Every finding on record at Chestnut Ridge Health & Rehabilitation

Based on interview, record review and review of the facility's policy, the facility failed to ensure residents received a therapeutic diet per the physician's order for 1 of 7 residents sampled for diets out of the total sample of 21 residents, (Resident (R)86). The physician ordered a pureed diet for R86; however, on 04/25/2025, a Certified Nurse Assistant (CNA) gave the resident a peanut butter sandwich. R86 choked on the sandwich and subsequently lost his pulse. The Emergency Medical Services (EMS) transferred R86 to a hospital where R86 expired. Review of the official Kentucky Certificate of Death listed the immediate cause of death as, choking on a food bolus. Immediate Jeopardy was identified on 09/19/2025 and was determined to exist as of 04/25/2025 (the day R86 choked on the sandwich), in the area of 42 CFR 483.60, Food and Nutrition Services. The Administrator was notified of the Immediate Jeopardy on 09/19/2025 at 6:01 PM and provided a copy of the CMS IJ Template and was notified that the facility failed to have a system to ensure residents received physician ordered, therapeutic diets. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 9:58 AM. The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance was 08/01/2025. The Immediate Jeopardy was determined to be past non-compliance. Review of the facility's policy titled Specialized Diets dated 10/01/2021 revealed that attending physicians prescribe therapeutic diets to support resident treatment and the plan of care. The policy defined mechanically altered diets as foods modified in texture or consistency to facilitate oral intake and thickened liquids as dietary adjustments intended to prevent choking. Further, the policy stated that snacks will be compatible with therapeutic diets. No policy or standard was provided or obtained from the facility regarding what food items were acceptable for the different types of therapeutic diets. However, review of the National Dysphagia Diet Task Force (2002), Dysphagia Diet Level 1 revealed to avoid breads not pureed, and peanut butter, unless purred into another food item. Review of Resident (R) 86's admission Record revealed an admission date of 07/14/2015 with diagnoses including unspecified cerebrovascular disease, anoxic brain damage, dementia, dysphagia - oropharyngeal phase (difficulty in swallowing), generalized anxiety disorder, major depressive disorder, and disturbances of salivary secretion. A Quarterly Minimum Data Set (MDS) Assessment, dated 07/18/2024, identified the resident with a Brief Interview of Mental Status (BIMS) score of 8/15, consistent with severe cognitive impairment.Review of the facility's comprehensive care plan for R86 initiated on 09/26/2018, revealed R86 has altered nutrition related to multiple diagnoses such as dysphagia, bipolar disorder, anoxic brain damage, mood and impulse disorders, dementia, type II diabetes mellitus, and unspecified protein-calorie malnutrition. Interventions included a physician-ordered general pureed diet with nectar-thickened liquids (NTL), initiated on 11/23/2024, and nutritional supplements per physician order, initiated on 02/07/2023. A subsequent care plan initiated on 06/30/2021 revealed risk for aspiration (inhaling food, liquid or other foreign substances instead of swallowing), with interventions including dietician and therapy consultation as needed, and provision of a modified diet. Another care plan initiated on 10/26/2022 documented the resident's behavior of chewing on foreign objects, including his fingers and fingernails, with interventions including the provision of a snack, initiated on 04/05/2023.Review of the physician's orders located in the Electronic Medical Record (EMR) revealed several changes to the resident's diet. On 04/04/2023, the order reflected a general diet with regular consistency and thin liquids. On 04/10/2023, the order was changed to a general diet with regular texture and NTL. On 11/05/2024, the order was changed to a mechanical soft texture with thin liquids. On 11/08/2024, the order was changed to a regular diet, pureed texture with NTL, sugar-free condiments, and beverages. The Order Summary Report also reflected one-to-one (1:1) staff supervision from 6:30 PM-6:30 AM, and 15-minute checks during daytime hours related to behaviors. Review of the Speech Therapy records revealed a referral on 11/05/2024 following an incident where R86 had choked on a peanut butter sandwich. An evaluation revealed swallowing disorders involving the pharyngeal and esophageal phases. The Speech-Language Pathologist (SLP) recommended a mechanical soft diet with thin liquids and explicitly noted no peanut butter sandwiches. A Fiberoptic Endoscopic Evaluation Swallow (FEES) study performed on 11/08/2024 revealed a decline from prior studies, and the SLP recommended a pureed diet with NTL. Therapy Encounters notes between 11/05/2024 and 12/24/2024 documented ongoing treatment, repeated education of staff and the resident, and trials of mechanical soft food and thin liquids. Despite occasional therapeutic trials, the physician order as of 11/08/2024 remained a pureed diet with NTL.Review of the facility's Initial Incident Report dated 04/25/2025 revealed CNA 11 was the sole witness to an incident at 6:40 PM when R86 requested CNA 11 to give him a peanut butter sandwich, which was not part of his physician-ordered diet. R86 started to eat the sandwich. NEED TO SAY GOT CHOKED , ETC.The report revealed the resident experienced a change in condition, required the Heimlich maneuver and Cardio-Pulmonary Resuscitation (CPR), and was transferred to the hospital, where he expired later that evening. The Kentucky Certificate of Death listed the immediate cause of death as choking on a food bolus.Review of the facility's 5-Day Follow-Up Report dated 04/30/2025 confirmed the resident was provided a snack inconsistent with his prescribed diet. The report described unsuccessful attempts with the Heimlich maneuver, CPR initiation by staff, and transfer to the hospital by EMS. Review of staff attestations revealed CNA 11 stated she provided the peanut butter sandwich at the resident's request. Further review revealed CNA 11 acknowledged she was aware R86 was ordered a pureed diet, but she had observed him eating peanut butter sandwiches previously without difficulty. The statement confirmed the resident choked, became distressed, and CPR was initiated until EMS assumed care. Statements from Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 6 and LPN 7 confirmed their actions during the code, including attempts at the Heimlich maneuver, initiation of CPR, and coordination with EMS.In an interview with CNA 11 on 09/19/2025 at 3:13 PM, she stated she was assigned to provide 1:1 care for R86 on 04/25/2025. She stated a peanut butter sandwich, milk carton, and banana were already present on R86's bedside table. She stated she was aware that R86 was ordered a pureed diet. She stated she had previously observed him eating peanut butter sandwiches without difficulty. She stated she opened the sandwich for him, and after nearly finishing it, he began choking. She attempted the Heimlich maneuver and called for help. Two nurses entered and took over as she called 911. She stated the resident became unconscious, CPR was initiated, EMS arrived, and he was transported to the hospital.In an interview with CNA 12 on 09/19/2025 at 9:19 AM, she stated that the last time she had provided 1:1 care for the resident, approximately two weeks earlier, his diet was pureed with NTL. She stated all staff were aware the resident was restricted from peanut butter sandwiches and that alternative snacks such as pudding and applesauce were available. She stated she had never observed the resident eating a peanut butter sandwich or choking, although he frequently coughed even when not eating or drinking.In an interview with CNA 13 on 09/19/2025 at 3:35 PM, he stated he was aware of the resident's swallowing difficulties and his ordered pureed diet with NTL. He stated when he had previously provided 1:1 care for R86, the resident never requested food outside of his diet order, although he frequently asked for snacks. CNA 13 stated CNA 11 had multiple options to verify the resident's diet order, including reviewing the KARDEX (a nursing tool that serves as a care plan chart or template to manage and reference critical resident/patient information), checking the EMR, or asking the nurse, and that she (CNA11) failed to do so. In an interview with CNA 20, on 09/20/2025 at 2:15 PM, she stated she received training on diets at hire and annually thereafter. She stated staff were instructed to check diet orders when residents were admitted , returned from the hospital, or experienced a change in condition. CNA 20 stated that when a resident asked for food, staff were to check the diet, confirm with the nurse, and provide the snack only if it was consistent with the orders. She stated that peanut butter and jelly sandwiches were not part of a pureed diet.In an interview with the MDS Coordinator, on 09/19/2025 at 4:29 PM, he stated the sandwich provided to R86 was inconsistent with his diet order. He stated the 1:1 care sheet included diet information, and the diet orders were available in the KARDEX and care plans. He stated that it was important for all staff to be able to access diet orders to ensure residents' safety.In an interview with the Assistant Director of Nursing (ADON) on 09/19/2025 at 3:26 PM, she stated CNAs can find diet orders on the KARDEX, which includes all relevant diet and Activities of Daily Living (ADLs) information. She reported that if CNAs were uncertain, they were to ask the nurse.In an interview with the Director of Nursing (DON) on 09/19/2025 at 11:00 AM, she stated there had been a prior incident in November 2024 when the resident choked on a peanut butter sandwich, which required the Heimlich maneuver. She stated that following that incident, the physician referred the resident to Speech Therapy, which completed a swallow study and recommended a pureed diet with NTL. The DON stated CNA 11 was suspended immediately following the April 2025 incident and terminated effective 05/01/2025 for failing to follow diet orders. She confirmed the resident's ordered diet was accurately reflected in the KARDEX.In an interview with the Administrator on 09/19/2025 at 4:43 PM, she stated she was notified of the incident immediately and the CNA was removed from the care area. She stated her expectation was staff verified diet orders through the KARDEX and confirmed with a nurse when in doubt, to prevent errors and protect residents.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 11:03 AM.The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance is 08/01/2025. The deficient practice was determined to be past non-compliance.The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:The Immediate Jeopardy identified at F803, related to the facility's failure to follow R86's physician-ordered therapeutic diet, was removed on 04/29/2025. The facility's plan of removal, submitted and initiated on 04/25/2025, was reviewed and validated through interviews, observations, record review, and audit verification on 09/20/2025.On 04/25/2025, all mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency. The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders. Education was initiated immediately by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides. Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards. All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.A 100% audit of all resident diet orders and Kardex entries was completed on 04/25/2025 by the DON, MDS nurse, and Regional Nurse. On 04/26/2025, the ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy. Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months, and the Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.The Administrator and DON confirmed that all new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.The QAPI Committee held an ad hoc meeting on 04/28/2025 to review corrective actions, with a monthly follow-up scheduled for three months. The Medical Director was notified on 04/26/2025 of all corrective measures and ongoing monitoring efforts and agreed with the plan.Through interviews with staff, review of educational materials and attendance records, validation of snack labeling and tray card audits, and confirmation of QAPI oversight, the survey team determined the Immediate Jeopardy was removed on 04/29/2025, although the facility remained out of compliance at F803 until 08/01/2025, the facility's alleged date of compliance for the IJ tags (F656 and F803). Top of Form Bottom of Form

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs for 1 of 7 residents sampled for dietary needs out of the total sample of 21 residents, (Resident (R)86). The facility failed to develop and ensure R86's care plans accurately reflected the resident's risk for choking, the Speech Therapy (ST) recommendations, dietary consistency requirements, and safe snack provisions consistent with the resident's physician's orders and with interventions necessary to address the risk. On 04/25/2025, Certified Nurse Aide (CNA) 11 gave R86 a peanut butter sandwich, the resident choked on the sandwich, became unresponsive, and eventually expired at the hospital. The official Kentucky Certificate of Death noted R86's immediate cause of death as choking on a food bolus (when an aspirated material occludes the upper airways resulting in the inability to breathe). Immediate Jeopardy (IJ) was identified on 09/19/2025 and was determined to exist as of 04/25/2025 (the day R86 choked on the sandwich), in the area of 42 CFR 483.21, Comprehensive Person-Centered Care Planning. The Administrator was notified of the Immediate Jeopardy on 09/19/2025 at 6:01 PM and was provided a copy of the CMS IJ Template notifying the facility of its failure to ensure residents had the necessary care plans to address a resident's risk for choking. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 9:58 AM. On 09/20/2025, the State Survey Agency (SSA) team validated the IJ was removed on 04/29/2025, following the facility's implementation of the IJ removal plan. The facility's alleged date of compliance was 08/01/2025. The IJ was determined to be past. The findings include: No policy related to resident centered care plans was provided or obtained. Review of the facility's policy titled Specialized Diets dated 10/01/2021 revealed that attending physicians prescribe therapeutic diets to support resident treatment and the plan of care. The policy defined mechanically altered diets as foods modified in texture or consistency to facilitate oral intake and thickened liquids as dietary adjustments intended to prevent choking. Further, the policy stated that snacks will be compatible with therapeutic diets. No policy or standard was provided from the facility regarding what food items were acceptable for the different types of therapeutic diets. However, review of the National Dysphagia Diet Task Force (2002), Dysphagia Diet Level 1 revealed to avoid breads not pureed, and peanut butter, unless purred into another food item. Review of the facility's comprehensive care plan for Resident (R) 86 for altered nutrition, dated 09/26/2018, revealed no specific interventions directing staff to ensure all snacks provided outside of scheduled meals met the resident's ordered therapeutic diet. The care plan only stated for the diet per physician's orders, general pureed and nectar thick liquids (NTL). Review of the Speech Therapy records revealed a referral on 11/05/2024 following an incident where R86 choked on a peanut butter sandwich. An evaluation revealed swallowing disorders involving the pharyngeal and esophageal phases. The Speech-Language Pathologist (SLP) recommended a mechanical soft diet with thin liquids and explicitly noted no peanut butter sandwiches. A Fiberoptic Endoscopic Evaluation Swallow (FEES) study performed on 11/08/2024 revealed a decline from prior studies, and the SLP recommended a pureed diet with NTL (nectar thick liquids). Therapy Encounters notes between 11/05/2024 and 12/24/2024 documented ongoing treatment, repeated education of staff and the resident, and trials of mechanical soft food and thin liquids. However, despite occasional therapeutic trials, the care plan was not developed to include individualized interventions to include the SLP's recommendations. Review of the facility's Initial Incident Report dated 04/25/2025 revealed a Certified Nursing Assistant (CNA) was the sole witness to an incident at 6:40 PM when R86 requested the CNA to give him a peanut butter sandwich, which was not part of his physician-ordered diet. R86 started to eat the sandwich. The report revealed the resident experienced a change in condition [choked] and required the Heimlich maneuver and Cardio-Pulmonary Resuscitation (CPR). R86 was transferred to the hospital, where he expired later that evening. The official Kentucky Certificate of Death noted R86's immediate cause of death as choking on a food bolus (when an aspirated material occludes the upper airways resulting in the inability to breathe).Review of the facility's 5-Day Follow-Up Report dated 04/30/2025 confirmed the facility provided a snack [peanut butter sandwich] inconsistent with his prescribed diet. The report described unsuccessful attempts with the Heimlich maneuver, CPR initiation by staff, and transfer to the hospital by EMS. Review of staff attestations revealed CNA 11 stated she provided the peanut butter sandwich at the resident's request. Further review revealed CNA 11 acknowledged she was aware R86 was ordered a pureed diet, but she had observed him eating peanut butter sandwiches previously without difficulty. In an interview with CNA 11 on 09/19/2025 at 3:13 PM, she stated she was assigned to provide 1:1 care for R86 on 04/25/2025. She stated a peanut butter sandwich, milk carton, and banana were already present on R86's bedside table. She stated she was aware that R86 was ordered a pureed diet. She stated she had previously observed him eating peanut butter sandwiches without difficulty. She stated she opened the sandwich for him, and after nearly finishing it, he began choking. She attempted the Heimlich maneuver and called for help. Review of written statements from Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 6 and LPN 7 confirmed their actions during the code, including attempts at the Heimlich maneuver, initiation of CPR, and coordination with EMS.In an interview with CNA 12 on 09/19/2025 at 9:19 AM, she stated that the last time she had provided 1:1 care for the resident, approximately two weeks earlier. She stated R86's diet was pureed with NTL. She stated all staff were aware the resident was restricted from peanut butter sandwiches and that alternative snacks such as pudding and applesauce were available.In an interview with CNA 13 on 09/19/2025 at 3:35 PM, he stated he was aware of the resident's swallowing difficulties and his ordered pureed diet with NTL. CNA 13 stated CNA 11 had multiple options to verify the resident's diet order, including reviewing the KARDEX (a nursing tool that serves as a care plan chart or template to manage and reference critical resident/patient information), checking the EMR, or asking the nurse, and that she (CNA11) failed to do so.In an interview with Licensed Practical Nurse (LPN) 4 on 09/19/2025 at 4:33 PM, she stated she believed the Director of Nursing and someone else were responsible for developing care plans for the residents. She stated all staff help implement the care plans by doing the interventions for the residents. In an interview with the Dietary Manager on 09/20/2025 at 2:42 PM, he stated he started working in this facility on 08/01/2025, and on his first day of work in this facility, he ensured all snacks in the facility were labeled clearly with the type of modified diet consistency. Prior to his employment, all the snacks were in the refrigerators, but they were not labeled with the type of diet they fit into. After he began his employment, the Dietary Manager stated he labeled all the snacks himself, pureed, mechanical and regular for sandwiches, cookies, chips, peanut butter crackers, or any snack that was in the snack rooms. The Dietary Manager stated the labeling of snacks was supposed to already be in place, but someone had, .dropped the ball. In an interview with the MDS Coordinator on 09/19/2025 at 3:26 PM, he stated R86's care plans included all interventions regarding his diet orders. He stated he implemented care plans for residents based on physician's orders and multiple other factors. When asked why there were no interventions regarding the SLP's recommendations or the dietary manager's recommendations, he was not able to answer. The MDS Coordinator stated he and the Director of Nursing were responsible for developing care plans for the residents. In an interview of the Director of Nursing (DON) on 09/20/2025 at 2:52 PM, stated she and the MDS Coordinator were responsible for developing the residents' care plans.In an interview with the Administrator on 09/20/2025 at 3:02 PM, the Administrator confirmed that on 04/25/2025, care plans had not been developed to incorporate the dietary manager or the SLP's recommendations for modified diets, resulting in unsafe and inconsistent practice.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 09/20/2025 at 11:03 AM.The survey team validated the Immediate Jeopardy was removed on 04/29/2025 following the facility's implementation of the plan of removal of the Immediate Jeopardy. The facility's alleged date of compliance is 08/01/2025. The deficient practice was determined to be past IJ.The Removal of Immediate Jeopardy Plan was validated with implementation of the following measures:On 04/25/2025, the Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.On 04/25/2025, the DON, ADON, and SDC immediately educated all licensed nurses, CMTs, and CNAs regarding:Reviewing the care plan, KARDEX, and diet orders before providing snacks.IDDSI standards for puree and mechanical soft diets.Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.Staff completed return demonstrations and will not work unsupervised until competency verified.Care plans for all residents on modified diets were immediately reviewed and updated by licensed staff to include:Speech therapist and dietary recommendations.Specific snack and supplemental food interventions.Cross-reference to diet order consistency requirements.Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.New staff will be educated during orientation and before working independently.

Based on observation, interview, record review, and facility policy review the facility failed to ensure it had an effective system to prevent the transmission of infection on 3 of 4 units for 5 of 21 sampled residents (R) 9, R12, R41, R63 and R77. The findings include:Review of the facility policy titled Infection Control Program, undated, stated the facility will establish and monitor environmental infection prevention and control practices in accordance with the Center for Disease Control (CDC), local and state requirements; develop isolation precaution protocols to control an infectious disease is required in accordance with current CDC guidelines and recommendations.The Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, facility policy, dated 09/23/2022 revealed if the facility has a resident with a positive test for COVID, or a resident with symptoms of COVID-19, or health care personnel with high risk exposure the facility will implement; a process to make everyone entering the facility aware of recommended actions to prevent transmission to others and universal use of Personal Protective Equipment (PPE) for staff.The Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, facility policy, dated 09/23/2022 revealed if the facility has a resident with a positive test for COVID, or a resident with symptoms of COVID-19, or health care personnel with high risk exposure, the facility will implement; a process to make everyone entering the facility aware of recommended actions to prevent transmission to others and universal use of Personal Protective Equipment (PPE) for staff.Observations on 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025 and 09/20/2025 revealed no signage at the facility entry to indicate there were resident/s with COVID.1. Observation of Lakeview Hall, on 09/16/2025 at 2:00 PM, revealed an Enhanced Barrier Precaution (EBP) sign on the open door of room [ROOM NUMBER], and Resident (R)77 could be seen lying in bed with closed eyes. Directly across the hall from room [ROOM NUMBER] was a plastic bin with drawers. The bin was to the left of room [ROOM NUMBER] and contained gloves, gowns, surgical masks and shoe covers. The door to room [ROOM NUMBER] was closed and a Contact Precaution sign was on the door.Observation of CNA3 on 09/16/2025 at 2:48 PM revealed she exited room [ROOM NUMBER] without any PPE on. She then retrieved a particulate mask and put it on as she walked down the hallway. An observation on 09/18/2025 at 9:55 AM on the Lakeview Hall. revealed CNA2 and CNA 4 exited R77's room [ROOM NUMBER] with no PPE on. During an interview on 09/18/2025 at 10:00 AM CNA4 stated she had doffed (removed) her PPE inside the room, applied new gloves, removed bag and walked it to dirty utility room. Immediately following her exit an observation of 313's garbage bin revealed a small open bin with plastic a liner and blue gloves inside.On 09/18/2025 at 2:30 PM an observation of revealed a Maintenance Assistant entered the open door of room [ROOM NUMBER] without putting on PPE. He crossed to the far side of the room and checked the light switches, then to the bed nearest the door and checked those switches. Interview with the Maintenance Assistant as he exited room [ROOM NUMBER] revealed he was educated on isolation precautions, he said this wasn't his first nursing home job. He further stated the yellow sign meant they have an infection or a skin graft that could go bad. 2. Observation on 09/16/2025 at 2:07 PM, revealed a sign for Enhanced Barrier Precautions (EBP) and a sign for Contact precautions on the door to Resident (R)12's room. Additional observation on 09/17/2025 at 8:22 AM revealed R12's door had an EBP and Contact Precautions sign.Observation on 09/17/2025 at 1:15 PM, revealed Registered Nurse (RN)1 in Resident (R)12's room. The nurse moved R12's overbed table closer to the resident sitting on the side of the bed. Another staff member handed RN1 R12's meal tray at the doorway to R12's room. A staff member then handed RN1 the meal tray for the R12's roommate. RN1 did not use any PPE while in the room delivering the meal tray to R12 and her roommate.In interview on 09/17/2025 at 1:21 PM, RN1 stated she spaced out for R12's EBP precautions (for wearing PPE). She stated she was not aware R12 had Contact precautions and looked at the Contact precautions sign on the door to R12's room. RN1 stated R12 should not be in Contact precautions, only EBP. She further stated using PPE was to keep herself safe from the resident who was positive for COVID-19.3. Observation at 2:36 PM revealed Certified Nursing Assistant (CNA)2 and CNA3 applying PPE before entering room [ROOM NUMBER] for R41 and R63. CNA2 donned a gown, gloves and two surgical masks. CNA3 donned a gown, shoe covers, gloves and a surgical mask. Observation of their exit revealed neither CNA wearing PPE. Continued observation revealed, revealed the Minimum Data Set (MDS) Coordinator carrying a Contact Precaution sign and two boxes of particulate masks toward rooms [ROOM NUMBERS]. He placed the masks into the plastic PPE bin but did not place the Contact Precaution sign.An interview with CNA2 on 09/16/2025 at 2:55 PM revealed R77 in room [ROOM NUMBER] and both residents in room [ROOM NUMBER], R53 and R41 diagnosed with COVID. She further explained the signs on the door indicate what PPE staff wore upon entry to the room. She was unsure why room [ROOM NUMBER] only had a EBP sign but she was certain R77 had COVID. She further stated, the facility supplies 'M14' masks, but I literally cannot wear them I feel like I am suffocating, so I put on two masks. Review of R41 and R63's records indicate they both tested positive for COVID 19 on 09/09/2025. Record review of R77 indicated they tested positive for COVID 19 on 09/11/2025. 4. Record review of R9, room [ROOM NUMBER], revealed an active order indicating the need for Contact Isolation Precautions related to C diff infection. On 09/17/2025 an observation of room [ROOM NUMBER], on the Maple hallway at 9:30 AM revealed room [ROOM NUMBER] with no signage at the entrance to the room.An interview, on 09/18/2025 at 10:36 AM, on the Maple Hallway with Registered Nurse (RN)4 revealed she was an agency nurse. She reported R9 did have a history of C diff. She further stated she thought she saw a note indicating the C diff ended and there should have been an end date on the Contact Precautions order. She noted there was no signage on the door. Additionally, she reported she found the order in the electrotonic medical record, and it was still active. An interview with the MDS coordinator on 09/19/2025 at 930AM revealed staff nurses were responsible for Infection Control, and they documented all COVID test results in the Progress Notes. If a resident tested positive, they notified the provider and placed the signage and the PPE. He stated facility communication regarding active resident infections occurred in stand-up and stand-down meetings each morning and evening. He further stated nurse managers attended those meetings and shared information with staff nurses Monday through Friday. He stated he was not sure who was responsible for facility Infection Prevention. Lastly, he stated residents with COVID 19 were placed in Contact/Droplet precautions, which meant gloves. gown, particulate mask and face shields. He wasn't sure how staff would know those residents needed droplet precautions, as there were no droplet precaution signs posted on their doors. A telephone interview on 09/19/2025 at 11:20 AM with Wound Medical Director (MD)1 revealed she provided care to R12 on 09/17/2025. She stated she was unaware R12 was in isolation. Wound MD1 further stated the Enhanced Barrier Precaution sign was up and she followed that protocol. On 09/19/2025 at 10:05AM an interview with the Director of Nursing (DON) revealed she was currently also working the Staff Development Coordinator and Infection Preventionist roles. She stated her expectation was when a resident tested positive for COVID they were placed in Droplet Isolation/Contact Precautions for 10 days. A Droplet Isolation/Contact Precaution sign was placed on their room door and PPE was provided outside the resident's room door in a bin. The nurses always have access to signs and PPE. Staff check the PPE stock in the bins every shift. She stated staff should wear gown, gloves, an N95 mask and a face shield upon entry to Droplet Isolation/Contact Precaution rooms. She stated PPE was important to prevent infectious diseases from spreading among staff and/or residents, which could potentially harm them. An interview with the Administrator on 09/20/2025 indicated she expected the appropriate signage posted on the residents' doors, whatever type of isolation the resident needed and access to hand sanitizer and PPE. Additionally, she expected staff to round daily and ensure the PPE was available. She further stated incorrect precaution and/or staff non-compliance may increase the likelihood of infection for other individuals.

