion needed to be treated and it was common for patients with a UTI to get [MEDICAL CONDITION].

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents did not develop Pressure Sores unless it was clinically unavoidable for one (1) of eight (8) sampled residents (Resident #1). The facility failed to have an effective system to ensure policy and procedures were implemented related to skin care management and to ensure treatment was provided. Resident #1 was assessed by the facility to be at risk for pressure sore development and to require limited assistance with toileting. The resident was care planned to put self on the bed pan, with staff to remove and empty. Record review revealed Resident #1 was noted to have increased confusion and a loss or decreased sensation related to his/her [DIAGNOSES REDACTED]. On 07/13/12, Resident #1 was found on the bedpan and had been sitting on it for an unknown amount of time. The resident was assessed to have long markings from the bedpan on both buttocks, with fluid filled blisters. There was no documented evidence facility staff accurately measured or staged the Pressure Sores as per the facility's policy or obtained treatment orders for the wound. On 07/20/12, Resident #1 was transferred to the hospital emergency room for an unrelated illness and assessed to have a "large pressure ulcer to the buttock; blistering noted"....and "pressure necrosis" on his/her sacrum and posterior thighs. The resident was readmitted to the facility on [DATE]. The findings include: Review of the facility's policy entitled "Skin Care Management (Pressure Sores)", undated revealed "on each shift, examine residents prone to decubitus for development of redness, discoloration, or blisters over pressure areas that include...sacrum and coccyx". Under the "treatment protocols & identification of stages" section of this policy it described partial thickness skin loss involving the epidermis, dermis or both as a Stage II Pressure Sore. Further review revealed a Stage II was superficial and presented clinically as an abrasion, blister or shallow crater. Review of the facility's policy entitled "Wound Care Policy and Procedure", undated, revealed if a Pressure Ulcer occurred documentation was to include the exact location of the wound, the size of the wound (length times width times depth), and a description of the wound surface. Review of Resident #1's clinical record revealed the facility admitted Resident #1 02/13/10 with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 03/07/12 and Quarterly MDS Assessment, dated 05/23/12, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) on both Assessments indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident required limited assistance of one (1) person for toileting and was at risk for Pressure Sores. Review of the Comprehensive Care Plan, dated 03/13/12 revealed a Plan of Care that addressed Resident #1's potential for pressure ulcer development. Interventions included the application of lotion one (1) to two (2) times daily by State Registered Nursing Assistants (SRNAs). Additionally, staff was to observe the resident's skin every shift for signs of skin breakdown (such as redness/discoloration or open areas). SRNA's were to inform nurses if any signs were observed. The nurse was to notify the Physician as needed for treatment orders. Further review of the Comprehensive Care Plan revealed an Activities of Daily Living (ADL) Function Care Plan that had an intervention stating the resident puts self on bedpan, staff was to remove and empty. In addition, there was an intervention that stated when the resident's MS flared up he/she may require extra assist with ADLs. Review of the Nurse's Note, dated 07/10/12 through 07/13/12, revealed the resident was experiencing increasing confusion. On 07/13/12 at 10:15 PM a Nurse documented a bedpan was found under the resident which he/she was "totally" unaware was under him/her. The Nurse indicated this was related to Resident #1's increased confusion. According to the Nurse's documentation the resident's buttocks and thighs had "multiple skin problems". The Nurse described Resident #1 to have an open area on the left inner buttock; redness, bruising, and fluid filled blisters were observed. The Nurse documented there was a "long" marking from the bedpan on both buttocks. Review revealed the Nurse estimated the right buttock marking to be approximately ten (10) inches long, with an area approximately three (3) inches wide, with fluid filled blisters. Further review the Note revealed there was a large fluid filled blister near the perineal area that the Nurse estimated to be approximately five (5) centimeters in circumference. There was no documented evidence the Nurse staged the wounds, measured the open area on the left inner buttock, or accurately measured the other areas described by this Nurse. The Nurse documented she notified the attending Physician at 10:55 PM and the Physician returned her call at 11:00 PM. According to the Nurse's documentation, the Physician wanted the bedpan removed from the resident's bedside and ordered the Nurse to bring the wound to the "skin nurse's" attention on 07/14/12. Interview, on 07/28/12 at 5:15 to 5:30 PM, with Licensed Practical Nurse (LPN) #3 (the Nurse who first observed the wound on 7/13/12) revealed Resident #1 was never confused like he/she was that night. The LPN stated she wanted to cry when she first saw the wound. She stated she notified the resident's Physician of the wound on 07/13/12. She stated she "impressed" upon the Physician "how bad the wound was". LPN #3 stated the wound looked like the "prints" of the bedpan. The LPN described the wound as brown, blue, purple, with open areas and blisters. She stated there was a "softball" size blister on Resident #1's perineal area. The LPN stated she didn't know what to do, she felt the Physician should have come to assess the wound. She stated she called the facility's Wound Care Nurse and left a message informing him of the wound. Interview, on 07/26/12 at 10:15 AM, with Resident #1 revealed he/she had put his/herself on the bedpan and "forgot" he/she was on it. Per interview, the resident had less sensitivity related to his/her [DIAGNOSES REDACTED]. Review of the Weekly Ulcer Assessment form, dated 07/14/12, revealed it was completed by the Wound Care Nurse. Review of this form revealed the Wound Care Nurse documented the resident had a "1.0 ring around buttock" and a "1.0 wide blister". Continued review of the form revealed no documented evidence the Wound Care Nurse staged the wound, measured the entire wound area, or accurately documented a description of the wound area. Under the "Treatment" section of the form the Wound Care Nurse documented "skin repair cream". Review of the Condition Change Form, dated 07/14/12 and completed by the Wound Care Nurse, revealed the resident was noted to have been sitting on a bedpan and had a large ring which had formed that presented with blistering and