Based on interview, record review, and facility documentation, the facility failed to complete all pre-employment checks for 2 of 8 sampled new employees' files, (a Dietary Aide and Activities Assistant). The findings include:Review of the facility's policy Abuse,' revised 10/20/2022, revealed the facility was committed to developing and operationalizing policies for screening employees and protection of residents. Further, under the section labeled Screening, the policy stated the organization will screen potential employees for a history of abuse, neglect or mistreating residents. Additionally, multi-state registry checks and license verifications will be checked from every State registry established that the facility believed will include information on the individual.Review of the personnel file for the Dietary Aide (DA) revealed the facility hired the DA on 09/05/2025. Review of the personnel file for the Activities Assistant (AA) revealed the facility hired the (AA) on 09/11/2025. However, continued review revealed no documentation the facility completed the Kentucky (KY) Nurse Aide Abuse Registry check for either employee before they began working at the facility.In interview on 09/19/2025 at 3:14 PM, the Administrator stated the facility did not have anyone in the Human Resources (HR) position at the moment and she was filling in for the HR role for about a month. She stated the pre-employment checks were completed for every employee. The Administrator stated the facility completed license verifications for Certified Nurse Aides (CNAs) and nurses. She further stated the KY Nurse Aide Abuse Registry check was not completed for non-clinical staff as those staff did not have a license to verify. She also stated the pre-employment checks were completed to keep residents in the facility safe.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents' care plans were implemented to provide the proper care, monitoring and documentation to enable residents to have effective coping skills for one (1) of thirteen (13) sampled residents (Resident (R) 6). On 12/14/2023, R6 threw coffee on R8 and R8 sustained an open blister/burn on his/her upper chest. Documentation provided by the facility revealed it failed to implement R6's comprehensive care plan to monitor the resident's behaviors and document observed behaviors, and attempted interventions after facility staff documented R6 was having behaviors on 08/09/2023. Staff learned on 12/13/2023 that R6 wrote a note on his/her notepad, which he/she showed to the Minimum Data Set (MDS) Coordinator, and the note indicated R8 called him/her a bitch. Additionally, it was not validated R6's care plan was implemented as written, as there was no documentation noting the facility assessed R6's understanding of the situation or allowed time for the resident to express himself/herself and his/her feelings towards the situation. The findings include: Review of the facility's Careplan Policy, Effective Date: 09/01/2017, revealed it was the policy of the facility to ensure every resident had a Baseline Care Plan completed and implemented within forty-eight (48) hours of admission. Per policy review, the Baseline Care Plan was to be discontinued upon the completion of the resident's Comprehensive Care Plan (CCP). Review revealed the CCP would further expand on the resident's risks, goals and interventions using the Person-Centered Plan of Care approach for each resident, which included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. Continued review revealed those needs were to be defined from observation, interview, clinical medical record review and thorough assessments. Per review, the Minimum Data Set (MDS)/Care Plan Coordinator and/or ancillary MDS staff were to attend the facility's Morning/CQI meetings, where an in-depth review of the 24 Hour Report(s), completed in the prior Morning/CQI meeting were reviewed and discussed. Further review revealed during the facility's Morning/CQI meetings any new or changed orders, new admissions, readmissions, falls and other pertinent circumstances regarding the residents was discussed, and the care plans for those residents was revised and updated as necessary. Review of R6's Admission Record, revealed the facility admitted Resident #6 (R6) on 03/17/2021, with diagnoses that included Schizoaffective disorder bipolar type, Impulsiveness, malignant neoplasm of larynx, acquired absence of larynx, aphonia, and Tracheostomy status. Continued record review revealed R6's Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/2023, noted the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of 15, indicating he/she had no cognitive impairment. Review of R6's CCP revealed on 08/10/2023, the facility initiated care plan interventions for the resident which focused on his/her verbal aggression towards other residents. Continued review revealed interventions included staff were to monitor R6's behaviors, document observed behaviors, and attempted interventions. Further review revealed additional interventions initiated on 08/10/2023 included staff were to assess R6's understanding of the situation and allow time for R6 to express self and feelings towards the situation. During an interview, on 12/19/2023 at 10:20 AM, the Regional Nurse Consultant (RNC) stated the facility's staff charted by exception, which meant if a resident exhibited a problematic behavior, staff were to document the behavior in the resident's Progress Notes or behavior charting notes. The RNC stated if a Certified Nursing Assistant (CNA) observed behaviors in a resident they were to report that information to the nurse, and the nurse was to document the behavior. The RNC further stated staff knew to document resident behaviors from the resident's care plan and from nursing huddles, (morning meetings with nursing staff). Review of the Progress Notes, dated 08/09/2023, revealed the Social Services Director (SSD) documented SSD advised that resident was having behaviors today. Continued review revealed the SSD would schedule a care plan (meeting) with R6, the interdisciplinary team (IDT) and a local behavioral health services provider. During an interview, on 12/18/2023 at 1:24 PM, the Social Services Director (SSD) stated he was not sure what R6's behavior had been when he wrote the note. During an interview on 12/18/2023 at 2:30 PM, the RNC stated the Behavior Meeting was held every other week on Fridays. She stated the resident behavior information which the facility used in the Behavior Meetings was the information about resident behaviors staff talked about in each weekday morning meeting. The RNC stated if someone told her a resident had a thumbs down day in the morning meeting, she relayed that information in the Behavior Meeting. She further stated any intervention from the bi-weekly behavior meeting was updated in the resident's care plan. During an interview on 12/18/2023 at 1:50 PM, the DON stated any behaviors a resident had displayed since the last morning meeting was discussed. The DON stated if new interventions were added to a resident's care plan, she talked to nursing about the intervention and added it to her charting guide which she typed out for each resident who had a new behavior intervention. She stated if something new happened and a resident had a new care plan intervention, she let nursing know about the new intervention so the facility could ensure the nurses were documenting about the resident's new intervention. The DON further stated if a nurse reported a behavior then it was discussed in the next morning meeting. During an interview on 12/18/2023 at 12:10 PM, the Minimum Data Set (MDS) Coordinator stated she recalled discussing in the facility's morning meeting on Thursday 12/14/2023, that R8 called R6 a bitch. She stated R6 gave her a note the afternoon of 12/13/2023, and said something about R8 called him/her a bitch. The MDS Coordinator stated she did not know if she told the facility's Administrator about the note R6 showed her. She stated she told R6 to take the note to State if you want, and she did not want R8's note because there was nothing she was going to do with it. The MDS Coordinator stated the note was not addressed to her, it was addressed to the State, and said R8 could write whatever he/she wanted to write. She further stated the facility could not have prevented what happened, not even a little bit. Review of the Long Term Care Facility - Self-Reported Incident Form dated 12/14/2023, revealed documentation noting on 12/14/2023, it had been reported R6 threw coffee on R8. Continued review revealed the residents were immediately separated and R6 was placed on one-to-one (1:1) supervision until he/she could be sent out for psychiatric (psych) services. Review of the CNA Bath and Skin Report, dated 12/14/2023, indicated the Assistant Director of Nursing (ADON) assessed R8's skin after the coffee was thrown on him/her and documented R8 had an open blister on his/her upper chest. During a telephone interview, on 12/16/2023 at 2:14 PM, the MDS Coordinator stated it did not surprise her that Resident #6 threw coffee on Resident #8, because he/she had it out for R8 for some reason, but did not know why. During an additional interview on 12/18/2023 at 2:20 PM, the MDS Coordinator stated she had removed the intervention to monitor R6's behaviors and document observed any behavior and attempted interventions from the resident's care plan on that day. She stated she removed that information because the facility was not monitoring R6, and the facility did not have the monitoring tools requested by the State Survey Agency (SSA) Surveyor. During a telephone interview on 12/19/2023 at 12:10 PM, the MDS Coordinator stated she had not told any facility staff she had removed the interventions to monitor R6's behavior, document observed behavior, and any attempted interventions from the resident's care plan the day before. She stated she took out the monitoring because the facility could not meet the State Survey Agency's (SSA's) expectations. The MDS Coordinator stated staff observed and discussed R6, and that she did not know what the SSA was wanting the facility to do. She stated, if we did behavior monitoring all day long nobody would get the job of passing medications done. In further interview, the MDS Coordinator stated the residents at the facility had the right to be safe from injury at all times. During an interview on 12/19/2023 at 10:20 AM, the Administrator stated in the day-to-day life of the facility, people talked about other people. She stated she and the RNC heard about R8 calling R6 a bitch, but were not aware of the note R6 had shown to the MDS Coordinator. The Administrator further stated she, the RNC and the DON also were not aware the MDS Coordinator had removed the intervention to monitor R6's behavior, document observed behavior, and attempted interventions from R6's care plan, the previous day. During an additional interview on 12/19/2023 at 10:25 AM, the RNC stated it would have been helpful to know about the note R6 wrote and showed to the MDS Coordinator, so the facility could address any potential problems. The RNC further stated if knowledge of the note had been shared in morning meeting on the 13th or 14th of December, that information would have been helpful so the facility could have increased monitoring of R6.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide necessary behavioral health services to thoroughly address the physical, mental, and psychosocial needs for one (1) of thirteen (13) sampled residents (Resident 6). On 08/09/2023, Resident (R) 6, exhibited behaviors that initiated a Behavior Comprehensive Care Plan (CCP), on 08/10/2023, for staff to monitor and document R6's observed behaviors. Staff; however, were unable to recall the behavior that prompted the resident's care plan, and the behavior was not addressed in the Behavior Logbook or Behavior Charting. On 12/12/2023, the resident expressed to staff that R8 was calling him/her inappropriate names, and on 12/13/2023, the resident wrote a letter, in his/her notepad, indicating that if the facility did not address his/her concerns he/she would do something about R8. The resident's care plan was revised on 12/13/2023 for staff to ensure the resident felt safe and to ensure the needs of the resident were met. However, there was no documentation to support staff were educated on the resident's needs. Subsequently, on 12/14/2023, Resident (R) 6 threw coffee on R8 and R8 sustained a burn with an open blister on his/her upper chest. The documentation provided by the Regional Nurse Consultant (RNC) revealed the resident was on the Behavioral Meeting caseload; however, no documentation was supplied to show evidence the facility monitored, discussed, or reviewed R6's behaviors, as per the Behavior Management Program policy. (Cross Reference F656) The findings include: Review of the facility's policy titled, Behavior Management Program, undated, revealed it was the policy of the facility to assess those residents exhibiting challenging behaviors. Continued review revealed residents exhibiting significant behaviors were to be monitored through a team effort on a weekly basis, involving all applicable disciplines to best cater to the improvement of the resident's psychosocial status. Per policy review, the interdisciplinary team (IDT) members monitored residents with problematic behavior and consisted of but was not limited to the Director of Nursing (DON), Nursing management staff, Social Services staff, Psychiatrist, Psychologist, Attending Physician, Family, Administrator, and Activities. Continued review of the policy revealed the IDT was to appropriately determine clinical and psychosocial interventions to best address each resident's needs. Per review, any interventions and/or issues in need of review by the Psychiatrist were to be listed on the Psychiatrist referral form and addressed at the routine visit. Further review of the facility's policy titled, Behavior Management Program, undated, for Special Elements, revealed the facility would complete the following: identification of the problematic behavior; assessment of new or worsening behavior symptoms; discuss with staff, Physician, and family members regarding the observance of the behavior and manifestation of the same to gain insight relative to the behavior and effective interventions. Continued review revealed the Special Elements also included: discussion with the facility's Psychiatrist/Psychologist regarding the resident's manifestation of behavior and/or evaluation if ordered by the attending Physician and the appropriateness of planned interventions. Review further revealed the Special Elements additionally included: initiation of the Behavior Management Logbook; educating staff members of specific interventions to be attempted for the individual resident exhibiting problematic behavior; weekly review of the resident's behavior, behavior management program and progress toward eliminating/controlling problematic behavior. Review of Resident (R) 6's Admission Record revealed the facility admitted R6 on 03/17/2021, with diagnoses that included malignant neoplasm of the larynx, acquired absence of larynx, Tracheostomy status, Schizoaffective disorder bipolar type, and Impulsiveness. Review of R6's Social Service Progress Note, dated 08/09/2023, revealed the Social Services Director (SSD) documented, SSD was advised the resident was having behaviors today. Continued review revealed the SSD would schedule a care plan meeting with R6 and include the IDT and a local behavioral health services provider. Review of R6's Comprehensive Care Plan (CCP) revealed the facility, on 08/10/2023, initiated a Behavior Care Plan with a focus on the resident's verbal aggression towards other residents. Interventions included to monitor and document R6's observed behaviors. A review of R6's Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) which indicated R6 had no cognitive impairment. Further review of the MDS, under Section E for Behaviors, revealed the resident was assessed to have no behaviors. Review of the Nurses Progress Note related to Behavior Charting, dated 11/29/2023 at 3:20 AM, revealed R6 was throwing his/her drink on the floor, slamming the bedroom door, damaging the doorknob, having a tantrum, and refused his/her medication. However, there was no documentation to support the facility monitored the resident's behaviors after the incident, as per the resident's care plan. Additionally, there was no documentation to support the resident was referred to the Psychiatrist for her next routine visit, as stated in the facility's policy. Review of the document titled, Behavior Meeting, dated 12/08/2023, revealed Advanced Practice Registered Nurse (APRN #1) attended the meeting. Continued review of the document revealed the Residents Reviewed section stated, Discussed resident seen on caseload today. Per the review, the residents' new behaviors were discussed, and they were added to the psychiatric (psych) caseload, and new orders were discussed. In addition, listed on the document in parenthesis were the names of five (5) residents; however, none of the residents discussed included R6. Review of a letter provided by Resident (R)6, on 12/13/2023, revealed the resident had written the following on two (2) pieces of note paper: Dear [sic] Sate of Kentucky I want you to [sic] kenow about [sic] wanth [sic] goneing hear and [sic] there are some this system was ok at first[ sic] aulie they stare behind R8 [sic] asshloe talk about last night and say this that why he/she had bitch cancer you thank that take hell no not head [sic] hem in the hall way night. If you don't do [sic] someing about he/she I will stop [sic] he/she from [sic] takeing about [sic] peolepe and he/she [sic] wont [sic] stoping it well he/she will to [sic] beceuse had [sic] ut to hear with it now. He/She will be [sic] stop so [sic] [NAME] do hear now. Do you [sic] thank I [sic] caer so what? R6's Comprehensive Care plan was updated on 12/13/2023 with new interventions for staff to ensure the resident felt safe and secure. Further review of the care plan revealed that trained staff would address the resident's needs. Review of the Long-Term Care Facility- Self-Reported Incident Form, dated 12/14/2023, revealed on that date it was reported that R6 threw coffee on R8. Further review of the Form revealed a skin assessment was completed on R8, and the resident was observed to have a quarter-sized area on his/her chest. Review of the Certified Nursing Assistant (CNA) Bath and Skin Report, dated 12/14/2023, revealed the Assistant Director of Nursing (ADON) assessed R8's skin after the coffee was thrown on him/her and documented R8 had an open blister on his/her upper chest. Review of the resident's Physician Orders, dated 12/15/2023, revealed the resident was to have Triple Antibiotic External Ointment (Neomycin-Bacitraci-Polymyxin) applied to his/her upper chest topically one (1) time a day for an open blister. Further, review of the orders revealed staff was to monitor the blister/open area to the resident's upper chest for signs and symptoms of an infection every shift. During an interview, on 12/15/2023 at 1:15 PM, R6 stated, by moving his/her lips, that he/she was angry earlier but was better now. R6 stated he/she threw coffee on R8 because he/she called him/her a bitch. R6 stated R8 had been calling him/her names for a long time. During an interview, on 12/15/2023 at 8:30 AM, R8 stated last night he/she heard a knock at his/her door so he/she got out of bed, opened the door, and R6 threw coffee on him/her. R8 denied calling R6 names and denied talking with R6. During an interview, on 12/16/2023 at 6:15 PM, Certified Nursing Assistant (CNA) 6 stated she had not received training from the facility before R6 threw coffee on R8 on how to manage R6's impulsive behaviors. However, the facility's Behavior Management Policy revealed staff would be educated on the resident's specific interventions, which included to monitor and document the resident's behaviors and ensure that the resident felt safe within the facility. During an interview on 12/18/2023 at 1:24 PM, the State Survey Agency (SSA) Surveyor read the Social Services Director's (SSD) Progress Notes, documented on 08/09/2023, to the SSD. The SSD stated that though he documented the resident had behaviors on 08/09/2023, he was not sure what behaviors R6 displayed in his Note. During an interview on 12/18/2023 at 12:10 PM, the Minimum Data Set (MDS) Coordinator stated she recalled discussing in the facility's morning meeting on Thursday 12/14/2023 that R8 called R6 a bitch. She stated R6 gave her a note the afternoon of 12/13/2023, and the note said something about R8 called him/her a bitch. The MDS stated she did not know if she told the facility's Administrator about the Note R6 showed her. She stated she told R6 to take the note to the State if you want, and further told the resident she did not want R6's note because there was nothing she was going to do with it. The MDS Coordinator stated the note was not addressed to her, it was addressed to the State and that R6 could write whatever he/she wanted to write. She further stated, we could not have prevented what happened, not even a little bit. However, review of the resident's care plan, dated 08/10/2023, revealed the resident's behaviors would be monitored and documented. During an additional interview on 12/18/2023 at 2:20 PM, the MDS Coordinator stated she had removed the intervention to monitor R6's behaviors and document observed behaviors, and attempted interventions from the resident's care plan on that day. She stated she removed that information because the facility was not monitoring R6, and the facility did not have the monitoring tools that were requested by the State Survey Agency (SSA) Surveyor. During an interview on 12/18/2023 at 2:30 PM, the Regional Nurse Consultant (RNC) stated the Behavior Meeting was held every other week on Fridays. She stated the resident behavior information that the facility used in the Behavior Meetings was the information staff talked about in each weekday morning meeting regarding resident behaviors. The RNC stated if someone told her a resident had a thumbs down day during the morning meeting, she would then relay that information in the Behavior Meeting. She stated any intervention from the behavior meeting was updated in the resident's care plan. She continued by stating she was unable to locate the facility's Behavior Meeting minutes for August 2023, which was the month the SSD documented R6 was having behaviors. In an additional interview with the Regional Nurse Consultant (RNC), on 12/19/2023 at 10:20 AM, she stated the facility's nursing staff charted by exception which meant if a resident exhibited a problematic behavior, nursing should document the behavior in the resident's Progress Notes or behavior charting notes. The RNC stated if a Certified Nursing Assistant (CNA) observed behaviors in a resident they were to report it to the nurse, and the nurse was to document the behavior. The RNC further stated nursing staff knew to document residents' behaviors from the resident's care plan and from nursing huddles (meetings with nursing staff). During an interview on 12/17/2023 at 12:22 PM, APRN #1 stated she provided psych med services for the facility and her last psychotherapy visit was on 12/08/2023. The APRN stated those visits were called behavior meetings, and were held at the facility every two (2) weeks on Fridays. The APRN stated if a resident had any agitation they talked about what needed to be done, and if it was an isolated incident they talked about what they needed to do. The APRN stated she saw the facility's residents for psych medications only. She stated she was very familiar with R6, and other medications R6 was taking. The APRN further stated she provided guidance to the facility's leaders and nurses on how to address R6's impulsivity when they talked about him/her in the behavior meetings. APRN #1 stated R6 got frustrated at times; however, was easily redirected. She stated, other than redirecting and talking to R6, there was no specific guidance on his/her outbursts that she provided to staff. In further interview, with Advanced Practice Registered Nurse (APRN) 1, on 12/17/2023 at 12:22 PM, she stated she had not seen the facility's Behavior Management Program Policy, nor was she familiar with the Behavior Management Log Book. The APRN stated she was unaware if any individual monitoring records or Recommended Intervention Worksheet forms had been documented on R6, per the procedure of the facility's Behavior Management Program Policy. She stated the Assistant Director of Nursing (ADON) typically guided the behavior meeting, the Social Services Director (SSD), and the Director of Nursing (DON) also came in and discussed the residents. APRN 1 stated she usually told the ADON, the SSD, and the DON if she had seen the resident being discussed in the behavior meetings and informed them on how to proceed. She stated she was not aware of a formal guideline or protocol for the behavior meetings and stated the SSD kept track of the meetings. The APRN further stated she did not know R8 and was very surprised R6 threw coffee on him/her. During an interview on 12/18/2023 at 1:50 PM, the DON stated any behaviors residents had since the last morning meeting were discussed. The DON stated if new interventions were added to a resident's care plan, she talked to nursing about the intervention and added it to her charting guide which she typed out for each resident who had a new behavior intervention. She stated if something new happened and a resident had a new care plan intervention, she let nursing know about it, so the facility could ensure the nurses were documenting the new intervention(s). The DON further stated if a nurse reported a behavior, then it was discussed in the next morning meeting. During a telephonic interview on 12/19/2023 at 10:20 AM, the Administrator stated in the day-to-day life of the facility, people talked about other people. She stated she and the RNC heard about R8 calling R6 a bitch, on 12/12/2023 and discussed R6's concerns with both residents. According to the Administrator, R8 denied making any inappropriate comments to R6. The Administrator stated, however, she and the RNC were not aware of the Note R6 had shown to the MDS Coordinator nor were they aware the MDS Coordinator had removed the intervention from the resident's CCP to monitor R6's behaviors, document observed behaviors, and attempted interventions on 12/18/2023. In an additional telephonic interview with the Regional Nurse Consultant (RNC), on 12/19/2023 at 10:25 AM, the RNC stated it would have been helpful to know about the Note R6 wrote and showed to the MDS Coordinator so the facility could have addressed any potential problems. The RNC stated if knowledge of the Note, on which R6 wrote R8's name and the word bitch and showed to the MDS Nurse, had been shared in the morning meeting on the 13th or 14th of December, the information would have been helpful to the facility so R6 could have been provided increased monitoring.