discoloration. "Pressure relief" and skin repair cream were applied along with a low air loss mattress. However, review of the monthly physician's orders [REDACTED]. Interview, on 07/27/12 at 11:00 AM, with the facility's Wound Care Nurse revealed he was contacted by the Nurse to assess Resident #1's buttock area. He stated he observed the wound on 07/14/12. According to the Wound Care Nurse the wound was a large red blistered ring around the whole buttock area, approximately 1.5 centimeters (cm) wide. He stated he informed staff to use the skin repair cream to keep the area moisturized and to change the resident's mattress to a low air loss mattress. Additionally, the Wound Care Nurse stated he informed staff to turn Resident #1 at least every two (2) hours. When questioned on how long a person would have to be on a bedpan to cause a wound such as this, the Wound Care Nurse stated it would "probably take two (2) to three (3) hours". The Wound Care Nurse stated he was notified on 07/18/12 the Physician had discontinued the skin repair cream and ordered the wound left "open to air". Although there was a PRN order dated 11/24/11 for skin barrier cream to Resident's buttocks, there was no documented evidence the Wound Care Nurse obtained an order specific to this wound. Additionally, review of the physician's orders [REDACTED]. Further review revealed a Weekly Ulcer Assessment form, dated 07/18/12, completed by the Wound Care Nurse. Review of this form revealed the Wound Care Nurse documented the wound to be a "ring" approximately one and a half (1.5) centimeters (cm) "around complete buttocks". The Wound Care Nurse staged the wound as a Stage II Pressure Ulcer with no documented evidence of the length, width, or depth of the Pressure Ulcer. Under the "Treatment" section of the form, the Wound Care Nurse documented to continue "pressure relief" along with "keeping clean & dry". The Wound Care Nurse further documented blistering had stopped, skin was sloughing, and granulating tissue was present. Further review of the physician's orders [REDACTED]. Review of the hospital record revealed Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital ER Physician's record revealed Resident #1 had a "large pressure ulcer to the buttock; blistering noted". Review of the admission History and Physical revealed the resident had "pressure necrosis" on his/her sacrum and posterior thighs. Further review of the History and Physical revealed "there is an obvious imprint of a bedpan on the right caudal margin. It is not quite full thickness. The remainder is more superficial". Review of the hospital's Wound Care Nurse assessment, dated 07/20/12 and timed 11:30 AM, revealed Resident #1 had "ring abrasions with pressure necrotic tissue. Also noted to have pressure ulcer Stage II with further deep tissue injury". The hospital Wound Care Nurse further documented there was an area to the right sacrum with a small amount of clear to yellow drainage; "left buttock/thigh with abrasion area, closed @ (at) present. Purple discoloration to coccyx, suspect deep tissue injury". Interview, on 07/25/12 at 10:50 AM, with the hospital Wound Care Nurse revealed she was contacted by the emergency room (ER) Nurse to assess the wound and take pictures. She stated Resident #1 had a "discolored ring" around his/her buttock area. The hospital Wound Care Nurse stated the skin breakdown on the right buttock was greater than the left buttock; it was a Stage II Pressure Ulcer. According to this Nurse, the coccyx area was "really bad, with suspected deep tissue injury". Resident #1 was readmitted to the facility on [DATE] with treatment orders to cleanse the open areas to bilateral buttocks with Normal Saline, apply Santyl (a [MEDICATION NAME] agent) ointment to areas, cover with folded 4x4 dressing, then cover with [MEDICATION NAME] (transparent film dressing), change twice a day. Observation, on 07/31/12 at 10:00 AM, of a skin assessment performed by the Wound Care Nurse on Resident #1 revealed the first wound on the resident's left buttock was an open area which measured nineteen (19) centimeters (cm) in length by 0.8 cm in width, and the second wound on the left buttock was an open area which measured two (2) cm in length by one (1) cm in width. Continued observation of the skin assessment revealed a necrotic area on Resident #1's right buttock which measured six and a half (6.5) cm in length by two and a half (2.5) cm in width. Further observation revealed immediately adjacent to the necrotic area was an open area which measured three (3) cm in length by one (1) cm in width. An additional interview, on 07/31/12 at 1:30 PM, with the facility's Wound Care Nurse revealed he was not certified in wound care. According to the Wound Care Nurse he used a book he had received at a seminar as his resource for wound care. He stated his description on 07/14/12 of Resident #1's wound should have been more in depth. The Wound Care Nurse stated he wanted the skin repair cream treatment to be performed at least once a day, however it wasn't put on the Treatment Administration Record (TAR) like this and therefore was ineffective. Interview, on 08/01/12 at 5:30 PM, with the Director of Nursing (DON) revealed some of the nurses were trained to measure and stage wounds; however, the facility was accustomed to the Wound Care Nurse to perform the majority of the wound assessments. In addition, the DON stated the Wound Care Nurse should have staged and measured the wound on 07/14/12. Interview, on 07/31/12 at 11:10 AM, with Resident #1's attending Physician revealed he was contacted by the Nurse who found the wound. The Physician stated he did not recall the Nurse informing him of the stage of the wound. He stated he was contacted the next morning (07/14/12) by the Unit Manager regarding the wound found on 07/13/12. The Physician stated the Unit Manager gave a "proposed" treatment plan and he agreed with it. He stated the facility had a "wound care team" and he trusted them and their recommendations. The Physician stated he observed the wound on 07/18/12. According to the Physician, the wound was "horseshoe" shaped on the resident's buttocks, like an "inverted U". He indicated the wound was the shape of a bedpan. The Physician stated the facility was already pursuing wound care and he was going to have staff continue what they were doing for the wound. He stated he did not give new orders for treatment of [REDACTED]. Interview, on 08/01/12 at 3:15 PM, with the Unit Manager of Unit 1 (where Resident #1 resided) revealed she notified the Physician of the resident's wound and about the Wound Care Nurse's recommendation for skin repair cream. According to the Unit Manager, the Physician agreed with the recommendation. When questioned why it wasn't written as an order, she stated the Wound Care Nurse usually obtained the orders for wound treatments. Interview, on 07/31/12 at 12:00 PM, with the facility's Medical Director revealed a loss of sensation would be expected with a [DIAGNOSES REDACTED]. He stated it was not safe for Resident #1 to have a bedpan within reach. The Medical Director stated "we know that now".