Based on observation, interview, record review, review of the facility's investigation report, and review of the facility's policies, it was determined the facility failed to ensure a safe environment that was free from accidents and hazards to ensure resident safety and supervision for one (1) of thirty one (31) sampled residents (Resident #595). On 10/07/2023 at approximately 1:00 PM, Resident #595, whom the facility assessed to lack safety awareness, was seen by the Regional Director of Operations for Food/Nutrition Services, outside, behind the facility, sitting in his/her wheelchair near the street unsupervised by facility staff. By the time staff inside the facility were alerted by the Regional Director of Operations for Food/Nutrition Services, the resident was found two (2) blocks away from the facility. The findings include: Review of the facility's policy titled, Standard Supervision and Monitoring, dated 05/17/2023, revealed the general purpose of the policy emphasized a proactive intervention to promote enhanced physical and psychosocial well-being. Further review of the policy revealed that when a resident had been assessed by the staff nurse or psychosocial staff to have stable physical and psychosocial needs that regular rounds would be maintained. In addition, per the policy, the staff member that had been assigned to care for the resident would visualize the resident at the start and end of the shift, during meal times, and at a minimum every two (2) hours between. Review of the facility's policy titled, Elopement and Missing Resident Prevention, dated 04/20/2023, revealed the facility would provide adequate supervision to meet each resident's nursing and personal care needs. Further review revealed staff would be trained on elopement prevention upon hire and at a minimum annually. Review of Resident #595's Admission Record revealed the facility admitted the resident on 10/03/2023, with diagnoses of rhabdomyolysis (sore, weak muscles), hemiplegia affecting left nondominant side, convulsions, and alcohol abuse. Record review revealed Resident #595 was homeless before he/she was hospitalized and later admitted to the facility. Resident #595 also had a guardian. Review of Resident #595's Admission Minimum Data Set (MDS) Assessment, dated 10/03/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS Assessment revealed Resident #595 required substantial to moderate assist for safe transfers, sit to stand, and bed mobility. Review of Resident #595's Admission Elopement Risk Assessment, dated 10/03/2023, revealed a score of three (3), which indicated the resident was at low risk for elopement. Further review revealed the resident had no history of elopement episodes for the past three (3) months, and the resident had readily accepted nursing home placement. Review of Resident #595's Care Plan, dated 10/04/2023, revealed a focus of decreased safety awareness as the resident required assistance with Activities of Daily Living (ADL), transfers, and mobility related activities. Observation of Resident #595 on 10/19/2023 at 8:59 AM, revealed the resident lying in bed with eyes closed. The resident was neat, clean, appropriately dressed, well groomed, and without odor. Review of Resident #595's Nurse Progress Note, dated 10/07/2023 at 2:56 PM, entered by Registered Nurse (RN) #5, revealed the aides were looking for Resident #595, and the resident was located outside of the facility. Review of Resident #595's Nurse Progress Note, dated 10/07/2023 at 2:57 PM, revealed the resident was back from the street, where he/she was found a few blocks away from the facility. Review of the Facility's Investigation, dated 10/07/2023, revealed Resident #595 went to the front entrance door and requested the security guard let him/her outside. Per the report, the security guard opened the door allowing the resident to exit the facility. Review of the typed summary of the Facility's investigation, not signed or dated, revealed on 10/07/2023 at approximately 1:15 PM, Licensed Practical Nurse (LPN) #11 was standing outside the facility with Resident #595 and could not get him/her to come back to the facility. Continued review revealed the resident was returned to the facility within thirty (30) minutes of leaving with the assistance of his/her sister/guardian, and staff. Further review revealed Resident #595 was mad because he/she had a legal guardian, and the resident felt he/she was able to make his/her own decisions. During an interview with Resident #595's Guardian (sister) on 10/19/2023 at 2:26 PM, she stated she was appointed the resident's guardian in August or September of 2023. The guardian stated she had been unable to reach the resident by phone, went to the hotel where the resident was staying, and found him/her unconscious on the floor. She stated the resident was sent to the hospital, and upon discharge from the hospital, he/she was admitted to the facility. She stated she was at the facility visiting Resident #595 on 10/07/2023 around 11:00 AM to 12:00 PM, and she could not remember the resident stating he/she wanted to leave. The guardian stated she had left the facility to get Resident #595 some cigarettes when she received a call from the facility at 1:38 PM. She stated staff called her to inform her that Resident #595 was outside the facility a few blocks away, and refused to go back to the facility. The Guardian stated she went to Resident #595's location and talked Resident #595 into going back to the facility. Review of Security Guard #5's witness statement, dated 10/07/2023, revealed she saw a male/female walking toward the front entrance door. Continued review revealed Security Guard #5 stood up and asked Resident #595 if he/she was a resident of the facility, and Resident #595 stated No, and continued to walk out the door. During an interview on 10/19/2023 at 9:20 AM with Receptionist #1, she stated if a resident was leaving the facility for any reason, they must sign and date the Resident Sign In/Out Log located at the front desk. Receptionist #1 further stated she had a binder located at the front desk with photos of the residents that were identified as an elopement/risk. She stated, as of last week, she now had a second binder located at the front desk with photos of all residents in the facility. Receptionist #1 stated if anyone came to the window, and wanted out the front door, and she did not know them, she would call the nurse to come and identify the person prior to letting him/her exit the facility. She further stated she conducted orientation with new hires on the sign in/out process and the two (2) binders located at the front desk. Additionally, she stated she informed new hires if they did not know who the resident was, they needed to check at the nurses' station prior to opening the door and letting anyone exit the facility. Review of the facility's Resident Sign In/Out Log dated 10/07/2023, revealed Resident #595 had not signed out prior to exiting the facility. Further review revealed Resident #595 had not signed out of the facility since being admitted on [DATE]. During an interview with Resident #595 on 10/19/2023 at 9:00 AM, the resident stated he/she had been appointed a new state guardian, and he/she had seen her two (2) weeks ago. The resident stated he/she did leave the facility the other day without staff knowledge. He/she stated the lady at the front office asked if he/she was a resident, and when he/she told the lady no, the lady at the front desk let the resident exit the front door. The resident stated he/she was able to walk some, but normally used his/her wheelchair for mobility. The resident further stated, I am grown, I can make my own decisions, and I do not need a guardian. During an interview with the Business Office Manager (BOM) on 10/19/2023 at 9:39 AM, she stated she was responsible for updating the resident binder as needed, and the binders were kept at the front desk for the receptionist and the security guards to use to identify residents residing in the facility. The BOM stated the binders should be used to identify residents who were assessed as an elopement risk and to prohibit those residents from exiting the building unattended/unsupervised by staff. The State Survey Agency (SSA) Surveyor attempted a phone interview with Security Guard #5, on 10/19/2023 at 10:18 AM, 11:25 AM, 4:43 PM, and again on 10/20/2023 at 11:27 AM. All attempts to contact Security Guard #5 by phone were unsuccessful. During an interview with the Social Services Director (SSD) on 10/19/2023 at 9:46 AM, he stated he had completed the BIMS Assessment on Resident #595 on admission. He stated Resident #595's BIMS' score was thirteen (13), which indicated the resident was cognitively intact. The SSD stated Resident #595 did not mention he/she had a desire to leave the facility. He further stated he had contacted the guardian to obtain permission for Resident #595 to go outside and smoke with staff supervision but failed to obtain consent for the resident to leave the facility at will. During an interview with the Regional Director of Operations of Food/Nutrition on 10/19/2023 at 10:52 PM, he stated on 10/07/2023 he was leaving the facility to go get supplies and noted a person outside in a wheelchair struggling to wheel the chair. The Regional Director of Operations (RDO) stated he stopped his car and asked the person if they needed assistance and if he/she was a resident of the facility, and the person stated No. The RDO stated he felt the person in the wheelchair was a resident. He stated he drove back to the front entrance of the facility, went to the nurses' station, and asked the staff at the nurses' station if there was a resident missing from the facility. He stated three (3) staff, (Certified Nursing Assistant [CNA] #33, CNA #24, and CNA #22) went outside with him to see what the person looked like, and the resident was no longer in the area where he/she was last seen. The RDO stated he saw the resident at the next block down the street and drove his car over to the resident. Continued interview with the RDO on 10/19/2023 at 10:52 PM, he stated he asked the resident his/her name, and the resident stated again he/she was not a resident at the facility. The RDO stated he came back to CNAs #22, #24, and #33, who were outside near the facility next to the street, and gave them the resident's name. He stated the CNAs did not recognize the resident's name and went back into the facility and asked Licensed Practical Nurse (LPN) #11 if Resident #595 was a resident. He stated LPN #11 stated, Yes, that is our resident. The RDO stated he let the staff handle the situation from that point on. During an interview with CNA #33 on 10/19/2023 at 1:09 PM, she stated she was at the nurses' station on 10/07/2023 when the RDO came to the nurses' station and informed them a person was outside in a wheelchair, and he thought the resident might reside at the facility. CNA #33 stated she, CNA #22, and CNA #24 went outside to the area where Resident #595 was last seen. CNA #33 stated Resident #595 was not there, the RDO found the resident two (2) blocks away, and he asked the resident for his/her name. CNA #33 stated when the RDO came to where the CNAs were standing and told them the name of the person in the wheelchair, she did not recognize the name and went back to the facility to check with a nurse (LPN#11). CNA #33 stated she gave LPN #11 the person's name, and LPN#11 stated it was Resident #595. CNA #33 stated she, CNA #22, and CNA #24 drove to the location where the resident was sitting in his/her wheelchair on the sidewalk, which was approximately two (2) blocks away from the facility. CNA #33 stated the resident refused to go back to the facility, and LPN #11 had to call the resident's guardian to assist with getting the resident back into the facility. She stated the guardian arrived and talked Resident #595 into getting into the car and returning to the facility. During an interview with LPN #11, on 10/20/2023 at 4:50 PM, he stated on 10/07/2023 around 1:00 PM, CNA #33 yelled from the nurse's station, asking if they had a resident (Resident #595) in the facility. LPN #11 stated CNA #33 informed him the Regional Director of Operations had found the resident outside the fenced area of the facility. LPN #11 stated he ran to Resident #595's room and noticed he/she was not in the room, then went to the breakroom and other areas of the facility, but could not locate Resident #595. LPN #11 said he then went to the security guard who was at the front desk, described Resident #595, and asked if the resident had gone outside. LPN #11 stated the security guard said yes. LPN #11 stated at the same time CNA #33 was calling stating Resident #595 had been found. LPN #11 stated he drove to Resident #595. He stated while on the way, he called the Assistant Director of Nursing (ADON) and the resident's legal guardian to notify them the resident had been found outside the facility. LPN #11 stated the guardian arrived at the location where the Resident was sitting in his/her wheelchair and encouraged Resident #595 to return to the facility. LPN #11 stated the security guard at the desk should have called the nurses' station prior to letting anyone out of the facility to make sure he/she was not a resident trying to exit. During an interview with Registered Nurse (RN) #5 on 10/20/2023 at 12:05 PM, he stated on 10/07/2023 sometime between 12:00 PM and 1:00 PM, one (1) of the CNAs (he could not identify) made him aware Resident #595 was out of the facility, unsupervised. RN #5 stated he was informed the security guard at the front desk had let Resident #595 out of the building. RN #5 stated he was assigned to care for Resident #595 on 10/07/2023 from 6:00 AM to 6:00 PM. The RN stated sometime between 10:00 AM to 11:00 AM he had taken medications to Resident #595 and had not seen him/her since that time. RN #5 stated Resident #595 had not stated he/she desired to leave the facility the last time he saw the resident. Continued interview revealed he was on break during the time the resident exited the building. RN #5 stated the security guard should not have allowed the resident to exit the building before checking with the nurse. During an interview with Security Guard #2 on 10/20/2023 at 2:35 PM, he stated he worked at the front office on Saturdays and Sundays from 8:00 PM to 8:00 AM. He further stated there were two (2) books, a visitors' book and a resident book, located at the desk, and staff was to refer to the books prior to letting anyone outside the facility. Additionally, he stated there were two (2) sign in and sign out logs located at the desk, one (1) for visitors and one (1) for residents. He stated he was aware of the elopement book with pictures and the resident book, which were both located at the front desk. During an interview with the ADON on 10/19/2023 at 11:00 AM, she stated she was contacted between approximately 1:00 PM to 2:00 PM on 10/07/2023 by LPN #11. She stated LPN #11 stated he was standing outside the facility with Resident #595 and could not get the resident to come back into the building. The ADON stated she instructed LPN #11 to stay with Resident #595 and continue to try to get the resident to come back to the facility. She stated she contacted the Director of Nursing (DON) and Administrator (ADM) on a three (3) way call and informed them Resident #595 was located outside the facility and was refusing to come back in. The ADON stated Resident #595 was placed on one-to-one (1:1) supervision which meant someone had their eyes on Resident #595 at all times. The ADON stated the security guard at the desk should have checked with the nursing staff prior to letting Resident #595 exit the facility. The ADON stated the facility's New Resident Binder identifying all residents in the facility was not added to the front desk for staff to use until after Resident #595 had exited the building. During an interview with the Medical Director (MD) on 10/20/2023 at 10:58 AM, he stated he was made aware of the incident and could not remember who called him or when he was called. He stated by the time he had been notified, Resident #595 was already back in the facility. The MD stated this was an unfortunate incident. and He further stated from what he understood about the incident involving Resident #595, someone dropped the ball and placed the resident at increased risk of harm. He further stated any elopement/missing person could put a resident at high risk for harm, and it was his expectation the facility should keep residents 100% safe. During an interview with the Administrator (ADM) on 10/20/2023 at 11:55 PM, she stated she was notified on 10/07/2023 of the incident with Resident #595. She further stated the resident was found quickly and was placed on one-to-one (1:1) supervision. She stated all staff, including the security guards, had been educated on not allowing persons to leave the facility without knowing their identity. The Administrator also stated the facility did not have a policy related to signing in/out of the facility. The Administrator stated all processes were put in place to quickly locate the resident when the incident occurred. She stated it was her expectation for all staff to follow the facility's process in regard to viewing the binders located at the front desk prior to allowing anyone outside the facility.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' comprehensive person-centered care plans were developed and implemented that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for nine (9) of sixty-one (61) sampled residents, Residents #6, #15, #11, #51, #72, #84, #242, #243, and #244. 1. The facility failed to thoroughly develop and implement a comprehensive care plan for dialysis for Residents #242, #243, #244 and #11. (a) The facility failed to ensure Resident #242 received his/her dialysis treatment on 04/23/2022 and on 04/26/2022, as per the resident's care plan. Therefore, upon arrival at the dialysis clinic on 04/28/2022, Resident #242 presented slumped over, unresponsive, with his/her body twitching, and required transport to the emergency room (ER). (b) The Physician ordered in-house dialysis treatments for Resident #243 three (3) times a week on Monday-Wednesday-Friday at the in-house clinic. However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule for the resident's dialysis on Mondays, Wednesdays, and Fridays. Therefore, review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility. (c) The facility admitted Resident #244 on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments. The facility failed to develop and implement Resident #244's care plan to include his/her dialysis orders, days of dialysis, his/her access site location; the dialysis center where he/she was to go with the dialysis time and transport company listed. Therefore, Resident #244 was sent back to the acute care hospital on 02/25/2023 to receive his/her dialysis treatment and did not return to the facility. (d) The facility failed to develop Resident #11's care plan to include the dialysis center, the time, frequency, days of the week for treatment, and transport method. Additionally, the facility failed to implement Resident #11's care plan to ensure it communicated with the dialysis center regarding the resident's treatment. 2. The facility failed to thoroughly develop and implement the comprehensive care plan with necessary fall interventions for Residents #6, #15, #51, and #72. (a) The facility failed to implement Resident #6's care plan on 07/23/2023, when Certified Nursing Assistant (CNA) #21 transferred the resident via mechanical lift alone, and left the resident suspended in the lift sling to try to get assistance from Registered Nurse (RN) #3. Resident #6 stated he/she was afraid when left alone in the lift sling. (b) On 06/28/2023, Resident #15 sustained a fall which resulted in a hip fracture, and on 06/29/2023, the facility implemented an intervention not to leave the resident sitting in a chair alone in his/her room. However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with his/her feet elevated in his/her room alone, and attempting to climb out of chair with no staff near the resident's room. (c) The facility failed to develop and implement Resident #51's fall risk care plan as necessary. Resident #51 therefore sustained ten (10) falls after admission to the facility on [DATE] through 07/08/2023, seven (7) of which resulted in injury and the resident being transferred to the emergency room (ER). (d) The facility failed to develop and implement Resident #72's care plan related to his/her history of falls. Resident #72 sustained a fall from his/her bed on 07/06/2023 at 10:00 AM, resulting in a gash to his/her leg requiring transport to the ER where the resident's gash was closed with sutures. 3. The facility admitted Resident #84 with a diagnosis of Post Traumatic Stress Disorder (PTSD); however, failed to develop and implement a care plan for the resident's PTSD diagnosis and ensure staff were knowledgeable of his/her diagnosis. The facility's failure to ensure residents' comprehensive person-centered care plans were developed and implemented to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.21(b)(1) Quality of Care F656 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility's policy titled, Care Plan Policy, revised 11/24/2022, revealed it was the facility's policy to ensure every resident had a Baseline Care Plan completed and implemented within forty-eight (48) hours of admission to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events most likely to occur right after admission. Continued review revealed the Baseline Care Plan was to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan was completed, then discontinued. Review revealed the Comprehensive Care Plan further expanded on the resident's risks, goals, and interventions using the Person-Centered Plan of Care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs. Further review revealed the resident's needs were to be defined from observation, interviews, clinical medical record review and thorough assessments and Care Area Assessments (CAAs). Review further revealed the facility's Interdisciplinary Team (IDT), in conjunction with the resident, resident's family, or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant were to discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. 1. Review of Resident #242's medical record revealed the facility admitted the resident on 04/21/2022, with diagnoses which included: Hypotension, End Stage Renal Disease (ESRD), and Pain in Leg. Review of the resident's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #242 to have a Brief Interview for Mental Status score of eleven (11) out of fifteen (15), indicating he/she was moderately cognitively impaired. Review of Resident #242's baseline care plan initiated on 04/22/2022, revealed a potential for complications related to ESRD and dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday, resident to be picked up at 2:00 PM; however, the facility listed no dialysis company on the baseline care plan. Continued review revealed the care plan interventions included: protect the resident's shunt (dialysis access) site from injury; avoid constriction on affected arm, such as a blood pressure (BP) cuff, carrying purse, constrictive clothing; however, the facility did not list the site of the dialysis access on the care plan. Further review of the care plan revealed additional interventions: to monitor/record/report to Physician/Medical Director (MD) as needed (PRN) for signs and symptoms related to renal disease, including fluid overload, itching, BP changes, confusion, altered mental status, fatigue, hair/skin/nail texture changes, nausea/vomiting, and restless leg syndrome. In addition, the further interventions included to make transportation arrangements for dialysis; however, the facility listed no transport company on the care plan. Review of Resident #242's records from the outpatient dialysis center revealed he/she did not receive a dialysis treatment on Saturday, 04/23/2022 or on Tuesday, 04/26/2022, as per the resident's care plan. Continued review revealed on Thursday, 04/28/2022, Resident #242 was transported from the facility to the dialysis clinic's lobby; however, was sent to the local hospital Emergency Department (ED) from the lobby. Further review revealed Resident #242 had presented to the dialysis clinic lobby slumped over and unresponsive, with his/her body twitching. Review of Resident #242's facility medical record revealed no documented evidence of the resident's missed dialysis treatments on 04/23/2022 and 04/26/2022. Continued review revealed manual BPs were taken with the BP cuff on 04/23/2022 at 12:56 AM, 04/23/2022 at 10:40 AM, 04/26/2022 at 1:39 AM, 04/27/2022 at 8:08 AM, and 04/28/2022 at 2:02 AM on Resident #242's affected arm with the shunt site, even though the resident's care plan interventions specified this was not to be done. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport for dialysis should have already been set up by the facility prior to the resident being admitted , and this was stated in his/her care plan. She stated Resident #242's missed treatment on 04/23/2022 was on a weekend (Saturday), and the facility could not get transport because it was not set up prior to the resident coming to the facility. 2. Review of Resident #243's Admission Record revealed the facility admitted the resident, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Record review revealed the facility discharged Resident #243 on 07/14/2023, therefore, the resident's BIMS score was not assessed due to his/her short stay in the facility. Review of Resident #243's baseline care plan initiated on 07/11/2023, revealed care plan interventions to monitor/document/report PRN (as needed) the following signs and/or symptoms: edema, weight gain of over two (2) pounds a day, neck vein distension, difficulty breathing (dyspnea), increased heart rate (tachycardia), elevated blood pressure (hypertension), peripheral pulses, level of consciousness, and breath sounds for crackles. Continued review revealed additional interventions included: to check and change dressing daily at the dialysis access site and document; and do not draw blood or take BP in arm with graft (dialysis access, however, no site was listed). Further review revealed the interventions also included monitor/document/report PRN for signs and/or symptoms of renal insufficiency: changes in level of consciousness; changes in skin turgor; oral mucosa; and changes in heart and lung sounds. Review further revealed however, the facility documented no dialysis clinic, frequency of dialysis treatments, or days of dialysis treatment on Resident #243's care plan. Continued review of Resident 243's medical record revealed the facility ordered in-house dialysis treatments for the resident on 07/12/2023, a Wednesday. Review further revealed the order was for Resident #243 to have dialysis treatments three (3) times a week on Monday-Wednesday-Friday at the in-house clinic. However, the facility failed to develop Resident #243's care plan to include the in-house dialysis clinic's schedule of dialyzing the resident on Monday-Wednesday-Friday. Review of Resident #243's Nurse Progress Note dated 07/14/2023 at 3:55 PM, revealed the resident had received no dialysis since Monday, 07/10/2023, prior to his/her admission to the facility. In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had a dialysis order in place. She stated if Resident #243 had an order for dialysis on 07/12/2023 and she had known, she would have taken the resident to dialysis. She stated she relied on the resident's care plan to inform her on how to care for the resident. 3. Review of Resident #244's Admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Diabetes, and Hypertension. Continued review revealed Resident #244 had a tunnel catheter in the right upper chest for dialysis access. Further review revealed Resident #244 was discharged on [DATE], and therefore, a BIMS score was not assessed to determine the resident's cognition. Continued review of Resident #244's medical record revealed the facility admitted the resident on 02/23/2022, without an outpatient dialysis clinic order for him/her to receive his/her dialysis treatments. Review of Resident #244's baseline care plan initiated on 02/25/2022, revealed a potential for complications related to end stage renal disease and dialysis treatments three (3) times a week; however, there was no documented evidence of the resident's dialysis orders or days listed. Continued review revealed other interventions included: to make transport arrangements for dialysis; protect shunt site from injury; and avoid constriction on affected arm, such as with BP cuff, carrying purse, constrictive clothing. Further review revealed however, no documented evidence of Resident #244's access site listed. In addition, review further revealed no documented evidence of a dialysis center listed, the time listed, or a transport company listed. Further review of Resident #244's medical record revealed the resident was sent back to the acute care hospital on 02/25/2023 to receive his/her dialysis treatment and did not return to the facility. Review of Resident #244's Nurse Progress Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed the resident was being transported to a local ED because the resident needed to have dialysis. Further review of the Note revealed upon Resident #244's return to the facility, a dialysis center needed to be assigned to establish a regular dialysis schedule; however, the resident did not return to the facility. In interview on 07/23/2023 at 8:05 AM, LPN 11 stated for HD residents nurses got their vital signs and made sure their medications were given. She stated they checked the resident's access site for infection and swelling, and monitored the residents for swelling. LPN #11 stated for fluid overload the nurse would talk to the doctor and send the resident out if their dialysis was missed. She stated they used a monitoring form and filled it out on residents' HD days, monitoring the access site and weights prior HD. The LPN further stated nurses used residents' care plans and orders for dialysis information about their access site and how to care for the resident. 4. Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date 07/25/2019, revealed a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session. Review of Resident #11's medical record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating he/she was cognitively intact. Review of Resident #11's Comprehensive Care Plan revealed care plan interventions initiated on 10/27/2022 to: communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis access) site from injury; avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing; and avoid any possible injury to the arm with the fistula (the orders stated to monitor the left upper arm fistula). Continued review revealed the care plan stated to monitor Resident #11's right upper chest and left upper arm fistula for bleeding initiated on 10/27/2022. Further review revealed the facility failed to develop Resident #11's care plan to include the dialysis center, the time, frequency, days of the week for treatment, and transport method. In addition, there was no documented evidence of mention of the method of communication with the dialysis center. Review of Resident #11's communication sheets provided by the facility on 07/11/2023 at 2:56 PM, between the dialysis center and the facility, revealed the resident received dialysis at an outside dialysis clinic on Tuesday, Thursday, and Saturday. However, review of Resident #11's communication sheets revealed no documented evidence of communication sheets for the resident's dialysis treatment after 05/17/2023, approximately seven (7) weeks. Therefore, the facility failed to follow Resident #11's care plan intervention to communicate with the dialysis center. In interview on 07/23/2023 at 8:15 AM, LPN #12, who just started working at the facility a month ago, stated she had not received any education on residents that had dialysis. She stated she relied on the residents' care plans and orders to instruct her on how to care for residents that received dialysis. She stated she was unsure about ongoing monitoring or what to do if a resident missed a dialysis treatment. 47852 5. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #15 required two (2) person assist for bed mobility and one (1) person physical assist with transfers. Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the resident was at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention, initiated on 06/29/2023, not to leave the resident up in the chair in the room alone. However, observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair in his/her room alone, with his/her feet raised. Continued observation revealed Resident #15 was attempting to climb out of chair, and no staff were present near the resident's room. The State Survey Agency (SSA) Surveyor notified staff who went to Resident #15's room. Review of Resident #15's Progress Notes revealed the resident slipped out of the wheelchair on 06/28/2023, when he/she was left alone in his/her room. Continued review of the Progress Notes revealed Resident #15 complained of right hip pain on 07/04/2023, at which time an x-ray of his/her right hip was ordered by the Physician. Review of the Progress Notes revealed an x-ray was obtained on 07/07/2023 (nine [9] days after the resident's fall), with a final x-ray report received on 07/08/2023, which revealed Resident #15 had a right hip fracture. Further review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023, when Resident #15 was admitted to the hospital for the right hip fracture. During an interview with CNA #21 on 07/16/2023 at 7:20 PM, she stated Resident #15 required total assist with transfers and was currently out to the hospital. During an interview with the MDS Nurse on 08/07/2023 at 11:15 AM, she stated the nurse should implement an immediate intervention following a resident's fall and the Interdisciplinary Team (IDT) met at the next scheduled IDT meeting, which was usually held Monday through Friday, to discuss if the intervention was appropriate. She further stated she then placed the intervention on the resident's Comprehensive Care Plan. 6. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses which included Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued review of the MDS, section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility and review of section J revealed the resident had a history of falls prior to admission. Review of the facility's baseline care plan for Resident #72 dated 05/01/2023, revealed the facility identified and care planned the resident for his/her risk for falls; however, the facility did not initiate the comprehensive fall care plan until 06/20/2023. Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of base line care plan dated 05/02/2023, the section H safety risks Resident #72 was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed bed in lowest position was listed under specify other safety devices. Further review revealed under the comments documentation noting: Resident #72 was only oriented to self; could not comprehend where he/she was; his/her gait was weak and unsteady; he/she attempted unassisted transfers; and he/she used the call light. Review of Resident #72's Comprehensive Care Plan dated 06/20/2023 revealed a focus for the resident as at risk for falls related to decreased safety awareness, incontinence of bowel, and incontinence of bladder. Review of the goal dated 06/20/203, revealed Resident #72 was to have a safe environment maintained through the next review target date of 11/07/2023. Further review revealed interventions dated 06/23/2023 for a reacher (grabber) for safety with frequently used items within reach, and on 07/07/2023 for bilateral (enabler) side bars added to bed to assist resident to lay in center of bed. Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified. In interview on 08/06/2023 at 10:10 AM, the Director of Nursing (DON) stated the baseline care plan was in place and was in place for the twenty-one (21) days until the comprehensive care plan. In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan. In interview on 08/07/2023 at 11:14 AM the MDS Coordinator stated the comprehensive care plan took twenty-one (21) days to be developed. The MDS Coordinator stated the fall comprehensive care plan should have been formulated for Resident #72 within the twenty-one (21) day period. 7. Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident had intact cognition. Continued MDS review, Section G functional status, revealed the facility assessed the resident to require assistance of two (2) persons for transfers. Review of Resident #6's Comprehensive Care Plan dated 06/21/2023, revealed the facility care planned the resident to require assistance with Activities of Daily Living (ADLs) related to Disease Process and Limited Mobility. Continued review revealed interventions which included extensive assistance by two (2) staff to move between surfaces. Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift and being transferred from the bed to the chair by CNA #21. Per observation, CNA #21 had no other staff member present in the room to assist her. Continued observation revealed Registered Nurse (RN) #3 was standing in the hallway outside Resident #6's room at a medication cart. CNA #21 was observed to go to the doorway of the Resident #6's room to ask RN #3 to assist her with the mechanical lift transfer, leaving the resident suspended in the lift sling alone. Observation further revealed RN #3 told the CNA she would help her after she gave the resident's medication. In interview on 07/23/2023 at 9:24 AM, CNA #21 stated that day there were only four (4) CNAs for the whole building, in addition to the CNA sitting 1:1 with a resident. She stated there were two (2) CNA call ins, and no other CNAs were available to assist her at the time of Resident #6's transfer. The CNA stated she knew she should have two (2) staff for all lift transfers and as per the resident's care plan. She stated that day however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be gotten up and into his/her wheelchair to attend church services. CNA #21 stated the DON told her before Resident #6 was to be gotten up for church services if he/she wanted to go to church. The CNA further stated Resident #6 could have fallen from the lift, or the lift could have tipped over or the straps have broken, which could have caused the resident injury. In interview on 07/23/2023 9:27 AM, RN #3 stated she was passing medications for the entire hall and was attempting to give the medication she had already prepared for a resident before she assisted CNA #21. She stated two (2) staff should always perform lift transfers so one (1) person could move the lift while the second person assisted the resident so the lift did not move, the sling did not break, or the resident fall out of the sling and cause injury to the resident. In interview on 08/05/2023 at 10:50 AM, Resident #6 stated he/she was very afraid when being in the lift with only the one (1) staff person using it on 07/23/2023. Resident #6 stated he/she had hurt his/her left shoulder and hip after experiencing a fall from a lift at another facility. The resident further stated he/she had been a nurse and knew there should always be two (2) staff with all lift transfers for resident safety. 8. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of Resident #51's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded as zero (0). Further review of the MDS, Section G, functional status revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers, and review of the MDS, section J revealed Resident #51 had a history of falls. Review of Resident #51's Comprehensive Care Plan, dated 04/23/2023, revealed the resident was care planned for a risk for falls with interventions including: two (2) staff for ADL care for safety; bolsters to left side of bed; one-to-one (1:1) supervision for safety due to frequent falls; call light within reach at all times, therapy to assess for locking tray table for geri chair; low bed related to decreased safety awareness; full size mattress to right side of bed; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation. Review of Resident #51's medical record revealed Resident #51 sustained ten (10) falls after admission to the facility on [DATE], which were as follows: a). On 04/13/2023, Resident #51 was found lying on the floor in his/her room and the facility determined the resident sustained a fall which resulted in a laceration and hematoma over the resident's right eye and a laceration over his/her left eye. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain {dura}and the surface of the brain). Review revealed Resident #51 was hospitalized from 04/13/2023 to 04/20/2023. b). On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted from the head beside him/her and he/she was transported to the hospital emergency room (ER). On 04/25/2023, the IDT implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat on the floor. However, review of the resident's care plan revealed the facility implemented a full size mattress beside the bed on 04/23/2023. c). On 04/26/2023, Resident #51 was found lying on the floor with feces on him/her, on the bed, mat, and floor. The IDT implemented an intervention on 04/27/2023, to toilet the resident every two (2) hours. d). On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT implemented an intervention for therapy to do wheelchair modifications. However, care plan review revealed the facility failed to develop the falls care plan further with this intervention. e). On 05/20/2023, Resident #51 was found lying face down on the floor with blood on his/her face and gown, and the resident stated he/she tripped on the mattress beside the bed. Resident #51 was transferred to the ER, and returned on 05/21/2023, with sutures in place to the right eyelid. On 05/23/2023, the IDT placed the resident on 1:1 supervision while in bed. The facility continued the mattress beside the bed as an intervention, even though Resident #51 tripped over it. f). On 05/29/2023, Resident #51 was found sitting on the floor mat beside his/her bed and the facility placed him/her on 1:1 supervision at all times. g). On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment with admission overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan. h). On 06/21/2023, a staff member witnessed Resident #51 fall to the floor and hit his/her head. Resident #51 was sent to the ER and admitted overnight. Review revealed no documented evidence of an IDT note or of an intervention implemented and added to his/her care plan. i). On 07/01/2023, Resident #51 sustained a fall from his/her chair to the floor, and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation. j). On 07/08/2023, Resident #51 fell and hit his/her nose on the table while staff were providing 1:1 care. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with the resident's ADLs. Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray across the tray physically restraining the resident. CNA #11 was assigned to be sitting 1:1 with Resident #51; however, the CNA was observed walking around the nurse's station and

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards for four (4) of sixty-one (61) sampled residents, Residents #6, #15, #51, and #72. Observation on 07/23/2023, revealed Resident #6 being transferred by a mechanical lift with the assistance of one (1) staff member. The facility assessed Resident #6 to require extensive assistance of two (2) staff to move between surfaces on 06/21/2023. Record review revealed Resident #15 had a fall on 06/28/2023 and was diagnosed with a right hip fracture on 07/07/2023. Review revealed Resident #15 was noted to be rolling to the edge of the bed on 07/28/2023. Further record review revealed Resident #15 fell from his/her bed on 07/28/2023. Record review revealed Resident #51 sustained ten (10) falls after his/her admission to the facility on [DATE] through 07/08/2023. Review of medical record Resident #72 revealed the facility assessed the resident as a high risk for falls. On 07/06/2023, Resident #72 rolled out of bed and fell to the floor sustaining an injury which required eleven (11) sutures to his/her leg. The facility's failure to to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards 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 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(d)(1)(2) Quality of Care F689 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility policy titled, Incident, Accidents and Falls revised 01/30/2022, last reviewed 02/01/2023, dated revealed it was the facility's policy to ensure any incident/accident to include falls was reported immediately to the nurse or appropriate person designated to be in charge. Continued review revealed after the resident had received immediate attention and their safety was established, a written report was to be entered into Risk Management. Further review revealed the facility was to ensure incidents and accidents involving residents were identified, reported, investigated, and resolved. 1. Review of the facility policy titled, Mechanical Lift Transfer Usage Guideline dated 01/09/2023, revealed to avoid slinging the resident lift only high enough to clear the bed or chair to facilitate a transfer. Continued review revealed one (1) person was to always maintain control of the resident in the sling while the second person did not move once the mechanical lift was in the correct position. Review of Resident #6's medical record revealed the facility admitted the resident on 06/20/2023, with diagnoses including Hypertension, Parkinson's Disease, Anxiety, and Depression. Review of Resident #6's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Further MDS review, Section G functional status, revealed the facility assessed Resident #6 as a two (2) person assist for transfers. Observation on 07/23/2023 at 9:20 AM, revealed Resident #6 suspended in a lift sling from a mechanical lift being transferred from the bed to the chair by Certified Nurse Assistant (CNA) #21. Continued observation revealed no other staff member present in the room; however, Registered Nurse #3 was standing in the hallway outside Resident #6's room at the medication cart. Observation revealed CNA #21 went to the doorway of the resident's room to ask RN #3 to assist with the mechanical lift transfer, leaving Resident #6 suspended in the lift sling. Further observation revealed RN #3 informed CNA #21 she would assist after she passed the resident's medication. In interview with Resident #6 on 08/05/2023 at 10:50 AM, the resident stated he/she was very afraid while in the lift with only the one (1) person using it on 07/23/2023. The resident stated he/she had fallen from a lift at another facility and hurt his/her left shoulder and hip. Resident #6 stated he/she had been a nurse and was aware there should always be two (2) staff with all lift transfers for resident safety. In interview with CNA #21 on 07/23/2023 at 9:24 AM, she stated there were only four (4) CNAs for the building in addition to the CNA sitting one-to-one (1:1) with another resident. The CNA stated there had been two (2) call ins, and there were no other CNAs available to assist her at the time of Resident #6's transfer. She stated she was aware she should have two (2) staff for all lift transfers; however, she had twenty-four (24) residents to care for by herself on the hall and Resident #6 needed to be assisted into his/her wheelchair to attend church services. CNA #21 stated the Director of Nursing (DON) had previously told her Resident #6 was to get up for church services if he/she desired to go to church. She further stated Resident #6 could have fallen from the lift, the lift could have tipped over or the straps could have broken, causing the resident injury. In interview RN #3 she stated she had to pass medications for the entire hall and was attempting to give the medication she had already got ready for a resident before assisting the CNA. She further stated two (2) staff should always perform lift transfers so one person could move the lift while the second person assisted the resident so the lift doesn't move, the sling break, or the resident fall out of the sling and cause injury to the resident. 2. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #51 as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded zero (0). Continued MDS review, Section G functional status revealed the facility assessed Resident #51 to require two (2) person assist for bed mobility and transfers and review of section J revealed the resident had a history of falls. Review of Resident #51's Comprehensive Care Plan revealed the facility care planned the resident for his/her risk for falls. Continued review revealed interventions which included one-to-one (1:1) supervision for safety due to frequent falls; two (2) staff for Activities of Daily Living (ADL) care for safety; and call light within reach at all times. Further review revealed additional intervention included: bolsters to left side of bed; full size mattress to right side of bed; low bed related to decreased safety awareness; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation. Review of Resident #51's medical record revealed the resident experienced a history of ten (10) falls since admission to the facility on [DATE] which included: a) On 04/13/2023, Resident #51 was found in room with a laceration and hematoma over his/her right eye and laceration over his/her left eye and the facility determined he/she had fallen. Resident #51 was sent to the hospital and underwent a left frontotemporoparietal craniotomy (brain surgery) for evacuation of a right-sided acute on chronic subdural hematoma (bleed between the covering of the brain [dura] and the surface of the brain). The resident was admitted to the hospital from 04/13/2023 to 04/20/2023. b) On 04/22/2023, Resident #51 was found lying on the floor beside the bed with blood noted coming from his/her head beside him/her and around the room. Resident #51 required transport to the hospital emergency room (ER) due to his/her sutures pulling loose from his/her head trauma on 04/14/2023. On 04/25/2023, the Interdisciplinary Team (IDT) implemented an intervention for Resident #51 to have his/her bed in the low position with a fall mat to the floor by the bed. c) On 04/26/2023, Resident #51 was found on the floor with feces on his/her bed, mat, floor and the resident. The IDT implemented an intervention on 04/27/2023 to toilet the resident every two (2) hours. However, review of the care plan revealed no documented evidence of the intervention for toileting the resident every two (2) hours. d) On 05/11/2023, Resident #51 was found lying on the floor and was sent to the ER. On 05/12/2023, the IDT determined therapy would make wheelchair modifications to the resident's wheelchair. e) On 05/20/2023, Resident #51 was found lying face down on the floor, behind his/her closed door, with blood noted on his/her face and gown. Resident #51 stated he/she tripped on the mattress beside the bed. Resident #51 required transfer to the ER where he/she required sutures to his/her right eyelid. The resident returned to the facility on [DATE]. The IDT met on 05/23/2023 and implemented 1:1 supervision of Resident #51 while he/she was in bed. f) On 05/29/2023, Resident #51 was found sitting on the floor mat beside the bed and was placed 1:1 supervision at all times. g) On 06/11/2023, Resident #51 was found lying on the floor with a laceration to his/her head and was sent to the ER for treatment and was admitted overnight. Review revealed no documented evidence of an IDT note or intervention noted on the care plan. h) On 06/21/2023, Resident #51 fell to the floor and hit his/her head which was witnessed by a staff member. Resident #51 was sent to the ER and was admitted overnight. Review revealed no documented evidence of an IDT note and the intervention on the Care Plan was to send to the ER. i) On 07/01/2023, Resident #51 fell from his/her chair to the floor and was sent to the ER. The resident returned to the facility on [DATE]. On 07/03/2023, the IDT implemented an intervention to take the resident to activities to be engaged in other forms of stimulation. j) On 07/08/2023, Resident #51 fell on his/her hands and knees and hit his/her nose on the table. On 07/10/2023, the IDT implemented an intervention for two (2) staff members to assist with Resident #51's ADLs. Observation, on 07/12/2023 at 6:20 PM, revealed Resident #51 sitting at the nurse's station in his/her chair with a lap tray physically restraining the resident while CNA #11 walked around the nurse's station and chatted with other staff. In interview with CNA #8 on 07/12/2023 at 10:20 AM, she stated she had been sitting with Resident #51 to provide a break for the CNA taking care of the resident at 2:30 PM yesterday (07/11/2023) and the other CNA left for the day without notifying her. She stated Resident #51 kept trying to reach out of bed and she turned around to turn on the television, and, when she turned back around, the resident was coming up out of the bed like he/she was going to choke her. CNA #8 stated Resident #51 then got fidgety with his/her gastrostomy tube (G-tube) and pulled it out and had to be sent to the hospital. She further stated she had sat with Resident #51 in the past and the resident tried to get out of bed which had not been locked. During interview with LPN #7 on 07/12/2023 at 10:35 AM, she stated Resident #51 had been pretty much 1:1 since he/she had been at the facility. The LPN stated Resident #51 had behaviors since admission, was ambulatory on admission, and continued to be ambulatory; however, needed assistance as he/she was now unsteady on his/her feet. She stated Resident #51 had a psychiatric evaluation and medication changes which worked temporarily, but we can't chemically restrain the resident. During interview with Resident #51's family member on 07/27/2023 at 10:42 AM, she stated the resident had a traumatic brain injury in January 2023 and she felt the facility did not have resources to take care of the resident. She stated Resident #51 was wasting away and had been self ambulatory upon admission but now the resident can't stand and cannot walk now. The family member stated Resident #51 had declined since admission to the facility and had to have a craniotomy related to a fall the very first week he/she was a resident in the facility. She further stated she was unsure how Resident #51 kept falling if he/she was on 1:1 supervision. 3. Review of Resident #15's medical record revealed the facility admitted the resident on 06/16/2023, with diagnoses which included Respiratory Failure, Liver Transplant, Seizures, Dependence on Renal Dialysis, Anemia, Muscle Weakness, and Cognitive Communication Deficit. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #15 to have a BIMS score of fourteen (14) out of fourteen (14) which indicated the resident was cognitively intact. Continued review of the MDS, section G revealed the facility assessed Resident #15 to require two (2) person assist for bed mobility and one (1) person physical assist with transfers. Review of Resident #15's Comprehensive Care Plan dated 06/19/2023, revealed the facility care planned the resident as at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, use of psychotropic medications, and visual impairment. Continued review revealed interventions which included bed in low position, call light within reach, and keep frequently used items close to the resident. Further review revealed an intervention initiated on 06/29/2023, not to leave Resident #15 up in the chair in the room alone. Observation on 07/13/2023 at 2:55 PM, revealed Resident #15 sitting in a reclining chair with feet raised, attempting to climb out of chair in his/her room alone with no staff present near the resident's room. Staff were notified and went to the resident's room. Review of Resident #15's Progress Notes revealed the resident fell on [DATE], then complained of right hip pain on 07/04/2023 at which time an x-ray of the right hip was ordered by the Physician. Continued review of the Progress Notes revealed an x-ray was obtained on 07/07/2023, with a final x-ray report on 07/08/2023, which revealed a right hip fracture. Review of the Progress Notes revealed no documented evidence of entries noted from 07/08/2023 until 07/10/2023. Further review reveale Resident #15 was transported to the hospital on 07/10/2023 and admitted for a right hip fracture. Additional review of Resident #15's Progress Notes revealed the resident returned from the hospital on 07/11/2023; however, was readmitted to the hospital on 07/14/2023, for oxygen saturation levels of seventy-eight percent (78%) and facial edema. Review of the Progress Notes revealed Resident #15 continued to be in the hospital until 07/24/2023. Review of the 07/31/2023 Hospital History and Physical Note revealed the diagnosis for Resident #15 had been Sepsis with acute on chronic Encephalopathy due to Pneumonia. Interview with CNA #21, on 07/16/2023 at 7:20 PM, revealed Resident #15 required total assist with transfers and was currently out to the hospital. 