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the Comprehensive Care Plan was revised for one (1) of eight (8) sampled residents (Resident #1). Resident #1 was care planned to put self on the bed pan, with staff to remove and empty. Record review revealed Resident #1 was having increased confusion and had decreased sensation due to the [MEDICAL CONDITION]. The facility failed to revise the Comprehensive Care Plan to include this information and the resident was allowed to continue to use his/her bedpan independently. On 07/13/12, Resident #1 was found on the bedpan and had been sitting on it for an unknown amount of time. The resident had put the bedpan under himself/herself and "forgot" it was there. The resident was assessed to have long markings from the bedpan on both buttocks, with fluid filled blisters. On 07/20/12, Resident #1 was transferred to the hospital emergency room for an unrelated illness and assessed to have a "large pressure ulcer to the buttock; blistering noted"....and "pressure necrosis" on his/her sacrum and posterior thighs. The resident was readmitted to the facility on [DATE]. (Refer to F314) The findings include: Review of the facility's policy entitled, "Care Management", undated revealed "Coordination of the plan of care is the responsibility of nursing; however, planning, implementation, and evaluation require joint participation by each discipline rendering service...the plan of care is reviewed and revised to reflect current needs of the resident...". Review of Resident #1's clinical record revealed the facility admitted the resident on 02/13/10 with [DIAGNOSES REDACTED].) on both MDSs indicating the resident's cognitive status was oriented. Further review revealed the facility assessed the resident to require limited assistance of one (1) person for toilet use. Review of the Comprehensive Care Plan, dated 03/13/12, revealed a Plan of Care that addressed Resident #1's potential for pressure ulcer development. Interventions included: apply lotion to skin one (1) to two (2) times daily; observe skin every shift with care for signs and symptoms of potential breakdown (e.g. redness/discoloration or open areas); keep skin clean/dry and bed linens clean, dry, and wrinkle free every shift. Review of the Activities of Daily Living (ADL) Function Care Plan revealed the resident put his/herself on the bedpan and staff were to remove it. Interventions included: continues to require assist with ADLs; assist with turning and repositioning as needed; when MS flares up may require extra assist with ADLs. Review of the Nurse's Note revealed Resident #1 had been having increased confusion from 07/10/12 through 07/13/12. Review of the Nurse's Note, dated 07/13/12 at 10:15 PM, revealed Resident #1 was found on a bedpan and was not aware he/she was sitting on it related to the increased confusion. The Nurse documented the resident had numerous skin problems related to this. Continued review of the Note revealed the resident to have an open area on the left inner buttock, redness, bruising, and fluid filled blisters, and a "long" marking present on his/her buttocks. Further review of the Note revealed there was a large fluid filled blister near the perineal area that the Nurse estimated to be approximately five (5) centimeters in circumference. Interview, on 07/28/12 at 5:15 to 5:30 PM, with Licensed Practical Nurse (LPN) #3 (the Nurse who first observed the wound on 7/13/12) revealed the resident had never been as confused as he/she was on 07/13/12. Interview, on 07/30/12 at 6:40 PM with Unit Manager revealed Resident #1 had started having increased confusion on 07/09/12. Interview, on 07/29/12 at 12:25 PM, with State Registered Nursing Assistant (SRNA) #4 revealed Resident #1 did not get his/her bedbath on 07/10/12 as he/she refused. SRNA #4 stated the resident attempted to do his/her own bedbath "but was confused". Interview, on 07/28/12 at 5:15 PM, with LPN #2 revealed Resident #1 was confused on 07/11/12 and 07/12/12. Interview, on 07/26/12 at 12:05 PM, with Kentucky Medication Aide (KMA) #1 revealed she was in Resident #1's room twice on 07/12/12. KMA #1 stated the resident was coherent but she noticed a change in his/her mental status. Interview, on 07/31/12 at 4:55 PM, with Registered Nurse (RN) #2 revealed that prior to 07/13/12 she was aware Resident #1 was experiencing confusion. Interview, on 07/26/12 at 10:15 AM, with Resident #1 revealed due to his/her [DIAGNOSES REDACTED]. He/She stated on 07/13/12 he/she had put the bedpan under himself/herself and "forgot" it was there. Resident #1 stated he/she could not feel the bedpan and that's why he/she forgot about it. Interview, on 08/01/12 at 3:50 PM with the Minimum Data Set (MDS) Coordinator revealed nurses on the floor could update the care plans, as well as, she and her assistant. She stated there was no care plan specific to loss of sensation due to the resident's [DIAGNOSES REDACTED]. to make that choice; however, she was unsure if the risks versus benefits had been explained to Resident #1 and stated the interventions related to decreased/loss of sensation should have been added to the Care Plan. Interview, on 08/01/12 at 5:20 PM with the Director of Nursing (DON) revealed Resident #1 was capable of making his/her own decisions related to using the bedpan. She stated the facility had not discussed the risks versus benefits of allowing the resident to use the bedpan on his/her own. Interview, on 07/31/12 at 12:00 PM, with the Medical Director revealed in residents with a [DIAGNOSES REDACTED]. The Medical Director revealed it was not safe for Resident #1 to have a bedpan within reach. The Medical Director stated "we know that now". Further review of the Comprehensive Care Plan revealed no documented evidence the facility revised the Care Plan to reflect Resident #1's increasing confusion, decreased/loss of sensation related to his/her [DIAGNOSES REDACTED].