32635 4. Review of Resident #72's medical record revealed the facility admitted the resident on 05/01/2023, with diagnoses including Major Depression, Anxiety, End Stage Renal Disease, and Altered Mental Status. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section G, revealed the facility assessed Resident #72 as a one (1) person physical assist for bed mobility. Further MDS review of section J revealed the resident had a history of falls prior to admission. Review of the facility's fall risk assessments dated 05/01/2023 and 07/06/2023, revealed the facility assessed Resident #72 with a score of thirteen (13) which indicated he/she was a high fall risk. Review of the baseline care plan dated 05/02/2023 for Resident #72 revealed the facility identified the resident's risk for falls; however, did not initiate a comprehensive fall care plan for him/her until 06/20/2023. Review of Resident #72's base line care plan dated 05/02/2023, was a safety risk, was identified fell at home, had a history of falls prior to admission, and within the last two (2) to six (6) months. Continued review revealed listed under specify other safety devices-bed in lowest position was noted. Further review revealed under comments it was noted Resident #72 was only oriented to self, could not comprehend where he/she was and could not use a call light. In addition, it was noted Resident #72 attempted unassisted transfers, and his/her gait was weak and unsteady. Review of Nurse Progress Note dated 07/06/2023 at 10:00 AM, revealed LPN #2 was notified Resident #72 had been found lying on the floor. Continued review revealed Resident #72 was assessed and found to be bleeding from a gash on his/her left leg below the knee. Further review revealed the medical doctor was notified and gave an order to send to Resident #72 to the emergency room (ER). In addition, the resident's family and management were notified. Interviews with LPN #2 were attempted on 08/01/2023, 08/02/2023, and 08/03/2023; however, were unsuccessful. Review of the Emergency Department history and physical dated 07/06/2023 revealed Resident #72 presented to the ER after a fall out of bed that morning. Continued review revealed Resident #72 had an open laceration to the left proximal tibia (upper part of the shinbone next to the knee). Review revealed the bone was exposed, and the description of the repair noted as a laceration eight (8) centimeters (CM) in length on the left lower extremity, anterior, lateral, lower leg. Further review revealed the repair included skin closure with eleven (11) sutures in a single layer. In addition, review revealed Resident #72 tolerated the procedure well. Review of the Nurse Progress Note dated 07/07/2023 at 10:34 AM, documented by the DON, revealed Resident #72's fall was reviewed in the facility's Interdisciplinary Team (IDT) meeting. Continued review revealed the Note stated Resident #72 was lying to close to the edge of the bed and rolled out of bed while sleeping. Further review revealed Resident #72 needed assistance with moving to the center of the bed, and side rails were to be added to his/her bed for bed positioning. In interview with Resident #72's spouse and family member on 08/03/2023 at 2:38 PM, they stated Resident #72 had rolled out of bed and hit his/her leg on the floor. Resident #72's sister-in-law stated she had requested bed rails ever since the resident's admission because he/she had a history of falls from the bed at home. In interview on 08/04/2023 at 2:05 PM, Resident #72 stated he/she rolled out of bed and had a hard fall to the floor. Resident #72 stated there had been nothing in the way of the side on the side of the bed and the floor. The resident further stated he/she had not rolled out of bed since the side rails were added. In interview on 08/06/2023 at 9:42 AM, the DON stated Resident #72 had been independent in his/her room and since admission he/she had lain too close to the edge of the bed. The DON stated Resident #72 was assessed as a high fall risk. She further stated Resident #72 appeared as less of a risk for falls after receiving dialysis and therapy; however, the resident had not been reassessed for falls. In interview on 08/06/2023 at 10:08 AM, the Administrator stated Resident #72 was a high risk for falls and had interventions on his/her baseline care plan which covered his/her fall risk. 47567

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents, who required dialysis/hemodialysis received such services, consistent with professional standards of practice for four (4) of nineteen (19) sampled residents who received dialysis (Residents #242, #243, #244, and #11). In addition, the facility failed to ensure communication sheets, used to communicate information on the resident, were completed for each dialysis treatment. 1. The facility failded to secure and set-up Resident #243's dialysis treatments prior to admission to the facility on [DATE]. The facility failed to ensure Resident #243 received his/her dialysis treatment on 07/12/2023. The resident was discharged on [DATE], and transported to the hospital for acute care dialysis. 2. The facility failed to ensure Resident #242 received his/her dialysis treatments on 04/23/2022, 04/26/2022, and on 04/28/2022. On 04/28/2022, when Resident #242 arrived to his/her dialysis appointment, the resident presented in the dialysis lobby slumped over, unresponsive, with his/her body twitching. The resident was immediately sent to the hospital for emergent care. Review of Resident #242's diagnoses when he/she presented to the hospital were Acute Metabolic Encephalopathy, from Uremia; Sepsis; End Stage Renal Disease; Hyperkalemia (high potassium); and Adult Neglect, concern for lack of hemodialysis for one (1) week. 3. The facility admitted Resident #244 on 02/23/2022. However, the facility failed to set up the resident's dialysis treatments prior to admission. On 02/25/2022, Resident #244 was readmitted to the hospital for acute care dialysis. 4. The facility failed to ensure Resident #11, who received out of facility dialysis on Tuesdays, Thursdays, and Saturday's, had communication sheets between the facility and the dialysis center, which were required for each treatment. The communication sheets were not completed from 05/17/2023 to 07/11/2023. The facility's failure to have an ongoing assessment of the resident before and after dialysis treatments, including monitoring the resident's condition for complications; and the failure to conduct ongoing communication and collaboration with the dialysis facility regarding residents' dialysis care and services; and failure to ensure residents had dialiysis appointments and failure to ensure residents were transported to their dialysis appointments is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/21/2023 and determined to exist on 02/25/2022 in the area of 42 CFR 483.25(l) Quality of Care F698 Dialysis, at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/21/2023, and the IJ is ongoing. The findings include: Review of the facility's policy titled, Community Hemodialysis (HD), effective and last revised date of 07/25/2019, revealed all residents admitted to the facility with the need for hemodialysis were to have coordination of services between the facility and the hemodialysis unit prior to admission. Per the policy, dialysis services were to be set up with the dialysis center by the hospital or community agency prior to the resident's admission to the facility. Continued review revealed when the dialysis schedule was determined, the facility would set up the transportation arrangements. The policy revealed a schedule would be provided to the nursing units for the resident's dialysis days, including the time and day of the week that the resident was to attend dialysis. Review revealed the facility was to obtain orders from the Physician for the resident's dialysis days, which was to be written on the Physician order sheet. In addition, a dialysis communication sheet was to return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session. Further review revealed the facility was to continue to monitor the resident after dialysis for any signs and symptoms of disequilibrium syndrome (a serious and rare complication of dialysis that involves a range of neurological symptoms), nausea, vomiting, or bleeding from the dialysis access site. The policy review revealed changes in the resident's condition were to be documented and reported to the Physician. Review of the In-House Dialysis Company's policy titled, Patient Selection Criteria for Staff Assisted Home Hemodialysis in the Skilled Nursing Facility, dated 10/26/2021, revealed their clinical team reviewed patient (resident) records to ensure the patient could be safely dialyzed in a group environment, and the patient was not at risk of becoming unstable during treatment. Per the policy, the patient's services intake team was the central hub for all referral activity, returning patients, and admission related updates. Continued review revealed the admission items needed for acceptance were dialysis treatment records, lab reports within seven (7) days; a nephrology note including renal diagnosis, history and physical, face sheet with insurance information, hepatitis B surface antigen results within thirty (30) days, and chest x-ray or Purified Protein Derivative (PPD) test within 90 (ninety) days. The policy stated the patient services team would work with the facility to proactively reach out to hospitals to collect the necessary documents. Per the policy, it was helpful for the facility that wanted to admit the patient/resident to share relevant case worker contact information so the in-house clinic could support the facility's efforts to collect paperwork and admit residents/patients as quickly as possible. 1. Review of Resident #242's Admission Record revealed the facility admitted the resident, on 04/21/2022, with diagnoses of End Stage Renal Disease (ESRD), Pain in Leg, and Hypotension. Review of Resident #242's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #242's Nursing Progress Note, dated 04/21/2022 at 9:04 PM, revealed the resident was total care for bed mobility and total care with transfers. Review of Resident #242's Nursing Progress Note, dated 04/23/2022 at 11:53 PM, revealed the resident had an arteriovenous (AV) fistula (a vascular access for hemodialysis) in the left upper arm. Further review of the 04/23/2022 Progress Note revealed the resident received hemodialysis three (3) times a week. Review of Resident #242's care plan initiated on 04/22/2022, revealed a potential for complications related to dialysis because of ESRD, with intervention which included dialysis treatment three (3) times a week on Tuesday, Thursday, Saturday at the dialysis clinic, pick up 2:00 PM, with no transport company listed, and make transportation arrangements for dialysis. Continued review of Resident #242's facility medical record revealed no documented evidence of the resident having a nursing assessment, progress note, or documentation of Physician/MD/NP notification of the missed HD treatment for 04/26/2022. Further review revealed a nursing assessment was performed on 04/23/2022; however, there was no documentation noting Resident #242 missing his/her HD or documented evidence of the Physician, Medical Director, or NP being notified of that information or of progress notes concerning the missed dialysis treatment. Review of the freestanding dialysis clinic progress notes dated 04/26/2022, revealed the clinic notified the NP of Resident #242's missed dialysis treatment. Continued review of the notes revealed on 04/28/2022, Resident #242 presented to the dialysis clinic lobby from the facility slumped over and unresponsive, with his/her body twitching. Further review revealed Emergency Medical Services (EMS) was called, and EMS transported the resident to the local Emergency Department (ED). Review of the EMS Run Sheet/Report dated 04/28/2022, revealed the EMS personnel arrived at the dialysis center and found Resident #242 seated in wheelchair. Per the report, Resident #242 was lethargic, difficult to arouse, and non-verbal when awakened. Continued review revealed the dialysis center staff told EMS staff the resident was discharged from the hospital on the previous Saturday and received his/her most recent dialysis treatment at that time. Per the report, EMS staff were informed Resident #242 was transferred to the facility from the hospital and had not been transported to dialysis until that day (04/28/2022), and upon arrival presented lethargic and non-verbal. Review revealed dialysis center staff, informed EMS staff, the skilled longterm care facility had requested Resident #242 receive only one (1) hour of the normal three (3) and a half hours of his/her dialysis treatment for every treatment because of scheduling convenience. Further review revealed the EMS assessment revealed no visible or palpable signs of trauma; all vital signs within normal limits; and blood glucose checked and was 105 mg/dl (normal). Review of Resident #242's hospital records of the History and Physical (H&P) dated 04/28/2022 at 10:30 PM, revealed the resident had admission diagnoses of Acute Metabolic Encephalopathy, likely multifactorial, Sepsis, ESRD, Hyperkalemia, Hyperthermia, Malnutrition, Decubitus Ulcer, and Adult Neglect. Continued revealed Resident #242 had a negative head Computed Tomography (CT) scan; had been febrile with a temperature of 100.7 degrees Fahrenheit; had a heart rate greater than ninety (90) beats per minute; and his/her chest X-ray noted possible inflammatory infiltrate. Per review, intravenous (IV) Vancomycin and Zosyn started (antibiotics) were initiated, and for the resident's ESRD dialysis was scheduled on a Tuesday, Thursday, Saturday schedule, and he/she received HD today in the ED. Review revealed cooling blankets were ordered for treatment of Resident #242's hyperthermia; and the resident's potassium level of 6.5 (normal range was 3.5-5) was noted as related to lack of receiving HD. Further review revealed Resident #242 had a basic metabolic index (BMI) of 17.5 (underweight), appeared cachectic (wasting away), and nutrition was consulted. Review further revealed Resident #242's Stage 3 Decubitus Ulcer which was noted on his/her last admission, appeared to have increased in size. In addition, review revealed documentation noting there was concern for neglect given the patient's nutrition status, lack of HD for one (1) week, and Stage 3 Decubitus Ulcer; and Hypertension. In an interview on 07/11/2023 at 3:23 PM, the Social Worker, from the out of facility freestanding dialysis center, stated Resident #242 had been a no call/no show on 04/23/2022 for his/her dialysis treatment. She stated, on 04/26/2022, the resident was sent back to the facility from the dialysis center without receiving a dialysis treatment. According to the Social Worker, the resident's transportation arrived after 3:00 PM and would only pick up the resident at 5:00 PM or earlier. She stated Resident #242 would not have been able to get a full dialysis treatment as ordered due to the transportation issue. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated when Resident #242 was accepted by the facility the transport should have been set up for dialysis by the facility prior to the resident coming. She said it was the responsibility of the facility. She stated Resident #242's missed treatment on 04/23/2022 (Saturday) happened on a weekend, and the facility could not get transport because it had not been scheduled yet. She stated the referrals went to the Business Office Manager (BOM) and then to the Director of Nursing (DON), prior to the resident's admission. The former ADON stated if the facility decided to accept the resident, facility staff corresponded with the liaison (facilitator of communication of information between the hospital or outside facility and the facility). She stated then the BOM set up dialysis transport for the resident. In an interview on 07/25/2023 at 8:38 AM, with the Director of Nursing (DON), she stated the facility did not have the Physician/Medical Director (MD) communication book sheets from April 2022 because the facility had changed medical providers since then. The DON further stated the scheduler and not the BOM set up transport for dialysis residents to the dialysis clinic. 2. Review of Resident #243's facility Admission Record revealed the facility admitted the resident from a hospital, on 07/11/2023, with diagnoses of ESRD, Diabetes, and Abnormal Findings of Blood Chemistry. Review further revealed Resident #243 was discharged from the facility on 07/14/2023; prior to the facility being able to assess the resident's BIMS score for cognition. Review of an email to the facility's Liaison #1 from the in-house dialysis clinic, dated 07/10/2023 at 12:51 PM, revealed Resident #243's name was on the in-house dialysis clinic's waitlist. Review of the hospital record Dialysis Notes for Resident #243, dated 07/10/2023 at 7:00 AM, revealed dialysis was in progress. Continued review of the Dialysis Notes at 10:00 AM on 07/10/2023, revealed Resident #243's dialysis session was completed. Further review of Resident 243's hospital record revealed laboratory results dated [DATE] at 6:46 AM, revealed a Potassium level of 5.3 millimoles per liter (mmol/L, normal value 3.5-5.1 mmol/L), BUN 83 milligram per deciliter (mg/dL, normal value 8 to 26 mg/dL), and Creatinine-Blood 6.01 mg/dL (normal 0.73 to 1.18 mg/dL). Review of Resident #243's care plan, initiated by the facility on 07/11/2023, revealed care plan interventions which included to monitor/document/report as needed (PRN) signs and/or symptoms of renal insufficiency such as: changes in level of consciousness; changes in skin turgor or oral mucosa; and changes in heart and lung sounds. Continued review revealed additional interventions included: check and change dressing daily at dialysis access site and document; and do not draw blood or take Blood Pressure (BP) in the arm with graft; however, no site was listed. Review further revealed no documented evidence of dialysis clinic, frequency of treatment, or days of treatment listed in the care plan. Continued review of Resident #243's facility medical record revealed a Physician's order dated 07/12/2023, for the resident to receive in house dialysis three (3) times per week, on Monday-Wednesday-Friday. Review of a Nurse Progress Note for Resident #243, dated 07/14/2023 at 3:55 PM, documented by Registered Nurse (RN) #3, revealed the resident had received no dialysis since Monday (07/10/2023), and the Physician had been notified. Per review of the Note, Resident #243 was transported to a local Emergency Department (RD) via medical transport. Continued review revealed facility staff accompanied Resident #243 to the ED, and the resident was alert and oriented when transported and displayed no signs and/or symptoms of distress or discomfort. Additional review of the 07/14/2023 Nurse Progress Note documented by RN #3 revealed the documentation had been struck through (a line drawn through the text) by RN #3 on 07/22/2023 at 3:52 PM. The State Survey Agency (SSA) Surveyor attempted a telephone interview with RN #3 on 07/25/2023 at 3:07 PM; however, no answer was received. The SSA Surveyor left RN #3 a message requesting a return call. In an interview on 07/25/2023 at 4:01 PM with Registered Nurse (RN) #3, she stated she had only taken care of Resident #243 once. She stated on 07/14/2023, she was told in report that Resident #243 was an Hemodialysis (HD) patient, and was told by the ADON the resident needed to go to the hospital. RN #3 stated the ADON said it was something about Resident #243's HD and that the resident had missed a few days of his/her HD. She stated she struck through her Nurse Progress Note from that date because it had not been an accurate note. The RN stated she made a mistake by charting an assumption on the time frame. According to RN #3, she had just been employed at the facility within the last month. She stated she received education on dialysis; however, every facility was different regarding residents' weights, such as if staff at the facility weighed the resident or if the staff at the dialysis clinic weighed the resident. RN #3 further stated if a resident missed a dialysis treatment, the resident usually was sent to the ED to get the missed treatment. Review of Resident #243's facility medical record revealed the resident had one (1) nursing assessment completed on 07/11/2023, while residing in the facility. Further review revealed for 07/12/2023, there was no documented evidence of a Nurse Progress Note, assessment of Resident #243, or documentation of notification to the Physician or Nurse Practitioner (NP) of the missed dialysis treatment on 07/12/2023. In an interview with the Unit Manager (UM) on 07/27/2023 at 2:05 PM, she stated she put the change of condition note in for Resident #243, dated 07/14/2023, due to the resident having behaviors and needing dialysis. She further stated she was unsure about Resident #243's missing HD treatment on 07/12/2023. In an interview on 07/19/2023 at 2:10 PM, with the in-house dialysis RN, she stated Resident #243 was never accepted by the in-house dialysis clinic when the SSA Surveyor requested the resident's missed HD documentation. The RN stated Resident #243 had been on the in-house dialysis clinic's pending list, and the Medical Director had not yet accepted Resident #243. She stated before acceptance, the DON and Medical Director of the in-house dialysis clinic met and determined, by doing a medical review, whether the patient/resident would be accepted into the dialysis clinic. She reiterated that Resident #243 had not been accepted into the in-house dialysis clinic. In an interview on 07/25/2023 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, she stated it was not communicated to her that Resident #243 had an HD order placed. She stated if she had known the resident had a dialysis treatment due on 07/12/2023, she would have taken Resident #243 to dialysis. In an interview on 07/25/2023 at 9:49 AM, with the Staff Development Coordinator (SDC), she stated she placed the order on 07/12/2023 for Resident #243 to have dialysis three (3) times per week on Monday, Wednesday, and Friday, and for it to be done by the in-house dialysis clinic. She stated she put the order in during the Interdisciplinary (IDT) meeting because Resident #243 was a new admission and needed dialysis orders. She stated the members of the IDT were Therapy, Nursing, the Social Services Direct, the Activity Director, the Minimum Data Set (MDS) Coordinator, the Dietary Director, and the Staff Development Coordinator (SDC). She stated the IDT clinical meeting was held every Monday through Friday. However, there was no documented evidence the order was followed-up. In an interview with the Director of Nursing (DON), on 07/19/2023 at 2:26 PM, she stated there was a Pending Outpatient list for residents until a dialysis chair became open, and there was currently one (1) resident on that list, Resident #243. In an additional interview on 07/25/2023 at 9:55 AM with the DON, she stated it was her understanding the in-house dialysis clinic had approved Resident #243. She stated she was not aware the resident was on a waiting list. The DON stated two (2) facility residents that were on dialysis were in the hospital, and she did not understand why the in-house dialysis clinic could not put Resident #243 in one (1) of those dialysis chairs. The DON stated there would not be anything in the Physician/MD communication book about a missed dialysis treatment on 07/12/2023 for Resident #243, because staff should have completed a change of condition form. She stated the change of condition form for 07/12/2023 was not entered. She stated Nurse Practitioner (NP) #3 was aware of the missed dialysis for Resident #243, but there was no documented evidence the facility notified NP #3. The DON stated for in-house dialysis, the facility must have approval by Liaison #1, who coordinated treatments between the facility and the in-house dialysis clinic. In an interview on 07/25/2023 at 2:42 PM, with NP #3 she stated she worked on Tuesdays and Thursdays; however, had been on call 07/12/2023 (Wednesday). She stated she did not recall receiving a call about Resident #243. The NP stated if a resident missed dialysis, she expected a nursing assessment and stat (immediate) labs (laboratory work) drawn on the resident. She stated she would want the nurse to monitor for lethargy; vital signs, especially low or high blood pressure; increased confusion; seizure activity; and high potassium, blood urea nitrogen (BUN), creatinine, and sodium. NP #3 stated she always ordered lab work on new admissions; however, had covered for another NP at another facility on Thursday, 07/13/2023, so she had not seen Resident #243. She further stated Resident #243 had been seen by the Medical Director on 07/14/2023. In an interview on 07/25/2023 at 3:17 PM with the facility's Liaison #1, he stated for dialysis residents he sent all the information to the in-house dialysis clinic. He stated he and the facility would get an approval email and then admit the resident. He stated he received an email that said Resident #243 was accepted. When the SSA Surveyor asked for the email and previous emails dealing with that subject, or the email thread, he stated there was only an email with Resident #243's approval for the waitlist. In an interview on 07/25/2023 at 4:33 PM, with Liaison #2, she stated Resident #243 did come from her account, she had sent information to the in-house dialysis clinic, and they went through an authorization saying Resident #243 was good to go. She stated she received an email from the in-house dialysis clinic saying Resident #243 was approved for the waitlist, and they had seventeen (17) chairs. She stated when she gave this information to the facility's Admissions office, she was told the facility was good to accept the resident. In an interview on 07/25/2023 at 4:08 PM, with the Admissions Coordinator, she stated for outpatient dialysis the hospital set up the HD center or clinic for the resident, and the facility set up the transport. She stated once that was verified the facility could admit the resident. The Admissions Coordinator stated for in-house dialysis the facility sent information to the in-house dialysis clinic for approval for a chair, and the clinic was supposed to open more chairs on 07/10/2023. She stated she messaged the Administrator who responded that the in-house dialysis clinic was not opening more chairs. She stated the hospital had been holding Resident #243 for acceptance to the facility. She stated the DON spoke to the in-house dialysis clinic, who stated since the facility had two (2) residents at the hospital, the in-house dialysis clinic would accept Resident #243. The Admissions Coordinator stated she told the hospital the facility could accept Resident #243. However, the facility provided no documented evidence to corroborate the Admissions Coordinator's statement. In an interview with the in-house Dialysis Clinic Manager (DCM) on 07/26/2023 at 3:47 PM, she stated the clinical liaisons were updated regularly, and the facility was previously told the in-house dialysis clinic was at full capacity. The DCM stated an email was sent on 07/10/2023 at 12:51 PM, that informed the facility that Resident #243 had been waitlisted. She stated the clinic advised the facility not to admit the resident for their (in-house clinic) dialysis. The DCM stated they did allow one (1) extra spot because of the closure of two (2) other nearby facilities in June 2023. She stated the in-house dialysis clinic's RN had access to the facility's charting, and the RN noted Resident #243 was residing in the facility and had not had his/her HD. The DCM stated the facility then brought Resident #243 to them for HD on 07/14/2023; however, the in-house dialysis clinic did not have specific dialysis orders as they had not accepted Resident #243 at that point. The DCM stated the facility could admit a resident on dialysis that had not been accepted by the in-house dialysis clinic; however, the resident would have to go to an outpatient dialysis clinic to receive treatment. In an interview on 07/25/2023 at 2:56 PM, with the Medical Director, he stated the facility had many residents on dialysis with multiple co-morbidities. The Medical Director stated he would not send a resident to the hospital unless he/she missed multiple dialysis days. He stated he or the NP should be notified if a resident missed their dialysis. He further stated he had only been the facility's Medical Director for a month, but if resident rwuiring dialysis di not recieve the dialysis as ordered it could greatly affect the resident's renal staus. 3. Review of Resident #244's Admission Record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Kidney Disease Stage 4, Hypertension, and Diabetes. The resident was only in the facility for a short time, and a BIMS score was not assessed. Review of the facility's Nursing Admission assessment dated [DATE], revealed Resident #244 received hemodialysis and had a tunnel catheter (dialysis access) in the right upper chest. Per review of the Assessment, Resident #244 received dialysis treatments on Monday-Wednesday-Friday, and the resident's last treatment was on Wednesday, 02/23/2022. Continued review of Resident #244's medical record revealed the facility admitted Resident #244 without an outpatient dialysis clinic order to receive his/her HD. Review revealed Resident #244 was sent back to the acute care hospital two (2) days later (on 02/25/2022) to receive his/her HD. Per the record, Resident #244 did not return to the facility. Review of Resident #244's care plan dated 02/25/2022, revealed the resident had a potential for complications related to dialysis related to ESRD and dialysis treatments three (3) times a week. Continued review revealed interventions which included: make transport arrangements for dialysis; protect shunt (dialysis access) site from injury; and avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing. However, further review revealed no documented evidence of a dialysis clinic listed, times listed, or a transport company listed. Review of the Nurse's Note dated 02/25/2022 at 11:11 AM, documented by the former ADON, revealed Resident #244 was being transported to a local ED. Continued review revealed the former ADON notified the ED nurse that Resident #244 needed to have dialysis, and upon return to the facility, a dialysis center needed to be assigned on a regular schedule. In an interview with the former Assistant Director of Nursing (ADON) on 07/13/2023 at 12:11 PM, she stated she could not remember anything about Resident #244. 4. Review of Resident #11's Admission Record revealed the facility admitted the resident on 10/26/2022, with diagnoses of ESRD, Diabetes, and Hypertension. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating no cognitive impairment. Continued review of Resident #11's Point-Click-Care (PCC, software used by the facility) Physician's order, dated 06/28/2023, revealed the resident received out of facility dialysis on Tuesday, Thursday, and Saturday. Further review, on 07/11/2023 at 2:56 PM, revealed the communication sheets between the dialysis center and the facility, provided by the facility, showed the last communication sheet was dated 05/17/2023. Review of Resident #11's care plan revealed interventions initiated on 10/27/2022, which included: to communicate with dialysis center regarding medication, diet, and lab results; protect shunt (dialysis) site from injury; avoid constriction on affected arm, such as BP cuff, carrying purse, constrictive clothing; avoid any possible injury to the arm with the fistula; and monitor for bleeding of the right upper chest and left upper arm fistula. In an interview with Licensed Practical Nurse (LPN) #12 on 07/23/2023 at 8:15 AM, she stated she just started working at the facility a month ago and had not received any education on dialysis. She stated she knew to watch a resident's vital signs and change the resident's access bandage after HD. However, she stated she was not sure about ongoing monitoring or what to do if a resident missed HD. LPN #12 stated some residents got weighed every morning; however she was not sure about how residents receiving HD were to be weighed. She further stated the care plans and orders told staff how to care for residents. In an interview with the DON on 07/19/2023 at 2:26 PM, she stated the hospital had the responsibility to set-up HD for residents. She stated if not, the facility made sure transportation for the dialysis treatments was set up prior to the resident coming to the facility. The DON stated the facility did not accept a resident until HD and the transport was set up. The DON stated sometimes the hospital set up transport also, and sometimes it was the facility that set it up. She stated the HD schedule was posted at the nurse's station, and it was also written in the Physician's orders. According to the DON, the communication sheet utilized did not have an area for monitoring residents after their HD. However, she stated Physician's orders stated to monitor the fistula and remove the bandage over the fistula after four (4) hours. The DON stated the process for when a resident missed an HD treatment was for the Physician, Medical Director, or NP to be notified to send the resident to the ED to get dialysis, and for the resident to be monitored for fluid overload, shortness of air, and respiratory failure. She stated the Admissions Liaison talked to the hospital about admitting a resident that required dialysis. The DON stated the resident's hospital Discharge Summary was where dialysis orders were located, such as the chair time and the days of the week for the dialysis treatment. The DON stated the facility currently had no transportation issues regarding dialysis. She stated there was a Pending Outpatient list for residents until a dialysis chair became open. In an additional interview with the DON on 08/01/2023 at 3:54 PM, she stated she would expect HD to be set up prior to a resident being admitted to the facility. She stated she expected the facility to set up transportation for HD treatments. The DON stated she would expect communication to occur between the dialysis center and the facility. She stated the facility's process for if the communication sheet was not completed, was the facility would contact the dialysis center and get the sheet sent over. She stated the staff at the facility were to monitor for fluid overload and shortness of air of residents. The DON stated she expected a nursing assessment to be completed to monitor a resident when he/she missed an HD treatment, and she expected a post-HD nursing assessment to be completed to monitor for complications. According to the DON, intake and output were monitored for dialysis patients for those with fluid restrictions, she expected a weight pre/post treatment, and the facility had orders to monitor for complications of the access site twice a day. In addition, she further stated employees received education regarding HD in their orientation and she realized the importance for residents with renal problems to recieve the routine schedule dialysis to ensure their renal function did not decline. In an interview with the Administrator on 08/01/2023 at 3:40 PM, she stated she expected HD to be set up prior to a resident

Based on observation, interview, review of facility records and policy, it was determined the facility failed to ensure there were adequate, competent staff to ensure the safety of its residents. Observation on 08/07/2023 revealed three (3) Certified Nursing Assistants (CNAs) called off for day shift leaving one (1) CNA on the two hundred (200) hall. The findings include: Review of the facility's Staffing Guideline, revised on 05/11/2021, revealed during critical staffing periods there might be times when an incentive would be provided to nursing staff to work additional shifts outside their normal schedule. Review of the facility's Standard Staffing Supervision Monitoring Guideline Policy and Procedure, last reviewed 06/20/2023, revealed staff assignments were based on residents' needs as far as their acuity and their assessment results, and their person-centered care planning. Continued review revealed the requirement for meeting residents' needs to include physical, emotional, psychosocial, social, and spiritual, was to be accomplished by provision of as much hands on care as necessary. Further review revealed supportive services to include staff from various departments in the facility and/or outside resources/vendor services were to be provided when indicated. Review of the facility's assessment titled, Facility Assessment Tool, dated 02/28/2023, revealed the purpose of the facility assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. Per review of the Tool, the assessment was to be used to make decisions about the facility's direct care staff needs, as well as the facility's capabilities to provide services to residents in the facility. Continued review revealed the intent of the assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services residents required. Continued review revealed Administrator, Director of Nursing (DON) and a former Medical Director were involved in completing the assessment. Review of the facility's assessment, Part 1: Our Resident Profile, revealed the number of residents the facility was licensed to provide care for, and the average daily census questions were not answered and were left incomplete. Further review of the facility's assessment, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, revealed the total number of licensed nurses needed to provide direct care were (was) five (5) daily, and the total number of Nurse Aides needed daily were (was) eleven (11). Review of the Resident Census and Conditions of Residents, Form CMS 672, (the form completed by the facility which represented the current condition of its residents and their needs) received from the facility on 07/11/2023, revealed the facility had a census of eighty-seven (87) residents. Per review of the form, thirty (30) residents needed one (1) to two (2) direct care staff to assist them with bathing, and fifty-seven (57) residents were totally dependent on staff for bathing. Continued review revealed seventy-seven (77) residents needed assistance of one (1) to two (2) staff for dressing and ten (10) residents were totally dependent upon direct care staff for dressing. Further review revealed seventy-two (72) residents needed one (1) to two (2) staff to assist with transfers and fifteen (15) residents depended totally upon staff to transfer them between surfaces, such as the resident's bed and his/her wheelchair. The data also revealed seventy-three (73) residents needed the assistance of one (1) to two (2) staff for toileting and fourteen (14) residents depended totally upon the facility's direct care staff for all their toileting needs. Additional review revealed fifty-three (53) residents were on a scheduled program for urinary toileting, and forty-two (42) residents were on a scheduled program for bowel toileting. Review of the facility's Payroll Based Journal (PBJ) Staffing Report on 08/07/2023 at 8:41 AM, revealed the facility received a One-Star Rating, which indicated providers whose audits showed significant inaccuracies between hours reported and verified or those who fail to submit data by the PBJ reporting deadlines would have a One-Star rating on the staffing domain, which would result in a drop by one (1) star in their overall Five-Star rating. During an interview on 07/19/2023 at 2:13 PM, Certified Nursing Assistant (CNA) #16 stated sometimes staff called themselves off work, and there would be no one to replace them. CNA #16 stated that concerned her because her residents complained about not receiving their medications and not being treated well. She stated every time staff tried to address the issue nothing gets done. CNA #16 further stated staff who were supposed to be in the building were sometimes gone from 10:00 PM to 1:00 AM with no explanation as to why, when they returned, just as if they were gone on a long break. CNA #17 stated during interview on 07/19/2023 at 3:07 PM, that people would be on the schedule to work; however, would just not come to work. The CNA further stated at times there would only be three (3) aides for the whole building and that was not enough. During an interview on 07/25/2023 at 3:22 PM, Licensed Practical Nurse (LPN) #14 stated she worked at the facility on 05/08/2022; however, lasted only four (4) months because she had to remove herself from the facility due to it being so hectic. She stated during that time the facility seemed disorganized, and there were agency nurses who seemed to not know what they were doing regarding sending residents out to the hospital, reordering medications, charting, and performing resident assessments. LPN #14 stated she had to do lots of education about things she thought a nurse should already know. She stated a lot of staff would regularly show up to work around 8:30 AM to 9:00 AM for day shift which was supposed to begin at 6:00 AM, and that left a hole on the unit. She further stated an interim DON tried to nip this in the bud, but the interim DON left the facility, and staff continuing to show up late to work was an ongoing issue. During an interview on 07/23/2023 at 5:06 PM, LPN #13 stated nurses left the building at night for hours during their shift. The DON stated during an interview on 07/26/2023 at 1:40 PM, that CNA #11 did the nursing staff scheduling in the staffing coordinator's absence. CNA #11 had the scheduling book in the room where he was providing one on one (1:1) supervision to Resident #51 and CNA #11 was looking at the schedules in Resident #51's room, but he was not making phone calls. Observation, on 07/26/2023 at 4:05 PM, revealed Resident #51, who was assigned to be supervised (1:1) at all times related to his/her past unsupervised accidents and injuries, was alone in his/her room. The State Survey Agency (SSA) Surveyor, for the resident's safety, walked towards the nurses' station to find staff to supervise Resident #51. Continued observation at 4:07 PM revealed CNA #11 coming out of the facility's employee break room. Interview with CNA #11 at the time of observation revealed he stated he had to drop something off in the breakroom and could not find anyone to supervise Resident #51 while he did that. CNA #11 further stated he was only maybe gone thirty (30) seconds from Resident #51's room. Review of the facility's Daily Census revealed the resident census on 07/28/2023 was eighty-six (86) residents. On 07/28/2023 at 8:55 PM, LPN #13 stated during interview there was one (1) aide staffed to supervise one (1) resident, and there were only three (3) other nursing aides on duty from 6:30 PM until 10:30 PM to care for the facility's other residents. LPN #13 stated there were only two (2) nurses scheduled from 10:30 PM until 6:30 AM, and that made her feel overwhelmed. She stated she dreaded coming to work at the facility because they were always short staffed of either nurses or aides every time she came to work. LPN #13 stated, every time it is one or the other. These people are suffering. It is not right. Residents are not getting the care they need. She stated she would report the problems to the DON and the Administrator; however, it did not change anything. LPN #13 stated she had worked night shift at the facility for about one (1) year and had just been introduced to the DON for the first time last week. She further stated she had never seen the Administrator, and she had never seen any leadership rounding in the facility during the night. In interview, on 07/28/2023 at 9:20 PM, LPN #13 stated they had two (2) CNAs call in for night shift. LPN #13 again stated it was overwhelming working for the facility as it was always short staffed of nurses or CNAs. LPN #13 stated again she reported the issue to the DON and stated she also reported it to the Assistant Director of Nursing (ADON); however, reiterated that things never changed. Review of the Daily Staffing Sheet, dated 07/28/2023, revealed only three (3) Certified Nursing Assistants (CNAs) were assigned to care for the facility's (86) residents from 6:30 PM until 10:30 PM that evening. Observation and concurrent interview with LPN #11 on 08/06/2023 at 9:53 AM, revealed two (2) Registered Nurses (RNs) called off for dayshift. In interview with LPN #11, he stated that two (2) nurses called off for today on dayshift; which included the nurse that was originally scheduled to work the 400 Hall, and the backup on-call nurse (Supervisor). LPN #11 stated they were both Registered Nurses (RNs), and this resulted in the 400 Hall not having any nursing coverage. Observation further revealed LPN #11 was noted to be covering both the 300 and the 400 Hallways. Observation on 08/06/2023 at 10:30 AM, revealed no one came to relieve LPN #11 of his duties on the 400 Hall, and he continued to cover both the 300 and 400 Halls. Observation revealed the DON was present in the facility; however, she had not checked with staff, LPN #11, nor the CNA that was covering the 300 Hall. LPN #11 continued to cover both the 300 and 400 Halls without any assistance. Further observation revealed at 11:10 AM, the DON had not come to check the 300 or 400 Halls to see if LPN #11 or other staff needed assistance. Observation on 08/06/2023 at 2:15 PM, revealed the DON was performing treatments on the 400 Hall for residents because there was no staff nurse available to work the 400 Hall that day. Further observation revealed LPN #11 returned to the 300 Hall to care for the residents residing on that hall. Observation on 08/07/2023 at 8:51 AM, revealed three (3) CNAs called off for dayshift leaving one (1) CNA on the 200 Hall. Continued observation revealed the DON noted sitting at the nurses's station making calls on her phone attempting to contact other staff to come in and work. During an interview with LPN #11 on 08/06/2023 at 9:53 AM, LPN #11 stated that he was instructed to just come do the accuchecks and other nurse duties until coverage arrived. LPN #11 further stated this was the first time in a very long time they had two (2) different nurses call in for today on dayshift; which was the nurse that was originally scheduled to work the 400 Hall, and the backup On-Call nurse (Supervisor). LPN #11 stated that he had a CNA on the 300 Hall watching residents while he was over here on the 400 Hall, and that he had not finished his morning medication pass on the 300 Hall before he was directed by the DON to go to the 400 Hall. He said he was able to complete his accuchecks on the 300 Hall before beginning to cover the 400 hallway, as well. In an additional interview with LPN #11 on 08/07/2023 at 2:01 PM, he stated weekend staffing was not usually an issue, with maybe one (1) call in a weekend. He stated nurse staffing was usually good; however, CNAs were the ones that called in mostly on weekends. The LPN stated he did not know about the call in issue for the 400 Hall on 08/06/2023 until around 8:00 AM, and he got to the 400 Hall around 8:30 AM. He further stated only the Certified Medication Technician (CMT) working the 400 Hall volunteered to help him, with duties on the 400 Hall, that were within her scope of practice. In interview on 08/07/2023 at 10:23 AM, the Director of Nursing (DON), she stated the facility's staff coverage process was when a call-in occurred she contacted the staffing scheduler who assisted with calling in other staff. The DON stated she might offer to pay out bonuses to staff members who were willing to pick up a shift. She stated if no one picked up the shift then she went to the on-call staff member for that day, who was usually someone from management for coverage. The DON stated for this week the Staff Development Coordinator (SDC) was on vacation and the next person in line was the ADON, who had been absent from work the past two (2) days and who had recently submitted his resignation, and the DON said she did not anticipate the ADON's return at this point. She stated if the on-call staff or ADON were not available then she (the DON) would have to come in and cover the shift. The DON stated she was not aware LPN #11 was having issues with getting glucose checks done on time while he attempted to cover both the 300 and 400 Hall by himself. She further stated once she became aware of his situation she then came and assisted him as much as she could. In interview on 08/07/2023 at 3:00 PM, the Administrator stated the facility had a weekend on-call nurse, as necessary (PRN) staff, and offered staff bonus pay incentives to address weekend staffing issues, to get staff to come to work as ways to address the weekend staffing issues. She further stated staffing needs were based on the resident census, and the facility was okay as long as there were at least two (2) RN's and a CMT in the facility. The Administrator further stated if no one else was available to work, the DON would have to come in and work the floor. 47567

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, and prepare food under sanitary conditions. Observations, during the initial kitchen tour, revealed an ice scoop left stored in the ice machine; staff's personal drink cup was left sitting on the production table; and the snack room had food items not labeled and dated. Additionally, there was tube feeding, dated [DATE], stored on a shelf available for use. The dishwasher temperature log was incomplete from [DATE] to [DATE]. The findings include: Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated [DATE], revealed foods with a manufacturer's use-by-date would still require an opened-on date once the item was opened. Continued review revealed all opened containers of food in the dry storage area were to be placed in an enclosed container, labeled, and dated. Further review revealed the expiration date was the last day the product was to be used for the best quality. 1. Observation on [DATE] at 9:20 AM, during the initial tour of the kitchen revealed: a ,d+[DATE] pound bag of potato chips opened and undated; ingredient bins of oatmeal and flour were not dated; and another staff's personal cup of ice water with no lid was sitting on the table above the ingredient bins. Observation on [DATE] at 9:31 AM, of the Nourishment Room dry storage revealed a loaf of bread not labeled or dated, and an open vanilla wafer box with a manufacturer's date of [DATE] sitting on the counter. Observation on [DATE] at 9:50 AM, revealed clear containers of cornflakes and bran flakes that were not labeled or dated, and an open package of chicken flavored gravy mix not dated. In an interview on [DATE] at 9:51 AM, Dietary Aide #1 stated foods should be labeled and dated when opened with the time and date, and after three (3) days the food could be thrown out. The Dietary Aide stated staff should check with the supervisor on the proper way to dispose of food. Dietary Aide #1 further stated personal cups sitting on the counter could cause cross contamination. She stated the ice scoop should be stored in the holder to prevent cross contamination. In an interview on [DATE] at 9:57 AM, Dietary Aide #2 stated she labeled and dated the cereal boxes after opening them. The Dietary Aide stated if food was not labeled and dated the food should be thrown out as it would not be known how long it had been on the shelf. She further stated the ice scoop was to be washed daily, and stored in the holder to prevent bacteria. In an interview on [DATE] at 10:05 AM, Cook #3 stated food should be dated when opened and the ice scoop should not be in the ice. She further stated the ice scoop should be stored in the holder. In an interview on [DATE] at 2:33 PM, Cook/Dietary Aide #4 stated foods should be dated when opened, as it could spoil if not dated. Cook/Dietary Aide #4 stated undated food should be thrown out. The Cook/Dietary Aide stated staff were not to keep drinks on the production tables in order to prevent cross contamination. Cook/Dietary Aide #4 further stated the ice scoop should be stored in the holder and not in the ice machine to prevent cross contamination. In an interview on [DATE] at 2:46 PM, Cook #5 stated food should be placed in a container and dated, and if it was not dated staff were to toss the food item out. Cook #5 stated personal items were not allowed in the kitchen as those items could cause cross contamination. The Cook further stated the ice scoop should be kept in the holder and not stored in the ice to prevent cross contamination. In an interview on [DATE] at 10:46 AM, Restorative Certified Nursing Assistant (CNA) #8 stated residents' foods should be labeled with their name and room number, and dated. In an interview on [DATE] at 8:55 AM, CNA #18 stated residents' perishable foods which were placed in the refrigerator should have the resident's name and date. CNA #18 stated if food had no name or date staff were to dispose of the food. In an interview on [DATE] at 9:43 AM, the Dietary Supervisor stated her expectations for foods were for the food to be wrapped, put into a plastic container, labeled, and dated. She stated any foods not labeled and dated were to be thrown out. The Dietary Supervisor further stated staff must keep personal drinks covered and in the locker and not on the kitchen counters in order to prevent cross contamination. In an interview on [DATE] at 9:42 AM, the Director of Nursing (DON) stated all food items were to be labeled and dated and kept in the snack rooms and residents' refrigerators. The DON stated kitchen staff should follow expiration dates and rotate food on a first in and first out basis. Per the DON, food should be labeled and dated when opened and thrown out if not labeled and dated. In an interview on [DATE] at 10:08 AM, the Administrator stated dietary staff should not place their personal cups on the production counters in the kitchen as that was an infection control and cross contamination concern. The Administrator stated foods should be labeled and dated for First In/First Out, (FIFO) use, and if food was not dated it was to be thrown away. 2. Observation on [DATE] at 9:20 AM, during the initial tour of the kitchen revealed the ice machine had a large scoop stored in the ice, with staff using a small metal scoop to pour ice into individual resident glasses. Continued observation revealed staff had a personal cup with a lid sitting on the pot and pan rack near the hand sink in the main kitchen area. In an interview on [DATE] at 9:43 AM, the Dietary Supervisor stated the ice scoop should be stored in the scoop holder to prevent possible cross contamination. In an interview on [DATE] at 9:42 AM, the DON stated it was an infection control concern if the ice scoop was stored in the ice machine and not kept in the holder where it belonged. In an interview on [DATE] at 10:08 AM, the Administrator stated the ice scoop should be stored in the holder, and if not it was a cross contamination and infection concern. 3. Observation on [DATE] at 3:30 PM, of central supply revealed Glucerna (brand of tube feeding) 1.5 tube feed dated [DATE], seven (7) containers stored on a shelf. Further observation revealed Glucerna 1.2 dated ,d+[DATE]//2023, five (5) containers were stored on a shelf. In an interview on [DATE] at 9:05 AM, a Central Supply staff member stated he rotated the tube feeding supplements as they were received, and threw the expired supplements out. He stated he threw the tube feeding out after seeing the expired dates on the containers. 4. Observation on [DATE] at 10:04 AM, of the dish machine temperature log revealed no documented evidence it had been completed from [DATE] through [DATE]. In an interview on [DATE] at 9:42 AM, the Director of Nursing (DON) stated staff working on the dishwasher line should record the dishwasher temperatures because if temperatures were not recorded they would not know if the dishwasher was sanitizing the dishware. In an interview on [DATE] at 10:08 AM, the Administrator stated the temperature of the dishwasher was to be recorded daily, and the cook/supervisor was to oversee that it was recorded. The Administrator further stated if the dishwasher temperatures were not recorded staff might not know if the dishwasher was not working well or whether it was sanitizing the dishware. In an interview on [DATE] at 9:43 AM, the Dietary Supervisor stated the dishwasher temperature log should be recorded by the dietary staff as required. The Dietary Supervisor stated if the dishwasher temperatures were not recorded staff would not know if the dishwasher was working correctly and whether it was reaching the necessary temperatures.