Based on observation, interview, record review and review of the facility's policy, it was determined the facility's Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, or psychosocial well-being of each resident. The facility failed to have an effective system in place to ensure programs, policies and procedures were implemented. The facility's Administration failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in order to prevent the development and transmission of disease and infection as evidenced by failure to ensure the disinfectant used for the whirlpool tubs was effective against [MEDICATION NAME] Resistant [MEDICATION NAME] ((VRE)- specific species of bacteria which are known to be resistant to [MEDICATION NAME], an antibiotic used to treat infections). The facility's Administration failed to ensure a disinfectant effective against VRE was obtained after receiving information, on 05/11/12, that the current product in use had not been tested against VRE. The facility also failed to ensure Contact Precautions were followed. (Refer to F-441) Based on the above findings it was determined the facility's failure to have an effective administration is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/15/12 and was determined to exist on 05/02/12. An acceptable credible Allegation of Compliance (AoC) was received on 05/18/12 with the facility alleging removal of the Immediate Jeopardy on 05/18/12. The Immediate Jeopardy was verified to be removed on 05/18/12 as alleged, prior to exit with remaining non-compliance at scope and severity of an "E", while the facility develops, implements, and monitors a Plan of Correction to prevent recurrence. The findings include: Review of the facility's Infection Control policy revealed staff was to use a product entitled Cen-Kleen for use in the cleaning and disinfecting of the whirlpool tubs. Record review revealed Resident #2 was diagnosed with [REDACTED]. This resident was noted to receive a whirlpool tub bath on 05/02/12 and 05/09/12. Interview revealed thirty-seven (37) residents utilized the same whirlpool tub bath as Resident #2. Observation revealed a product entitled Simply Solutions was in place for use in disinfecting the whirlpools. However, review of this product's label revealed no documented evidence it was effective against VRE. Interview with the manufacturer revealed the product had never been tested against VRE and the facility's Administration was notified on 05/11/12. Interview with the Director of Nursing (DON) and Infection Control (IC) Nurse revealed they were not aware the Simply Solutions product had not been tested against VRE. Further observation of the whirlpool tub rooms, on 05/14/12, revealed Simple Solutions was still being used to disinfect the whirlpool bathtubs, even though Administration was informed on 05/11/12 this product was no effective against VRE. Interview, on 05/11/12 at 4:34 PM, with the facility's Administrator revealed she had entrusted her supplier to ensure the facility had a disinfectant for the whirlpool tubs that would "kill everything". The surveyor informed her of what the manufacturer had reported in the interview on 05/11/12 at 11:45 AM that day, which was the product had not been tested against VRE. She stated that was "disturbing" as she was not aware the Simply Solutions had never been tested against VRE. Further interview with the Administrator, on 05/18/12 at 5:00 PM, revealed she had relied on the whirlpool supplier to send the facility a product that would "kill" all organisms and he (the supplier) had indicated the Simply Solutions would. The Administrator stated the Housekeeping Supervisor and Supply Clerk were responsible for monitoring the products used to ensure they were effective and the Housekeeping Supervisor oversees all the facility's supplies. She stated the facility had policies in place and she relied on the Department Heads to follow the policies. The Administrator indicated the Quality Assurance Committee was responsible for updating policies. Interview, on 05/18/12 at 4:38 PM, with the Quality Assurance Director revealed the Administrator was part of the Quality Assurance Committee. Continued interview with the Administrator, on 05/18/12 at 5:00 PM, revealed when asked when the infection control policy had last been updated, she stated she did not know. Interview with the Housekeeping Supervisor revealed even though the facility's policy stated Cen-Kleen was to be used to disinfect the whirlpool tubs, this product had not been in use since 2001. Further interview, on 05/18/12 at 5:00 PM, with the Administrator revealed she did not know when the Cen-Kleen use had been discontinued and the Simply Solutions initiated. Review of the facility's AoC revealed the following: 1. The Infection Control (IC) Nurse was consulted to review the situation and determine actions necessary and performed culturing on the whirlpool tubs on 05/14/12. The results are pending. 2. The disinfectant was changed to a disinfectant tested to be effective to destroy VRE on 05/15/12. 3. The use of whirlpool bathtubs was permanently discontinued on 05/16/12. 4. All disinfectants and cleaning supplies used in the facility were reviewed by the Housekeeping Supervisor to assure they were effective to destroy VRE on 05/16/12. 5. Vendors were notified in writing that the facility would not purchase any cleaning supplies that were not tested to be effective to destroy VRE on 05/16/12. 6. As of 05/16/12, all residents using the whirlpool baths during the same time as Resident #2 were identified. 7. The facility's Medical Director was consulted on actions that should be taken as a result of the whirlpool situation. 8. With the Medical Director's input and approval, a tool was developed for nursing staff to use in assessing residents for signs and symptoms of VRE infection. 9. As of 05/16/12, the residents who were identified to have used the whirlpool bath during the time as Resident #2 used the bath, were individually assessed to determine whether any resident had signs or symptoms of VRE. 10. For residents identified to have wounds or open areas that had used the whirlpool since 04/29/12, a culture was taken and sent to be tested for VRE on 05/16/12 with the results pending. 11. The IC Nurse and Medical Director reviewed the facility Infection Control policy to assure it specifically included information about VRE, and made changes where necessary on 05/16/12. 12. Changes were made to the Infection Control policy to assign the IC Nurse the duty of reviewing all new resident prescriptions for antibiotics, as well as, new reports of resident wounds on a daily basis. The IC Nurse shall determine whether any reports of new bacteria or infections warrant an immediate change in disinfectants and cleaning supplies. The IC Nurse shall report any changes that need to be made to the Administrator. The IC Nurse shall also report new types of infections/bacteria and resident wounds to the Quality Control Committee. This procedure was added to the facility's Infection Control policy on 05/16/12. 13. An inservice training on infection control practices and VRE was conducted, by the IC Nurse, with special focus on use of disinfectants, proper cleaning techniques, and a review of proper infection control procedures for all members of the Housekeeping staff on 05/16/12. 14. The attending Physician for Resident #2 ordered tests to determine if the resident still had the VRE infection on 05/16/12, with the results pending. 15. An inservice training for all staff on the Infection Control policy and Contact Precautions, as well as VRE specifically, was conducted by the IC Nurse which included training about the signs and symptoms of VRE infection, as well as proper infection control procedures and techniques, with the facility-wide inservice completed by 05/17/12. Inservice for staff absent on this date was conducted via telephone and inservice for employees on leave will be conducted before they return to work. 16. Infection Control procedures and Contact Precautions were reviewed with the staff caring for Resident #2, who had the VRE infection, to assure the proper procedures were being followed to prevent the spread of the infection by 05/18/12. 17. The Quality Assurance Committee will review the IC Nurse's reports of new infections/bacteria, as well as, wounds and changes in disinfectant and cleaning supplies on a quarterly basis. The surveyors validated the corrective action taken by the facility, prior to exit on 05/18/12, as follows: *Observation on 05/18/12 of the whirlpool tub rooms revealed no evidence of the Simply Solutions. Further observation revealed a product entitled, "Dispatch" which according to the label was effective against VRE. *Interview, on 05/18/12 at 5:47 PM, with the Infection Control (IC) Nurse revealed she had helped prepare staff inservices, and assisted with the inservicing of staff on the infection control issues. *Observation, on 05/18/12, revealed the whirlpool tubs were no longer in use and had been disabled. *Interview, on 05/18/12 at 5:16 PM, with the Housekeeping Supervisor revealed on 05/15/12, she had reviewed all the facility cleaning/disinfectant products to ensure they were effective against VRE. Review of the literature provided indicated the products were effective against VRE. *Review of the letters sent to all the facility vendors/suppliers revealed they were dated 05/16/12. Interview, on 05/18/12 at 5:13 PM, with the Administrator revealed all facility vendors/suppliers had been notified via the letters that the facility would not purchase any cleaning supplies that were not tested to be effective to destroy VRE on 05/16/12. *Interview, on 05/18/12 at 5:47 PM, with the IC Nurse revealed all residents who had used the whirlpool tub, during the same time as Resident #2 were identified and assessed for signs and symptoms of VRE and this was verified through record review. Cultures were performed on residents with wounds, suprapubic catheter, residents with [DEVICE]s (feeding tube), and residents on antibiotics which was verified through record review, with results pending. In addition, the IC Nurse stated all the whirlpool tubs were cultured on 05/14/12 and 05/16/12. *Interview, on 05/18/12 at 3:30 PM, with the Medical Director revealed the facility had consulted with him regarding the whirlpool tubs and the decision to discontinue the whirlpool use was made. Continued interview revealed he was involved in the policy revisions. *Review of the "Signs and Symptoms of VRE" tool developed for nursing staff to use in assessing residents for signs and symptoms of VRE revealed all Unit 1 (unit on which Resident #2 resided) residents were assessed beginning on 05/16/12. With the Medical Director's input and approval, a tool was developed for nursing staff to use in assessing residents for signs and symptoms of VRE infection. Interview, on 05/18/12 at 3:30 PM, with the Medical Director revealed he had reviewed and approved the tool prior to it's use. *Interview, on 05/18/12 at 5:45 PM, with the IC Nurse and Medical Director revealed they had reviewed the facility's infection control policy to assure it included information related to VRE. Changes were made as necessary. *Review of the revised Infection Control policy revealed the IC Nurse had been assigned to review of all new resident prescriptions for antibiotics, as well as, new reports of resident wounds on a daily basis. Continued review revealed the IC Nurse was to determine whether any reports of new bacteria or infections warrant an immediate change in disinfectants and cleaning supplies and report any changes that need to be made to the Administrator. Further review of the policy revealed the IC Nurse was to report new types of infections/bacteria and resident wounds to the Quality Control Committee. The revision was made to the policy on 05/16/12 per interview on 05/18/12 at 5:13 PM with the Administrator. *Interview, on 05/18/12 at 5:40 PM, with the IC Nurse validated that she was aware of her responsibility outlined in the new Infection Control policy. *Interview, on 05/18/12 at 5:47 PM, with the IC Nurse and Director of Nursing (DON) revealed an inservice training on infection control practices and VRE was conducted with special focus on use of disinfectants, proper cleaning techniques, and a review of proper infection control procedures for all members of the Housekeeping. Further interview revealed all staff was inserviced on the infection control policy and VRE. They stated staff was inserviced on signs and symptoms of VRE infection and infection control procedures with the facility-wide inservice completed by 05/17/12. Staff was inserviced regarding the care of Resident #2 and the procedures to follow to prevent the spread of infection. *Review of the Inservice Sign-in sheets revealed inservices regarding the infection control policy were conducted on 05/17/12. Further review revealed evidence some staff was inserviced via telephone and validation that the facility conducted the inservice education for all staff. Interview, on 05/1812 at 5:13 PM, with the Administrator revealed there were six (6) staff members who had not been inserviced, however would not be allowed to work until they received the inservice. *Interviews were conducted on 05/18/12 to verify that staff had received education and verify staffs' knowledge of the new infection control policy as follows: Housekeeping Supervisor at 5:13 PM, Licensed Practical Nurse (LPN) #3 at 6:34 PM, Feeding Assistant #14 at 6:38 PM, Kentucky Medication Aide (KMA) #18 at 6:41 PM, State Registered Nursing Assistant (SRNA) #24 at 6:48 PM, SRNA #15 at 6:49 PM, Registered Nurse (RN) #2 at 6:50 PM, KMA #15 at 6:54 PM, SRNA #25 at 6:55 PM, Feeding Assistant #19 at 7:00 PM, SRNA #16 at 7:03 PM, Housekeeper #21 at 7:11 PM, Housekeeper #4 at 7:15 PM, and SRNA #17 at 7:17 PM. All staff verbalized knowledge of the new infection control policy and procedure, Contact Precautions and was aware of the discontinuation of the Simply Solution cleaner and the use of the whirlpool tubs. *Review of Resident #2's record revealed a urinalysis (U/A) with culture and sensitivity (C&S) were ordered on [DATE]. Interview, on 05/18/12 at 3:30 PM, with the Medical Director, who was the resident's attending Physician, revealed he had ordered the U/A with C&S to see if Resident #2 still had a VRE infection in his/her urine. He stated he ordered it to be obtained via an in and out catheter procedure. *Interview, on 05/18/12 at 4:38 PM, with the Quality Assurance Director revealed the Quality Assurance Committee will review the IC Nurse's reports of new infections/bacteria, as well as, wounds and changes in disinfectant and cleaning supplies on a quarterly basis.