Based on observation, interview, and review of the facility's menus, it was determined the facility failed to follow its menus. Observation revealed the menus were not always followed as posted. In addition, portion sizes were not always used according to the guidance on the production sheets. The findings include: Review of the facility's guide titled, Portion Control Chart, undated, revealed the color for the scoop and disher (type of ladle) for accurate portion servings. Scoops number and color were noted as follows: #8 scoop was gray; #12 scoop was green; #16 was blue; and, the #24 scoop was green. Scoop numbers and portion size were noted as: #8 scoop equaled four (4) ounces; #12 scoop equaled two and two thirds (2 and 2/3) ounces; the #16 scoop equaled two (2) ounces; and the #24 scoop equaled one and one-third (1 and 1/3) ounces. Observation of the breakfast tray line on 07/25/2023 at 8:35 AM, revealed scoops used were as follows: the #12 green scoop (2 and 2/3 ounces) was used for pureed sausage instead of the #24 red scoop (1 and 1/3 ounces) per the production sheet; the #16 blue scoop (2 ounces) was used for the pureed eggs instead of the #12 green scoop (2 and 2/3 ounces) per the production sheet. Observation of the breakfast tray line on 07/26/2023, at 8:15 AM, revealed scoops were used as follows: the #12 green scoop (2 and 2/3 ounces) was used for scrambled eggs instead of the #16 blue scoop (2 ounces) per the production sheet; the #16 blue scoop (2 ounces) was used for the pureed sausage instead of the #24 green scoop (1 and 1/3 ounces) per the production sheet; the #12 green scoop was used for the cooked pureed cereal (2 and 2/3 ounces) instead of the #8 gray scoop (4 ounces) per the production sheet. Observation of the supper tray line on 08/01/2023 at 6:50 PM, revealed the food on the tray line appeared with a hash like appearance, with mixed vegetables, and applesauce for dessert. However, review of the menu, week 1, for the week of 08/01/2023, revealed the supper meal listed beef and potato bake, seasoned mixed vegetables, and honey bun cake for dessert. Further observation of the tray line revealed scoops were used as follows: the #12 green scoop (2 and 2/3 ounces) was used for the pureed meat instead of the #8 gray scoop (four (4) ounces) per the production sheet; the #12 scoop (2 and 2/3 ounces) for pureed vegetable instead of the #8 gray scoop for four (4 ounces) per the production sheet; and a black ladle, unknown serving ounce, used for the main entree that appeared hash like instead of the #8 gray scoop (two (2) ounces), and for double portions, two (2) #8 gray scoops (eight 8 ounces) per the production sheet. During an interview with the Activities Director, on 07/24/2023 at 4:27 PM, she stated she was assisting with cooking in the kitchen for all meals, including breakfast. She stated she looked at the menu and had a history of working as a food service manager. During an interview with the Registered Dietitian/Licensed Dietitian (RD/LD), on 08/03/2023 at 1:31 PM, she stated the Portion Control Chart was posted at the tray line and in a book in the kitchen. During an interview with Cook #3, on 08/05/2023 at 10:05 AM, she stated dietary staff showed her which scoops to use. Cook #3 stated if she did not know, she would ask. During an interview with Cook/Dietary Aide #4, on 08/05/2023 at 2:33 PM, he stated he did not currently cook. However, the menu listed the scoop and portion size for the food and the guide listed the scoops by color. During an interview with Cook #5, on 08/05/2023 at 2:46 PM, she stated she knew the portion sizes and the size of the scoop by color. She stated the scoop guide and the portions were listed on the menu. During an interview with the Dietary Supervisor, on 08/07/2023 at 9:43 AM, she stated it was important to follow the menus and to use the food available. She stated if other foods were used, then the foods listed on the menu were substituted and noted on the substitution log. She stated the scoops were used according to the menu spreadsheet and scoop sizes were posted in the kitchen. The Dietary Supervisor stated it was important to provide the correct portion size because if the proper portion was not used, the facility could run out of food. During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated it was important for staff to use the correct serving sizes for calories and prevent residents' possible weight loss. During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated staff should always follow the menus and use the correct serving sizes and provide for the needs of the residents. 47852

Based on observation, interview, and review of the facility's mealtimes it was determined the facility failed to serve meals at regular times comparable to normal mealtimes in the community for eight (8) of twenty-seven (27) sampled residents (Residents #4, #40, #46, #55, #56, #71, #75, and #86) on the 400 Unit. Observations, during the survey, revealed breakfast, lunch and dinner meals were served two (2) hours after the posted mealtimes, on the 400 Unit. The residents did not receive dinner trays until 9:00 PM on 07/30/2023. In addition, interviews revealed the residents did not receive or were offered food from the always available menu. The findings include: Review of the facility's posted mealtimes titled, Mealtimes, not dated revealed Breakfast Dining room service was 7:00 AM; Lunch Dining room service was 12:00 PM; and, Dinner Dining room service was 5:00 PM. The breakdown of trays to the units, after the dining room was served, was to the 100 Unit Autumn; 200 Unit Evergreen; 300 Unit Lakeview; and then the 400 Unit Maple. Review of the facility's posted menu titled, Menu Always Available, undated, revealed for breakfast: sausage/bacon, eggs (hard boiled, scrambled, over easy). lunch and dinner: hamburger and French fries; hotdog and French fries; chicken salad sandwich and chips; tuna salad and chips; peanut butter and jelly; ham and cheese sandwich and chips; bologna, cheese and chips; chicken noodle and tomato soup with a grilled cheese sandwich; and house salad and dressing. Review of the facility's, Quality Assurance Tracking, (a grievance form) dated 07/31/2023, revealed it listed five (5) residents on the 400 Unit that had not received their dinner trays on 07/30/2023 until 9:00 PM (Residents #4, #46, #55, #56, and #71) 1. Observation of Resident #55 on 08/01/2023 at 6:55 PM revealed his/her supper tray was sitting on the bedside table untouched. In interview with Resident #55, on 08/01/2023 at 6:55 PM, when asked about supper and if he/she wanted something else to eat, Resident #55 stated No. Record review revealed the facility admitted Resident #55 on 05/30/2023, with diagnoses that included Diabetes Type 2, Bipolar Disorder and Major Depression. Review of the Admission Minimum Data Set (MDS) Assessment, dated 06/05/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. 2. During interview with Residents #75 and #40, on 08/01/2023 at 6:50 PM, the residents stated the food looked like dog food and they did not receive a meal substitution. The residents stated if they asked for a substitution, they were offered sandwiches at night and staff told them that salads were not available. Residents #75 and #40 stated even if they asked for a salad, they were told salads were not available and did not always receive the substitution requested. The residents stated they did not receive a meal tray on 07/30/2023 for dinner. They stated they ate the snacks their families had provided. Record review revealed the facility admitted Resident #75, on 11/06/2022, with diagnoses that included Major Depression, Bipolar Disorder, and Anxiety. Review of the Quarterly MDS Assessment, dated 08/01/2023 revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact. 3. Record review revealed the facility readmitted Resident #40, on 07/10/2023 with diagnoses that included Anxiety, Major Depression, and Cerebral Vascular Accident (CVA/stroke) with right and left side Hemiplegia. Review of the Quarterly MDS Assessment, dated 07/14/2023, revealed the facility assessed the resident as having a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. 4. Record review revealed the facility admitted Resident #71, on 01/25/2023 with diagnoses that included Protein-calorie Malnutrition, Depression, Anemia, and Anxiety. Review of the Admission MDS Assessment, dated 05/23/2023, revealed the facility assessed the resident as having a BIMS score of ten (10) out of fifteen (15) which indicated the resident had moderate cognitive impairment; however, was interviewable. In an interview on 08/01/2023 at 8:27 AM, Resident #71 stated sometimes he/she did not get his/her dinner trays. The resident stated neither he/she or his/her roommate got their dinner meal tray on Sunday night (07/30/2023). Resident #71 stated some of the food he/she got, he/she could not eat because it just did not taste good. Observation on 08/01/2023 at 7:00 PM on the 400 Unit revealed staff gave Resident #71 a sandwich, and his/her dinner meal tray revealed it sitting on the bed side table not eaten. During interview with Resident #71, at the time of observation, the resident stated he/she had wanted a sandwich. Observation on 08/03/2023 at 1:49 PM, of Resident 71's lunch meal tray revealed the meal was uneaten. In an interview, at the time of observation, Resident #71 stated he/she had his/her sister bring lunch in to him/her because the resident did not want the alternative which was peanut butter and jelly, and he/she did not like that. Observation on 08/01/2023 at 6:47 PM, revealed the dinner menu posted noted beef and potato bake, mixed vegetables, bread, and pudding/dessert. Continued observation revealed the dinner meal food being served appeared to be a hash/goulash, mixed vegetables, bread, and pudding. Further observation revealed all residents residing on the 400 hall were served dinner meal trays except one (1) resident whose family had brought food in for that resident. In an interview with Resident #71, at the time of observation, revealed he/she stated he/she did not want the dinner meal being served and had received an alternate meal of peanut butter and jelly sandwich and pudding dessert instead. 5. Record review revealed the facility admitted Resident #46 on 03/21/2023, with admitting diagnoses of End Stage Renal Disease, Hypertension, and Diabetes Mellitus. Review of Resident #46's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact and interviewable. In an interview on 08/01/2023 at 8:35 AM, Resident 46 stated there had been multiple times when he/she had not received his/her meal tray and had to go find someone to fix him/her and his/her roommate (Resident 71) something to eat. The resident stated it was usually the dinner meal that did not get served to them. In an additional interview on 08/03/2023 at 1:52 PM, Resident 46 stated he/she just tried to eat what was given to him/her because residents did not have a chance to ask for an alternative before they (staff members) took off before they could ask. Resident 46 stated he/she had not had a dinner tray delivered at least five (5) different times since he/she had been here. The resident further stated, They have been bringing them since you all have been here. 6. Record review revealed the facility admitted Resident #86 on 05/24/2023, with admitting diagnoses of Chronic Kidney Disease, Hepatitis C, and Hypertensive Emergency. Review of Resident #86's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15), which indicated he/she was cognitively intact and interviewable. In an interview on 08/02/2023 at 1:38 PM, Resident 86 stated he/she had experienced not receiving his/her meal trays in the past. 7. Review of Resident #4's Admission Record revealed the facility admitted the resident on 11/08/2022, with diagnoses which included Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Diabetes, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #4's Admission Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed to require the assistance of two (2) persons physical assist for bed mobility and transfers and one (1) person physical assist for dressing and eating. Review of the facility's Grievance Log revealed the resident did not receive his/her dinner tray on 07/30/2023 until 9:00 PM. Observation, on 07/16/2023 at 6:51 PM, revealed Resident #4's dinner tray was sitting on the overbed table with resident sleeping and room light turned off. Continued observation revealed CNA #21 woke Resident #4 up at 7:43 PM and took the resident's food to be reheated. Staff were observed assisting the resident to eat at 8:05 PM. During an interview with Resident #4, on 07/12/2023 at 9:23 AM, he/she stated his/her dinner tray had been brought into his/her room on 07/11/2023 at 6:30 PM with a hot dog and potato wedges and staff were not available to assist him/her with eating until 10:00 PM. The resident further stated this occurred frequently as his/her tray arrived to his/her room at about 6:30 PM, which was the time of shift change. The resident stated night shift staff told him/her they had to complete a round and get everyone into bed before assisting the resident with his/her meal. During an interview with CNA #21, on 07/16/2023 at 7:35 PM, he stated he was the only CNA on the hall taking care of thirty plus (30+) residents because another CNA was running late. Per the interview, the CNA stated and it happened a lot, that he was the only CNA for the hall. 8. Closed record review of Resident #56's Electronic Medical Record revealed the facility admitted the resident, on 06/10/2022, with diagnoses which included Diabetes, End Stage Renal Disease, and Heart Failure. Review of Resident #56's Quarterly MDS Assessment, dated 06/27/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's Grievance Log revealed the resident did not receive his/her dinner tray on 07/30/2023 until 9:00 PM. During interview with Certified Nurse Assistant (CNA) #22 on 08/04/2023 at 4:28 PM, she stated there were only two (2) aides per hall. She stated they passed the residents' meal trays and then they assisted residents who needed help with eating. During an interview with Cook #3 on 08/05/2023 at 10:05 AM, she stated she did not know about the facility's always available menu for alternatives for residents for lunch. During interview with Cook/ Dietary Aide #4 on 08/05/2023 at 2:33 PM, she stated the always available foods for residents each night was sandwiches. She stated the other foods on the list were prepared daily. She stated trays were sent out late because of the work habits of staff in the kitchen. During interview with the DON on 08/06/2023 at 9:42 AM, she stated there had been a change in dietary staffing. She stated residents were provided meal trays on the night the trays were missed. The DON stated the CNA could ask a resident what they preferred and get the item from the kitchen for them. The DON stated the CNAs asked dietary for the food, and if the food was not available, they returned to the resident and asked what the resident what he/she would like instead. During interview with the Administrator on 08/06/2023 at 10:08 AM, she stated they have had dietary staff to call off and not work and some were no show. The Administrator stated the residents' meal trays should be delivered on time. She stated, We have employed new staff and they need training. The Administrator stated the CNAs and/or nurses should let Dietary know the resident's request and they should not tell the resident their food request was not available. The Administrator stated they should check with dietary first on the availability of the requested food item. She stated residents had the always available foods, up even until Dietary closed for the night. 47567

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to label and date residents' food items. Observations of the residents' refrigerator and freezer revealed unidentified or undated residents' food items. The findings include: Review of the facility's policy titled, Food Brought into Facility, dated 03/28/2023, revealed residents were allowed the enjoyment of foods brought into the facility by family and other visitors, while maintaining the safety and sanitation requirements for the residents as set forth by local, state, and federal regulations. Perishable food brought in by a resident, relative, and/or friend, should be eaten immediately or at the next meal. Outside foods requiring storage and refrigeration must be dated, labeled, and stored per the facility's and state's guidelines. Observation of the residents' refrigerator and freezer, on 07/26/2023 at 9:40 AM, revealed an ice pack, which was a non-food item, pushed into the back right corner and frosted. Continued observation of the freezer revealed one (1) vanilla ice cream 48 ounce (oz.) container unidentified or undated; one (1) chocolate/vanilla ice cream half 48 oz. container unidentified or undated; one (1) package of four (4) Veggie Burgers open at the top, dated 07/02/2023 but unidentified; and one (1) frozen solid soft drink, frosted, twenty (20) fluid ounces, unidentified and undated. Further observation of the residents' refrigerator revealed an opened package of smoked ham located in the clear covered shelf of the door, dated 09/04/2023 and unidentified; and a package of individually sliced and packaged American cheese slices, dated 10/16/2023 and unidentified. Continued observation of the refrigerator shelf revealed a light mayo container, dated 09/13/2023 and unidentified, and one (1) unidentified whole milk carton, dated 07/17/2023, which was outdated. The food products were not marked with the resident information or identifier on the products. During an interview with Certified Nursing Assistant (CNA) #8, on 08/05/2023 at 10:46 AM, she stated family/resident's foods should be labeled with a name, date, and room number. During an interview with CNA #18, on 08/08/2023 at 8:55 AM, she stated residents' perishable foods should be put into the refrigerator with a name and dated, and if there was not a name or date the food was to be disposed. During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated all food items, in the snack room and residents' refrigerator, should be labeled and dated. During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated CNAs knew the process for residents' foods stored in the residents' refrigerator. She stated the CNAs were aware the food should be labeled and dated.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program as witnessed by staff using expired disinfectant wipes, dated [DATE], for cleaning the glucometers on [DATE], for two (2) of sixty-one (61) sampled residents, Resident #46 and #11. The findings include: Review of the facility's policy titled, Glucose Meter Cleaning Guideline, revised [DATE], revealed the glucose meters would be disinfected between each resident's use to prevent the spread of microorganisms including blood borne pathogens. Per the policy, disinfection of the machine would be completed with PDI Super Sani Germicidal Wipes or Bleach Wipes. The policy stated if the resident had his/her own meter, it still must be cleaned after each use. Per the policy, two (2) disposable wipes would be needed for each cleaning and disinfecting procedure: one (1) wipe for cleaning and the second wipe for disinfecting. Observation of Licensed Practical Nurse (LPN) #11, during a point of care glucose test, on Resident #46 on [DATE] at 10:06 AM and Resident #11 on [DATE] at 11:10 AM, revealed LPN #11 used expired disinfectant wipes to clean the residents' glucometers. Further observation revealed the treatment cart on 400 Hall was noted to have expired disinfectant wipes that were being used to disinfect the glucometers. These wipes came from a white container with a purple lid, labeled Germicidal Disinfection Wipes, and manufactured by WynnMed Healthcare products. The container had a manufacture date of [DATE] and an expiration date of [DATE]. In an interview with LPN #11 on [DATE] at 11:45 AM, he stated he did not realize the wipes were out of date and immediately discarded them and went to central supply to obtain new wipes for replacement. Observation of replacement wipes obtained by LPN #1, on [DATE] at 11:50 AM, revealed these new wipes were in a white container with a purple lid labeled Medline Microkill One Germicidal Alcohol Wipes with a manufacture date of ,d+[DATE] and a expiration date of ,d+[DATE]. In an interview with LPN #6 on [DATE] at 8:33 AM, he stated he primarily worked the 400 Hall and that pharmacy came to the unit and audited the carts. He stated he did not know when this occurred. LPN #6 further stated he did not know anything about the treatment cart having outdated disinfectant wipes on it. In an interview with the Director of Nursing (DON) on [DATE] at 10:23 AM, she stated that Night Shift staff was responsible for checking all the carts, and there were a total of three (3) treatment carts. She stated there was one (1) on each hall except for the 100 Hall. She stated all staff members were responsible for removing any outdated or damaged items and disposing of them. She stated staff members should replace the discarded supplies with proper supplies from the in house stock or pharmacy. She stated she expected the facility's staff to discard any expired disinfectant wipes and obtain new ones that were in date, in order to ensure cleanliness and disinfection. She also stated there were no check off lists for the cart audits. She stated if there was any problem she usually was informed through word of mouth by the facility's staff. However, she stated there were usually no issues with the carts. During an interview with the Administrator, on [DATE] at 1:45 PM, she stated she expected all staff to follow the facility's policies and the DON was in charge of the nursing staff.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to protect residents from physical and verbal abuse for seven (7) of sixty-one (61) sampled residents, Residents #2, #44, #243, #492, #493, #31, and #39. On 07/16/2022, staff responded to yelling and entered room shared by Resident #44, and Resident #492, witnessing Resident #492 yelling at Resident #44 and swinging an empty urinal at Resident #44. Resident #44 was covered in urine. On 04/17/2023, Resident #2 was observed pushing Resident #493 out of the doorway of Resident #2's room, causing Resident #493 to fall. On 07/13/2023, it was reported to the Administrator Resident #243 was at the nurses station upset and speaking loudly. When the Business Office Manager (BOM) asked Resident #243 what was wrong, Certified Nursing Assistant (CNA) #14 yelled that Resident #243 was an asshole. On 08/21/2022, Resident #31 made slight contact with Resident #39 at the Nurse's Station. The findings include: Review of the facility's Abuse Prevention Program policy, last revised 01/03/2023, revealed it was the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. 1 (a). Review of the Electronic Health Record (EHR) for Resident #492 revealed the facility admitted the resident on 11/15/2021, with diagnoses to include Unspecified Dementia without Behavioral Disturbance, Major Depressive Disorder, and Cognitive Communication Deficit. Continued record review revealed Resident #492's Quarterly Minimum Data Set (MDS) assessment dated [DATE], which noted the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating he/she had mild cognitive impairment. Further review of Resident #492's EHR revealed a psychiatry progress note dated 07/21/2022 which noted the resident's medications were reviewed. Continued review of the psychiatry progress note revealed Resident #492 had behaviors when placed in room with a roommate, and he/she was discharged to another facility on 12/12/2022. (b). Review of EHR for Resident #44 revealed the facility admitted the resident on 07/12/2022 with diagnoses to include Encephalopathy Unspecified, Cognitive Communication Deficit, and Altered Mental Status. Continued review of the EHR revealed Resident #44's Admission MDS assessment dated [DATE], noted the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15) indicating no cognitive impairment. Review of the Long-Term Care Facility - Self-Reported Incident Form dated 08/01/2022 revealed on 07/16/2022 a nurse heard yelling coming from the room shared by Resident #44 and Resident #492. Continued review revealed the nurse went to the room and saw Resident #492 swinging an empty urinal at Resident #44. Per review of the Form, Resident #492 was moved to another room, placed on 1:1 supervision, and emergency medical services (EMS) and police were contacted to take Resident #492 to the hospital, which he/she refused. Further review revealed Resident #44 was cleaned up and assessed, with no injuries noted. In an interview on 07/12/2023 at 9:45 AM, Resident #44 stated he/she had no recollection of any incident in which a former roommate threw urine on him/her. In an interview on 07/13/2023 at 10:12 AM, Certified Nurse Assistant (CNA) #2 stated although she had never worked with Resident #492, she heard the resident did not want anyone else in his/her room. She stated Resident #492 had been caught by staff smoking in his/her room on more than one occasion. CNA #2 further stated staff would take away cigarettes and lighters, but Resident #492 would obtain more. In an interview on 07/14/2023 at 1:11 PM, the DON stated she recalled the situation between Resident #492 and Resident #44. She stated Resident #44 was a new admission at the time, and although Resident #492 understood English, he had limited communication. The DON stated she would not consider the situation involving Resident #44 and Resident #492 as abuse, although Resident #492 had clearly been upset, flailing his/her urinal around and urine got everywhere, including on Resident #44. She stated she could not recall what Resident #492 had been yelling about. She further stated her expectation was that abuse did not occur, and for staff to follow the facility's process, and try to prevent harm to residents as much as possible. 2(a). Review of Resident #2's EHR revealed the facility admitted the resident on 10/14/2015, with diagnoses to include Dementia, Major Depressive Disorder, and Bipolar II Disorder. Continued review of the EHR revealed Resident #2's Annual MDS assessment dated [DATE], which noted the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) BIMS, indicating no cognitive impairment. (b). Review of Resident #493's EHR revealed the facility admitted the resident on 10/17/2022 with diagnoses to include Cerebral Ischemia, Impulsiveness, and Unspecified Dementia without Behavioral Disturbance. Further review revealed Resident #493's Quarterly MDS assessment dated [DATE], which noted the facility assessed the resident to have a BIMS score of six (6) out of fifteen, indicating severe cognitive impairment. Review of the Long Term Care Facility - Self-Reported Incident Form dated 04/21/2023 revealed on 04/17/2023 Resident #2 made contact with Resident #493 outside of Resident #2's room door. Continued review revealed the residents were separated and placed on every fifteen (15) minute checks. Per review of the Form, skin and pain assessments were completed, and Resident #493 was noted with a half-inch discoloration on his/her head, and neurological (neuro) checks were started. Further review revealed the facility noted there were two (2) staff witnesses, and the facility did not substantiate abuse, as it did not determine a willful intent by Resident #2 to cause harm to Resident #493. Review of the witness statements revealed a statement by Resident #2, undated, in which the resident stated he/she had not pushed Resident #493. Continued review of Resident #2's witness statement revealed Resident #493 had fallen on his/her own, and should not have been in Resident #2's doorway. Review of CNA #2's witness statement dated 04/17/2023 revealed staff heard Resident #2 yelling, observed Resident #493 half-way out the door to Resident #2's room, at which point Resident #2 pushed Resident #493, causing Resident #493 to fall and hit the right side of his/her head. In an interview on 07/11/2023 at 10:34 AM, Resident #2 stated he/she was treated well by other residents and by staff, and did not recall any incidents with any other residents. In an interview on 07/12/2023 at 4:58 PM, CNA #2 stated she observed Resident #493 walking into Resident #2's room on the day of the incident, and heard Resident #2 yell get out of my room,. CNA #2 stated she thought Resident #493 was going to walk on out, when she saw Resident #2 come out and push Resident #493. According to CNA #2, she was trying to get to Resident #493; however, everything happened so quick, and resulted in Resident #493 falling. She stated Resident #493 was off-balance, so even a little push could cause a fall. CNA #2 stated she had not noticed any changes in Resident #493's behavior after the incident. She stated Resident #2 was at one (1) minute the sweetest person, and the next moment yelling, that's just how the resident was. CNA #2 stated Resident #493 frustrated a lot of people as he/she had Dementia, and would go into other residents' rooms sometimes. CNA #2 further stated a Velcro stop sign was placed across Resident #2's door at the time, which appeared to be an effective deterrent for Resident #493. In an interview on 07/14/2023 at 1:11 PM, the DON stated Resident #2 had been placed in a private room as he/she did not like people being in his/her room, and did not get along with others. She stated Resident #493 had been pleasant, and walked around frequently; however, his/her equilibrium had been off. The DON stated Resident #2 pushed Resident #493 as he/she was trying to remove Resident #493 from his/her doorway. She stated she did not believe Resident #2 had meant Resident #493 any harm. The DON stated after the incident, the two (2) residents had been separated, and the facility performed its investigation. She stated as a result, a stop sign had been placed across Resident #2's doorway, and Resident #493 had been placed in the memory care unit due to his/her wandering. The DON stated the facility had not substantiated abuse, as Resident #2 had not willfully tried to hurt Resident #493. 