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. The facility failed to ensure the disinfectant used for sanitizing whirlpool tubs was effective against all Multi-Drug Resistant Organisms (MDROs), specifically [MEDICATION NAME] Resistant [MEDICATION NAME] ((VRE)- specific species of bacteria which are known to be resistant to [MEDICATION NAME], an antibiotic used to treat infections). Resident #2 was diagnosed with [REDACTED]. The facility failed to obtain a disinfectant effective against VRE after becoming aware, on 05/11/12, the product in use had not been tested against VRE. Residents received whirlpool tub baths on 05/14/12 with the same disinfectant still in use. In addition, the facility failed to ensure staff was knowledgeable related to Contact Isolation precautions as evidenced by observation of a staff member exiting Resident #2's room, who had been diagnosed with [REDACTED]. This same staff member was later observed to take a cup from Resident #2's room, open the closet and bathroom doors in the room, and exit the room without washing or sanitizing his hands. Further observation revealed Licensed Practical Nurse (LPN) #1 did not wear a gown when performing an in and out catheter procedure on Resident #2. Based on the above findings, it was determined the facility's failure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment in order to prevent the development and transmission of disease and infection is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/15/12 and determined to exist on 05/02/12. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/18/12 with the facility alleging removal of the Immediate Jeopardy on 05/18/12. Immediate Jeopardy was verified removed on 05/18/12 as alleged prior to exiting with the facility, with remaining non-compliance at a scope and severity of an "E", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure a safe, sanitary and comfortable environment and to prevent the development and transmission of disease. The findings include: 1. Review of the facility's policy entitled, "Cleaning of Whirlpool Tub", undated, revealed the standard was for the whirlpool to be "cleaned to prevent cross-contamination". Further review revealed the whirlpool was to be cleaned with an approved cleaning solution. The policy referred to the use of a product entitled "Cen-Kleen" for the cleaning of the whirlpool tubs. Interview, on 05/10/12 at 4:00 PM, with the Infection Control (IC) Nurse revealed the Cen-Kleen mentioned in the "Cleaning of Whirlpool Tub" policy had been "phased out" and a product entitled, "Simply Solutions" was being used. She stated the Infection Control policy needed to be updated. Interview, on 05/16/12 at 12:45 PM, with the Housekeeping Supervisor revealed the Cen-Kleen had not been used in the facility since 2001. Observation, on 05/10/12 at 4:30 PM, of the label on a gallon jug of the Simply Solutions disinfectant stored in the janitor's closet, revealed no documented evidence the product was effective against [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE). Interview at that time with the IC Nurse revealed Resident #2 had been diagnosed with [REDACTED]. Observation, on 05/10/12 at 4:35 PM, of the Unit 1 whirlpool tub room, where Resident #2 resided, revealed a disinfectant entitled "Simply Solutions" was present to disinfect the whirlpool tub after use. Interview, on 05/11/12 at 11:45 AM, with the Simply Solutions manufacturer's Regulatory Compliance Director, revealed the Simply Solutions product was not effective against [MEDICATION NAME]-Resistant [MEDICATION NAME]. Further interview revealed the Simply Solutions disinfectant had never been tested against VRE. Observations of the Unit 1, Unit 2, and Unit 3 whirlpool tub rooms, on 05/11/12 from 12:55 PM to 1:06 PM, revealed Simply Solutions disinfectant to be present for use in sanitizing the whirlpool tubs. Interview, on 05/11/12 at 4:23 PM, with the Housekeeping Supervisor, who oversees the ordering of products, revealed she was unaware the Simply Solutions disinfectant was not effective against VRE. Interview, on 05/11/12 at 4:34 PM, with the facility's Administrator revealed she had entrusted her supplier to ensure the facility had a disinfectant for the whirlpool tubs that would "kill everything". The surveyor informed her of what the manufacturer had reported in the interview at 11:45 AM. She stated that was "disturbing" as she was not aware the Simply Solutions had never been tested against VRE. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 03/14/12, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of five (5) which indicated Resident #2 was severely impaired cognitively. Review of the Comprehensive Care Plan, dated 03/21/12, revealed Resident #2 was frequently incontinent of bladder. Interventions included monitor for signs and symptoms of urinary tract infection. Review of the Urine Culture results reported on 04/29/12, revealed Resident #2 had greater than 100,000 CFU (colony forming units) per ml (milliliter) of VRE. Continued review of the Comprehensive Care Plan revealed the care plan was updated on 05/01/12 to include information related to the urinalysis results received that indicated the resident had VRE. Further review revealed Contact Precautions were implemented on that date. Review of the Nursing Assistant Care Plan, for 05/2012, revealed Resident #2 was to receive a "specialty tub" (whirlpool) bath every Wednesday, on the 3:00 PM to 11:00 PM shift. Further review of the Nursing Assistant Care Plan revealed the State Registered Nursing Assistants (SRNAs) signed off on Wednesday, 05/02/12 and Wednesday, 05/09/12 that Resident #2's care was provided which included the "specialty tub" (whirlpool) bath. Interview, on 05/11/12 at 3:10 PM, with SRNA #12, and on 05/11/12 at 4:18 PM with SRNA #13 revealed Resident #2 had been receiving a whirlpool tub bath on Wednesdays on the 3:00 PM to 11:00 PM shift. Observations of the Unit 1, Unit 2, and Unit 3 whirlpool tub rooms on 05/14/12 revealed the Simply Solutions disinfectant to still be in use, even though the facility had been notified of the product's ineffectiveness against VRE on 05/11/12. Interview, on 05/15/12 at 5:53 PM, with State Registered Nursing Assistant (SRNA) #18 revealed she had given three (3) whirlpools on Unit 1 on 05/14/12. She stated she had disinfected the whirlpool tub with the Simply Solutions disinfectant. When asked if she had been informed not to use the Simply Solutions, she stated "No, that's all we had to clean it with". Interview, on 05/16/12 at 4:45 PM, with SRNA #24 revealed she had given a whirlpool tub bath on 05/14/12 on Unit 1. She stated she had used the same disinfectant as she had always used (Simply Solutions). According to the SRNA she had not been informed to use anything different. Interview, on 05/15/12 at 4:00 PM, with the Director of Nursing (DON) revealed there were thirty-seven (37) total residents who received whirlpool tub baths on Unit 1, in the same whirlpool as Resident #2. Interview, on 05/15/12 at 3:10 PM, with the Supply Clerk revealed she was not notified until 05/14/12 to order a new product for use of disinfecting the whirlpool tubs. She stated the Simply Solutions disinfectant was still in use on 05/14/12. Further interview with the Supply Clerk, at 3:41 PM, revealed she "guessed" she should have ensured the Simply Solutions was effective; however, no one had told her to do this. In addition, she stated she and the IC Nurse should have looked at it together. Interview, on 05/15/12 at 5:10 PM, with the Housekeeping Supervisor revealed she had been informed of there being VRE in the building "a week or week and a half ago". She stated she was only informed of resident infections verbally during the morning meeting, at which all Department Heads were present. In addition, she stated if she was not present in the morning meeting there was no system in place to ensure she was made aware of new organisms. The Housekeeping Supervisor stated that sometimes communication didn't get passed along. According to the Housekeeping Supervisor, who supervised the Supply Clerk, if she was not made aware of a need for a different product then she couldn't inform the Supply Clerk of what to order. She stated she felt it was the Infection Control (IC) Nurse's responsibility to ensure the products used by nursing staff were effective against VRE. 2. Review of the facility's Infection Control policy revealed a policy entitled, "Policy and Procedure for MULTIDRUG RESISTANT ORGANISMS", undated, which included [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) infections, revealed staff should follow "Standard Precautions" for all resident care. Continued review of the policy revealed Standard Precautions, under the "Bloodborn Pathogen Exposure Plan", undated, stated gowns should be worn during procedures that were likely to generate splashing of blood or body fluids. Observation during the initial tour of the facility, on 05/09/12 at 11:55 AM, revealed the door to Resident #2's room had signage posted stating "Contact Precautions". Continued observation, on 05/10/12 at 1:35 PM, revealed gowns and gloves were available in the room. Observation, on 05/16/12 at 1:27 PM, of Licensed Practical Nurse (LPN) #1 revealed the LPN performed an in and out catheter procedure on Resident #2, who was on Contact Precautions for VRE in his/her urine. Observation revealed LPN #1 did not wear a protective gown during the procedure. Interview, on 05/16/12 at 1:33 PM, with LPN #1 revealed she was not aware of the facility's policy on when she should wear a gown. She stated she had always been told to wear a gown if there was a "big mess", such as stool. The LPN stated she had the "urine under control" when she performed the in and out catheter procedure. Interview, on 05/17/12 at 3:32 PM, with the Director of Nursing (DON) revealed she would expect her nurses to wear a gown when performing an in and out catheter procedure on a resident with Contact Precautions. 3. Observation, on 05/10/12 at 9:40 AM, of Unit 1 revealed SRNA #5 to exit Resident #2's room, who was on Contact Precautions related to a [DIAGNOSES REDACTED]. SRNA #5 proceeded down the hall without washing or sanitizing his hands. Observation, the same day at 1:40 PM, revealed SRNA #5 opened and closed the closet and bathroom doors in Resident #2's room and took a cup of water from the resident, and proceed out of the room to another resident's room without washing or sanitizing his hands. Interview, on 05/10/12 at 1:40 PM, with SRNA #5 revealed he knew Resident #2 had Contact Precautions in place and he should have washed his hands after disposing of the trash that morning. Further interview at 1:50 PM with SRNA #5 revealed he should have washed his hands prior to exiting Resident #2's room earlier. Interview, on 05/17/12 at 3:32 PM, with the Director of Nursing (DON) revealed staff should wash their hands after disposing of trash from Resident #2's room. She further stated her expectations were that staff wash or sanitize their hands prior to exiting Resident #2's room. Review of the facility's AoC revealed the following: 1. The Infection Control (IC) Nurse was consulted to review the situation and determine actions necessary and performed culturing on the whirlpool tubs on 05/14/12. The results are pending. 2. The disinfectant was changed to a disinfectant tested to be effective to destroy VRE on 05/15/12. 3. The use of whirlpool bathtubs was permanently discontinued on 05/16/12. 4. All disinfectants and cleaning supplies used in the facility were reviewed by the Housekeeping Supervisor to assure they were effective to destroy VRE on 05/16/12. 5. Vendors were notified in writing that the facility would not purchase any cleaning supplies that were not tested to be effective to destroy VRE on 05/16/12. 6. As of 05/16/12, all residents using the whirlpool baths during the same time as Resident #2 were identified. 7. The facility's Medical Director was consulted on actions that should be taken as a result of the whirlpool situation. 8. With the Medical Director's input and approval, a tool was developed for nursing staff to use in assessing residents for signs and symptoms of VRE infection. 9. As of 05/16/12, the residents who were identified to have used the whirlpool bath during the time as Resident #2 used the bath, were individually assessed to determine whether any resident had signs or symptoms of VRE. 10. For residents identified to have wounds or open areas that had used the whirlpool since 04/29/12, a culture was taken and sent to be tested for VRE on 05/16/12 with the results pending. 11. The IC Nurse and Medical Director reviewed the facility Infection Control policy to assure it specifically included information about VRE, and made changes where necessary on 05/16/12. 12. Changes were made to the Infection Control policy to assign the IC Nurse the duty of reviewing all new resident prescriptions for antibiotics, as well as, new reports of resident wounds on a daily basis. The IC Nurse shall determine whether any reports of new bacteria or infections warrant an immediate change in disinfectants and cleaning supplies. The IC Nurse shall report any changes that need to be made to the Administrator. The IC Nurse shall also report new types of infections/bacteria and resident wounds to the Quality Control Committee. This procedure was added to the facility's Infection Control policy on 05/16/12. 13. An inservice training on infection control practices and VRE was conducted, by the IC Nurse, with special focus on use of disinfectants, proper cleaning techniques, and a review of proper infection control procedures for all members of the Housekeeping staff on 05/16/12. 14. The attending Physician for Resident #2 ordered tests to determine if the resident still had the VRE infection on 05/16/12, with the results pending. 15. An inservice training for all staff on the Infection Control policy and Contact Precautions, as well as VRE specifically, was conducted by the IC Nurse which included training about the signs and symptoms of VRE infection, as well as proper infection control procedures and techniques, with the facility-wide inservice completed by 05/17/12. Inservice for staff absent on this date was conducted via telephone and inservice for employees on leave will be conducted before they return to work. 16. Infection Control procedures and Contact Precautions were reviewed with the staff caring for Resident #2, who had the VRE infection, to assure the proper procedures were being followed to prevent the spread of the infection by 05/18/12. 17. The Quality Assurance Committee will review the IC Nurse's reports of new infections/bacteria, as well as, wounds and changes in disinfectant and cleaning supplies on a quarterly basis. The surveyors validated the corrective action taken by the facility, prior to exit on 05/18/12, as follows: *Observation on 05/18/12 of the whirlpool tub rooms revealed no evidence of the Simply Solutions. Further observation revealed a product entitled, "Dispatch" which according to the label was effective against VRE. *Interview, on 05/18/12 at 5:47 PM, with the Infection Control (IC) Nurse revealed she had helped prepare staff inservices, and assisted with the inservicing of staff on the infection control issues. *Observation, on 05/18/12, revealed the whirlpool tubs were no longer in use and had been disabled. *Interview, on 05/18/12 at 5:16 PM, with the Housekeeping Supervisor revealed on 05/15/12, she had reviewed all the facility cleaning/disinfectant products to ensure they were effective against VRE. Review of the literature provided indicated the products were effective against VRE. *Review of the letters sent to all the facility vendors/suppliers revealed they were dated 05/16/12. Interview, on 05/18/12 at 5:13 PM, with the Administrator revealed all facility vendors/suppliers had been notified via the letters that the facility would not purchase any cleaning supplies that were not tested to be effective to destroy VRE on 05/16/12. *Interview, on 05/18/12 at 5:47 PM, with the IC Nurse revealed all residents who had used the whirlpool tub, during the same time as Resident #2 were identified and assessed for signs and symptoms of VRE and this was verified through record review. Cultures were performed on residents with wounds, suprapubic catheter, residents with [DEVICE]s (feeding tube), and residents on antibiotics which was verified through record review, with results pending. In addition, the IC Nurse stated all the whirlpool tubs were cultured on 05/14/12 and 05/16/12. *Interview, on 05/18/12 at 3:30 PM, with the Medical Director revealed the facility had consulted with him regarding the whirlpool tubs and the decision to discontinue the whirlpool use was made. Continued interview revealed he was involved in the policy revisions. *Review of the "Signs and Symptoms of VRE" tool developed for nursing staff to use in assessing residents for signs and symptoms of VRE revealed all Unit 1 (unit on which Resident #2 resided) residents were assessed beginning on 05/16/12. With the Medical Director's input and approval, a tool was developed for nursing staff to use in assessing residents for signs and symptoms of VRE infection. Interview, on 05/18/12 at 3:30 PM, with the Medical Director revealed he had reviewed and approved the tool prior to it's use. *Interview, on 05/18/12 at 5:45 PM, with the IC Nurse and Medical Director revealed they had reviewed the facility's infection control policy to assure it included information related to VRE. Changes were made as necessary. *Review of the revised Infection Control policy revealed the IC Nurse had been assigned to review of all new resident prescriptions for antibiotics, as well as, new reports of resident wounds on a daily basis. Continued review revealed the IC Nurse was to determine whether any reports of new bacteria or infections warrant an immediate change in disinfectants and cleaning supplies and report any changes that need to be made to the Administrator. Further review of the policy revealed the IC Nurse was to report new types of infections/bacteria and resident wounds to the Quality Control Committee. The revision was made to the policy on 05/16/12 per interview on 05/18/12 at 5:13 PM with the Administrator. *Interview, on 05/18/12 at 5:40 PM, with the IC Nurse validated that she was aware of her responsibility outlined in the new Infection Control policy. *Interview, on 05/18/12 at 5:47 PM, with the IC Nurse and Director of Nursing (DON) revealed an inservice training on infection control practices and VRE was conducted with special focus on use of disinfectants, proper cleaning techniques, and a review of proper infection control procedures for all members of the Housekeeping. Further interview revealed all staff was inserviced on the infection control policy and VRE. They stated staff was inserviced on signs and symptoms of VRE infection and infection control procedures with the facility-wide inservice completed by 05/17/12. Staff was inserviced regarding the care of Resident #2 and the procedures to follow to prevent the spread of infection. *Review of the Inservice Sign-in sheets revealed inservices regarding the infection control policy were conducted on 05/17/12. Further review revealed evidence some staff was inserviced via telephone and validation that the facility conducted the inservice education for all staff. Interview, on 05/1812 at 5:13 PM, with the Administrator revealed there were six (6) staff members who had not been inserviced, however would not be allowed to work until they received the inservice. *Interviews were conducted on 05/18/12 to verify that staff had received education and verify staffs' knowledge of the new infection control policy as follows: Housekeeping Supervisor at 5:13 PM, Licensed Practical Nurse (LPN) #3 at 6:34 PM, Feeding Assistant #14 at 6:38 PM, Kentucky Medication Aide (KMA) #18 at 6:41 PM, State Registered Nursing Assistant (SRNA) #24 at 6:48 PM, SRNA #15 at 6:49 PM, Registered Nurse (RN) #2 at 6:50 PM, KMA #15 at 6:54 PM, SRNA #25 at 6:55 PM, Feeding Assistant #19 at 7:00 PM, SRNA #16 at 7:03 PM, Housekeeper #21 at 7:11 PM, Housekeeper #4 at 7:15 PM, and SRNA #17 at 7:17 PM. All staff verbalized knowledge of the new infection control policy and procedure, Contact Precautions and was aware of the discontinuation of the Simply Solution cleaner and the use of the whirlpool tubs. *Review of Resident #2's record revealed a urinalysis (U/A) with culture and sensitivity (C&S) were ordered on [DATE]. Interview, on 05/18/12 at 3:30 PM, with the Medical Director, who was the resident's attending Physician, revealed he had ordered the U/A with C&S to see if Resident #2 still had a VRE infection in his/her urine. He stated he ordered it to be obtained via an in and out catheter procedure. *Interview, on 05/18/12 at 4:38 PM, with the Quality Assurance Director revealed the Quality Assurance Committee will review the IC Nurse's reports of new infections/bacteria, as well as, wounds and changes in disinfectant and cleaning supplies on a quarterly basis.