44974 3. Review of Resident #243's Admission Record revealed the facility admitted the resident on 07/11/2023 with diagnoses to include: Diabetes, Cerebral Infarction, Hemiplegia and Hemiparesis affecting the right dominant side. Review of Resident #243's Admission Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's investigation, dated 07/13/2023, completed by the Administrator revealed on the morning of 07/13/2023 at approximately 6:30 AM the Business Office Manager (BOM) reported to the Administrator, Resident #243 was at the nurses' station observed to be upset and speaking loudly. Continued review revealed when the BOM asked Resident #243 what was wrong, Certified Nursing Assistant (CNA) #14 yelled because he/she was an a-hole. Per review of the investigation, the BOM immediately separated CNA #14 and Resident #243. Continued review revealed CNA #14 was suspended, and Resident #243 was assessed for psychosocial distress. Further review of the investigation revealed the facility's Interdisciplinary Team (IDT) met, discussed the findings, and substantiated the incident, and CNA #14 was terminated. Review of CNA #1's witness statement dated 07/13/2023, revealed Resident #243 had been upset and CNA #14 was speaking nicely to the resident. Continued review revealed however, CNA #14 did not receive the response she wanted from the resident so she started cussing him/her and stated, fuck your mommy, fuck your dead ass mammy, fuck your granddaddy, fuck you and, I can go home motherfucker. The State Survey Agency (SSA) Surveyor attempted a telephonic interview with CNA #1 on 07/17/2023 at 6:35 PM and 6:37 PM; and on 07/20/2023 at 8:30 PM; however, received no answer or return call. Review of CNA #25's witness statement dated 07/13/2023 at 7:46 AM, revealed while standing at the nurses' station she overheard the commotion between CNA #14 and Resident #243. Per review of the statement, CNA #25 reported Resident #243 told CNA #14, bitch, fuck you, suck my dick. Continued review revealed CNA #14 did not walk away and became engaged in a verbal exchange with Resident #243 and told the resident, you had a heart attack, and I didn't. Review of CNA #14's witness statement dated 07/13/2023, revealed Resident #243 had been at the nurses' station and was upset and yelling. Continued review revealed CNA #14 went and introduced herself to Resident #243 and let him/her know she would be the aide taking care of him/her for the day. Per review, Resident #243 would not calm down and called her (CNA #14) a bitch. Further review of CNA #14's statement revealed the CNA denied verbally abusing Resident #243. The SSA Surveyor attempted a telephonic interview with CNA #14 on 07/17/2023 at 6:45 PM; however, received no answer or return call. Review of CNA #14's employee file, dated 12/14/2022, revealed the facility, completed a background check on 12/01/2022, with no concerns noted prior to hiring the CNA on 12/14/2022. Continued review revealed the facility did not complete the Kentucky Adult Abuse registry check until 07/18/2023, which was clear. Further review revealed the CNA was trained on abuse on 06/21/2023. In an interview with the Business Office Manager (BOM), on 07/17/2023 at 3:50 PM, she stated on 07/13/2023 at approximately 6:30 AM, she was in the front hallway and heard yelling. She stated she went through the doors to the nursing station and heard Resident #243 yelling. The BOM stated she asked Resident #243 what was wrong, and CNA #14 replied, the resident was an A-hole. She stated CNA #14 did not say the full word. According to the BOM, she immediately had CNA#14 go to the Staff Development Coordinator's (SDC's) office. She stated the SDC came to the nurses' station and stayed with Resident #243. The BOM stated she called the Administrator and the Director of Nursing (DON), by way of three (3) way calling, and was instructed to have CNA #14 clock out and leave the building. Interview with SDC on 07/18/2023 at 4:07 PM, she stated that she was coming on duty when she heard yelling and immediately went to the nurses' station where Resident #243 was observed yelling out. The SDC stated Resident #243's speech was unintelligible at times; however, the SDC did understand the words black bitch and fuck her the resident stated loudly. The SDC stated the CNA was going down the hall saying that Resident #243 was mad because he/she wanted to go to bed because he/she had not slept the night before. She stated while the BOM was on the phone with the Administrator and DON reporting the incident, she was attempting to calm Resident #243. The SDC stated she escorted CNA #14 out of the building. During an interview on 07/18/2023 at 3:30 PM with the Social Services Director (SSD), he stated he interviewed Resident #243 after the incident. Per the interview, the SSD stated the resident was apologetic for the incident and expressed no psychosocial harm. Interview with the Director of Nursing (DON), on 07/19/2023 at 1:25 PM, she stated Resident #243 was a resident of the facility for only twenty-four (24) hours when the incident occurred. In interview on 08/07/2023 at 11:45 AM, the Administrator stated Resident #243 was not coming back to the facility and that was all she was aware of. In additional interview with the Administrator on 08/07/2023 at 3:03 PM, she stated she was made aware of the incident between Resident #243 and CNA #14 in the morning, on 07/13/2023, after the incident occurred. The Administrator stated she instructed the BOM to send CNA #14 home, while the facility completed a thorough investigation. She stated when the investigation paperwork was completed, the decision was made to terminate CNA #14. The Administrator stated she would not tolerate any form of abuse in the facility, and any allegation of abuse was investigated immediately with the alleged perpetrator being suspended pending the investigation. She stated that all staff were educated on abuse by the SDC after the incident. The Administrator further stated Resident #243 did not return to the facility after his/her hospital stay on 07/14/2023. 47852 4a. Review of Resident #31's Admission Record revealed the facility admitted the resident on 11/11/2021 with diagnoses which included Hemiplegia/Hemiparesis, Cerebral Infarction, Aphasia, Malnutrition, Diabetes, Dysphagia, Weakness, Alzheimers, Vascular Dementia, Polyneuropathy, Borderline Personality Disorder, Anxiety, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, and Major Depressive Disorder. Review of Resident #31's Admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident chose not to participate or scored zero (0) on four (4) or more items because the resident did not answer or gave a nonsensical response. Review of the resident's 04/21/2022 and 08/12/2022 Quarterly MDS revealed the facility assessed the resident to have a BIMS score of 99 on both assessments. Review of the resident's Significant Change MDS, dated [DATE], revealed the facility did not assess a BIMS score and indicated the resident was rarely or never understood. Review of Resident #31's Comprehensive Care Plan, dated 11/29/2021, revealed the resident had limited physical mobility related to Alzheimers, Neurological Deficits, and Stroke with interventions which included the resident was totally dependent on staff for locomotion. Further review of the Comprehensive Care Plan revealed the resident had a communication problem related to Expressive Aphasia, Neurological Symptoms, and Stroke with interventions which included the resident would tap staff and/or peers on the shoulder or back to get their attention related to communication deficit; this was a communication technique and did not represent a willful intent to harm, and monitor/document frustration level, wait thirty (30) seconds before providing resident with a word. Continued review of the Comprehensive Care Plan revealed the resident had the potential for a psychosocial well-being problem related to Bipolar Disorder, with interventions which included to discuss resident concerns/fears of being unwanted or feeling useless and to discuss with the resident feelings, reminiscence, and issues. 4b. Review of Resident #39's Admission Record revealed the facility admitted the resident on 02/02/2018 with diagnoses which included Dysphagia, Diabetes, Heart Failure, and Abnormal Posture. Further review revealed diagnoses added, on 02/05/2020, of Anxiety Disorder and Cognitive Communication Deficit. Review of Resident #39's Admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), which indicated the resident was moderately cognitively impaired. Review of the resident's Quarterly MDS's, dated 08/16/2022 and 08/29/2022, revealed the facility assessed the resident to have a BIMS score of six (6) out of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #39's Comprehensive Care Plan, dated 11/28/2021, revealed the resident displayed an alteration in cognitive functioning and memory related to dementia with interventions which included to provide one-to-one (1:1) care as needed and staff to provide cueing and prompting as needed. Review of the facility's investigation, dated 08/21/2022, revealed it was alleged Resident #31 made slight contact with Resident #39 on 08/18/2022 at the Nurse's Station. The residents were immediately separated and Resident #31 was placed on immediate one-to-one (1:1) supervision and a skin and pain assessment was completed for both residents with no injuries or pain noted. The facility determined the incident to be unsubstantiated. Review of CNA #20's witness statement, dated 08/18/2022, revealed she witnessed Resident #31 make contact with Resident #39. However, there was no further information provided on the specifics of the incident. Review of an unsigned document, dated 08/18/2022, revealed the Social Services Director (SSD) spoke with Resident #31, who was crying and told the SSD no to questioning if anything happened that date. Further review revealed the SSD spoke with Resident #39 who stated he/she was fine, no one had touched him/her that date, and no one had made him/her feel unsafe. The State Survey Agency (SSA) Surveyor attempted to telephone CNA #20 on three (3) occasions without a return call. During an interview with the Administrator on 08/07/2023 at 1:45 PM, she stated she was the Abuse Coordinator for the facility, and she made sure an investigation was completed for all abuse allegations, although she could not speak about allegations that occurred before she came to the facility in the Fall of 2022. She further stated if a resident complained of abuse, she would make sure the resident was safe, pull the resident aside and talk with them, complete a room change if necessary, would notify the Social Services Director for any psychosocial interventions and psychiatric services as needed, and report to the appropriate people immediately. She further stated if a staff member was alleged to be involved, the staff member would be suspended pending the investigation being completed. She continued to state all abuse allegations had been reported, to her knowledge.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' right to a dignified existence and communication with and access to persons and services inside and outside the facility for four (4) of sixty-one (61) sampled residents (Residents #4, #40, #51, and #57). Resident #4 stated staff entered his/her room while he/she was having a private phone conversation with his/her family. Resident #40 stated staff members often turned his/her call light off, left the room not changing him/her, while telling the residents that all the residents were waiting to be changed. Observation revealed staff rolled his eyes at Resident #51 and stated how much he hated sitting with the resident in front of the resident. Resident #57 stated staff had been rude to him/her and laughed at him/her. The findings include: Review of the facility's policy, Resident Rights, revised 11/07/2022, revealed it was the policy of the facility to observe and implement Resident Rights as dictated by the Centers for Medicare and Medicaid Services (CMS) and each resident has the right to be treated with dignity and respect. Further review revealed the preferences and goals of the resident should be honored as much as possible and the resident's comfort, safety, and overall welfare should be promoted, protected, and enhanced at all times. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 11/08/2022, with diagnoses which included Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Diabetes, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #4's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS under Section G revealed the facility assessed Resident #4 to require the assistance of two (2) persons for bed mobility and transfers and one (1) person assist for dressing and eating. Review of Resident #4's Comprehensive Care Plan, dated 11/09/2022, revealed the resident had a potential for ulceration, infection, and/or complications of the ostomy site. Further review revealed Resident #4 had a urostomy related to neurogenic bladder. Record review revealed interventions that included: perform urostomy care daily and as needed; maintain urostomy site and keep clean and dry; and check urostomy for leakage. Observation, on 07/11/2023 at 10:35 AM, revealed a staff member from the therapy department came into the resident's room, while the resident was having a conversation. The staff worked with the resident's roommate, not providing any privacy for conversation with Resident #4. Further observation revealed another staff member knocked on the closed door during the conversation with Resident #4. The resident stated wait a minute, the staff member waited approximately thirty (30) seconds, then opened the door, looked inside, then closed the door. Observation, on 07/17/2023 at 9:42 AM, revealed Resident #4's urostomy drainage bag was touching the floor with no dignity bag covering it. During an interview with Resident #4, on 07/11/2023 at 10:30 AM, he/she stated staff would come into his/her room while he/she had visitors or was on the phone, and he/she felt he/she was receiving no privacy. He/she further stated he/she had requested from the scheduler and the main nurse that a male staff member not provide bathing, and he/she continued to receive male staff members for bathing. He/she continued to state staff members often laugh at her when she asked for care. During an interview with Resident #4, on 07/12/2023 at 9:23 AM, he/she stated his/her urostomy bag was full and leaking, and he/she had asked LPN #6 to change it, and he stated would when he had time. During an interview with Licensed Practical Nurse (LPN) #6, on 07/17/2023 at 9:45 AM, he stated the urostomy bag should have a dignity bag, and it was an infection control issue for the urostomy bag to touch the floor. 2. Review of Resident #40's medical record revealed the facility admitted the resident on 12/11/2022, with diagnoses which included Hemiplegia, Morbid Obesity, Osteoarthritis, Polyneuropathy, and Weakness. Review of Resident #40's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS under section G revealed the facility assessed Resident #40 to require extensive assistance of two (2) persons for bed mobility, transfers, dressing, and one (1) person assist for eating and personal hygiene. Review of Resident #40's Comprehensive Care Plan, dated 01/09/2023, revealed the resident had an alteration in elimination due to bowel incontinence and a potential for complications associated with urinary incontinence with interventions which included ask/encourage the resident to use the call system to report the need to toilet as needed and to provide incontinence care/peri care after incontinence episodes as needed. Further review revealed the resident had an alteration in comfort related to Osteoarthritis, Cluster Headache Syndrome, Low Back Pain, Muscle Spasms and Neuropathy with interventions which included pain medication per order and observe for effectiveness. Observation, on 07/16/2023 at 6:58 PM, revealed Resident #40 put on the call light. Observation revealed the call light was answered by Certified Nursing Assistant (CNA) #21 at 7:10 PM. CNA was in the resident's room for approximately thirty (30) seconds, then returned to the hallway and continued picking up dinner trays. During an interview with Resident #40, on 07/16/2023 at 7:32 PM, he/she stated he/she had asked for incontinence care and CNA #21 told him/her that no one had been changed on the hall yet and he/she would have to wait until he got time to change Resident #40. He/she further stated he/she had not received incontinence care since 2:30 PM and he/she often did not receive every two (2) hour incontinence care as he/she expected. He/she continued to state he/she was embarrassed and worried about skin breakdown because of lack of incontinence care. During an interview with CNA #21, on 07/16/2023 at 7:35 PM, he stated he was the only CNA on the hall taking care of thirty plus (30+) residents because another CNA was running late and it happened a lot that he was the only CNA for the hall. During an interview with Resident #40, on 08/03/2023 at 1:22 PM, he/she stated he/she had to wait one and one-half (1 1/2) hours last night for his/her call light last night. He/she further stated some nurses and medication technicians refuse to give him/her the headache medicine (Fioricet) along with my pain pill (Oxycodone) even though physicians and nurse practitioners have told him/her they can be given together. He/she continued to state it made him/her uncomfortable and sad that staff won't follow the doctors orders and left him/her in pain. 3. Review of Resident #51's medical record revealed the facility admitted the resident on 04/07/2023, with diagnoses including Hypertension, Malnutrition, Depression and Anxiety. Review of Resident #51's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), which indicated the resident chose not to participate, or four (4) or more items were coded as zero (0). Further review of the MDS, Section G, functional status revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers, and review of the MDS, section J revealed Resident #51 had a history of falls. Review of Resident #51's Comprehensive Care Plan, dated 04/23/2023, revealed the resident was care planned for a risk for falls with interventions including: two (2) staff for ADL care for safety; bolsters to left side of bed; one-to-one (1:1) supervision for safety due to frequent falls; call light within reach at all times, therapy to assess for locking tray table for geri chair; low bed related to decreased safety awareness; full size mattress to right side of bed; and the resident to be taken to activities to help keep him/her engaged in other forms of stimulation. Observation, on 07/21/2023 at 2:50 PM, revealed CNA #11 sitting with Resident #51 one-to-one (1:1). Resident #51 was observed taking off his/her shirt and CNA #11 stated put your shirt back on, I hate sitting with him/her and I can't wait to get off. Resident #51 stated Sorry. Observation, on 07/31/2023 at 10:05 AM, revealed LPN #6 had given Resident #51 medications per G-tube with the room door open. 4. Review of Resident #57's medical record revealed the facility admitted the resident on 03/17/2021, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Diabetes, Schizoaffactive Disorder, Bipolar Type, Arthritis, Dysphagia, Pain, Weakness, and Status Post Tracheostomy. Review of Resident #57's Admission MDS Assessment, dated 03/16/2021, and Quarterly MDS Assessment, dated 05/03/2023, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #57's Comprehensive Care Plan, dated 03/22/2021, revealed the resident was care planned to be at risk for complications related to his/her tracheotomy with interventions which included to maintain the resident's dignity during care and anticipate the resident's needs. Observation, on 07/31/2023 at 3:15 PM, revealed Resident #57 in his/her room crying and mouthed words I'll talk to you later. During an interview with Resident #57, on 08/05/2023 at 11:00 AM, the resident stated the staff laughed at him/her and were mean to me. The resident denied physical abuse but stated he/she felt the staff mocked him/her. The resident had also written notes he/she handed to the State Survey Agency (SSA) Surveyor because the resident had a difficulty time vocalizing words due to having a tracheotomy, which indicated the resident felt the staff made fun of him/her. During an interview with the Administrator, on 08/07/2023 at 1:45 PM, she stated she was the Abuse Coordinator for the facility and she was unaware of any resident that felt they were being made fun of or laughed at. She further stated she would expect residents to report to her if any staff members were making them feel uncomfortable.

Based on observation, interview, and review of facility's policy, the facility failed to protect resident rights to privacy related to electronic medical records (EMRs) as determined by observations of the computer located on top of the medication /treatment cart, on 08/01/2023 and 08/04/2023, being left open and viewable with resident information. The findings include: Review of the facility's policy titled, Resident Rights, dated 01/09/2023, revealed it was the policy of the facility to observe and implement resident rights as dictated by the Centers for Medicare and Medicaid Services (CMS). These rights and protections are mandated by federal and state laws and are a requirement in Medicare and/or Medicaid certified nursing homes. Review of the facility admission packet under title Resident Records, dated 08/01/2023, revealed residents' information in the clinical record was confidential and shall not be disclosed without residents' written consent, except as required or permitted by law. Observation of the medication/treatment cart located by the nurses' station, on 08/01/2023 at 7:00 PM, revealed the computer was left open with residents' information and the residents' medications in public view. Further observation of the computer screen revealed a resident picture in the upper left-hand corner with rectangular yellow boxes underneath. Observation of the medication cart on the 300 Hall, on 08/04/2023 at 11:04 AM, revealed a computer with the screen opened with residents' information and the residents' medications in public view. During an interview with Licensed Practical Nurse (LPN) #17, on 08/01/2023 at 7:03 PM, she stated she took pain medication to a resident in room [ROOM NUMBER] and could not see the computer screen from the room. However, she left the computer screen black and stated it should take two (2) to three (3) minutes for the screen to turn black. She further stated she had not taken over the medication/treatment cart from the nurse at the time the computer screen was viewed by surveyors. She stated if the computer was left open with resident information it could be a Health Insurance Portability and Accountability Act (HIPPA) concern and against facility policy. During an interview with Registered Nurse (RN) #1, on 08/04/2023 at 11:05 AM, he stated he was responsible for the computer, and he should have locked the computer screen to keep residents' information confidential. During an interview with the Director of Nursing (DON), on 08/06/2023 at 9:42 AM, she stated the nurse should not have left the computer open with any patient information and it was a HIPAA violation. She further stated the screen should be left black or closed. During an interview with the Administrator, on 08/06/2023 at 10:08 AM, she stated the computer screen should be closed when not in use.

Based on interview, record review, review of store receipts, and review of the facility's policy, it was determined the facility failed to ensure proper bookkeeping techniques. The facility's bookkeeping techniques failed to include an individual record established for each resident on which only those transactions involving his/her personal funds were recorded and maintained. The transactions failed to include information related to when the transactions occurred, what they were, the ongoing balance, and a receipt to give the resident and the facility to retain, for one (1) of sixty-one (61) sampled residents (Resident #14). The findings include: Review of the facility's policy titled, Resident Trust Fund Policy, updated 08/08/2022, revealed residents' funds were maintained in accordance with the State guidelines. The management of residents' funds was the responsibility of the Administrator and the Business Office Manager (BOM). Per the policy, residents' funds were maintained in a separate interest-bearing bank account that was the sole property of the residents, completely separate from any facility accounts. The policy stated it was mandatory that a reconciliation between the resident trust fund and the bank statement be completed monthly, and the residents' trust fund statements would be presented to the resident/responsible party on a quarterly basis. Per the policy, it was imperative to have proper segregation of duties in handling residents' funds, and this was for the protection of the individuals that performed the facility cash tasks. The policy stated the individual that received monies, gave receipts for monies, and prepared the deposits should not be the individual assigned to post the transactions into the accounting software. Per the policy, a resident on medical assistance would be notified whenever his/her funds were within two hundred dollars ($200) of the resource asset limit of two thousand dollars ($2,000). The policy stated the BOM was responsible for sending a notification letter to the resident/responsible party whenever his/her funds were within $200 of their resource limit. Per the policy, the BOM consultant would perform regular audits to verify the accuracy and completeness of the facility's trust fund records and cash box monthly reconciliations. Review of Resident #14's Admission Record revealed the facility admitted the resident, on 06/20/2020, with diagnoses of Diabetes, Dementia, and Hypertension. Review of Resident #14's Quarterly Minimum Data Set (MDS) Assessment, dated 02/12/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) which indicated moderate cognitive impairment. Review of the Annual MDS Assessment, dated 05/03/2023, and the Quarterly MDS Assessment, dated 08/01/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #14's variety store receipt for the resident's shopping on 04/22/2023 showed the itemized list that included: renew membership, renew plus membership, five (5) packs of thirty-five (35) cans of Sprite per pack; five (5) packs of thirty-five (35) cans of Coke per pack; five (5) cases of another soda; two (2) cases of root beer; three (3) cases of Ensure; three (3) cases of Faygo soda; two (2) cases of Tropicana; two (2) packs of tea, eighteen (18) per pack; four (4) cases of donuts; three (3) cases of honey buns; two (2) cases of muffins; two (2) snack packs; and multiple illegible items. Review of the facility's receipt for shopping for Resident #14 included clothes, snacks, drinks, and personals, dated 04/24/2023 for the amount of fifteen hundred and thirty dollars ($1530.00). This was signed by Resident #14. In an interview on 07/18/2023 at 1:35 PM, the BOM stated she did the shopping for Resident #14 on 04/24/2023. However, she stated the check was made out to the former Receptionist. She stated she and the Administrator could not write checks to themselves to reimburse for purchases made for residents using their own funds. However, she stated they could use a credit card for purchases and corporate would reimburse them after receiving a receipt. She stated the check was made out to the Receptionist because she (the BOM) could not write a check to herself. Review of Resident #14's receipt from an online purchase for a wheelchair and cushions, dated 04/26/2023 for the amount of $719.73, revealed the Administrator's name was on it. However, the check was made out to the former Receptionist. In an interview on 07/18/2023 at 3:30 PM, the Administrator stated she purchased Resident #14's wheelchair to spend down the resident's money. She stated she purchased the wheelchair from an on-line retailer, using her credit card. The Administrator stated she signed off on receipts from the BOM for purchases the BOM made for residents. However, she stated she could not verify she signed off on a $800 receipt from 04/22/2023 from the variety store for Resident #14. She stated the check to reimburse her for Resident #14's wheelchair was made out to the former Receptionist because they could not make checks out to themselves. Review of Resident #14's receipt from an on-line retailer, dated 04/26/2023, revealed items ordered included a ergonomic wheelchair in 16 seat, quick release axis, and red frame for the amount of $629.00. The other items ordered were two (2) comfort gel memory foam wheelchair seat cushions for pressure sores and ulcer pain relief in the amount of approximately $50.00. Review of Resident #14's other receipts totaling $1530, revealed these were copies and not the original reciepts and they were not legible. These copies looked as though they were altered with tape but they were all ending in the same credit card number. In an interview on 07/18/2023 at 2:45 PM, the Administrator stated she had not heard of checks being cashed into personal accounts. She stated she had never cashed checks. The Administrator stated she had not signed off on any receipts. She stated she thought the resident's money went to the facility minus $40, but she would have to ask the BOM about the process. The Administrator stated employees that had to sign off on receipts from last year were the MDS Coordinator and the Dietary Manager. She stated this year the employees that had to sign off on receipts were the Medical Records Director, the Scheduler, and the Dietary Manager. The State Survey Agency (SSA) Surveyor requested the Human Resources (HR) Director for employees' email addresses for terminated employees, the former Receptionist and the former MDS Coordinator, on 07/11/2023 at 11:00 AM. On 07/11/2023, at 1:07 PM, the State Survey Agency (SSA) Surveyor emailed the former Receptionist requesting a call to the SSA Surveyor. On 07/11/2023 at 1:10 PM, the former MDS Coordinator was emailed requesting a call back to the SSA Surveyor. Interview with the former Receptionist and former MDS Coordinator was attempted, on 07/15/2023 at 3:00 PM, but their phone numbers were not working numbers. In an interview on 07/18/2023 at 3:15 PM, the Dietary Manager stated she was asked to sign off on receipts, but she had not done so. She stated she had not done any shopping for residents. The Dietary Manager stated she had signed off on two (2) petty cash receipts for residents. She stated she had bought snacks, drinks, and other things for employees. In an interview on 07/11/2023 at 10:20 AM, Resident #14 stated he/she did not have any concerns with finances. Resident #14 stated he/she was given a trust fund statement recently. The SSA Surveyor, on 07/18/2023 at 3:45 PM, requested the Director of Nursing (DON) ask the BOM for Resident #14's variety store membership and premium membership cards that were listed on Resident #14's store receipt from purchases dated 04/22/2023. O 07/18/2023 at 4:40 PM, the SSA Surveyor went to the BOM's office to request to see Resident #14's membership cards. The BOM stated she did not realize she bought her membership cards with Resident #14's money. The BOM stated the purchase was an honest mistake. She stated she had placed the money back into Resident #14's account. Review of a receipt, dated 07/19/2023 at 9:25 AM, revealed it was a deposit into Resident #14's resident fund account with two (2) deposits listed. One deposit listed was $50 dollars for the variety store membership, and the other deposit was $60 for the variety store plus membership. Both memberships were purchased by the BOM, using Resident #14's account on 04/22/2023. In an interview on 07/19/2023 at 9:36 AM, the Receptionist stated she had never gone shopping and had not cashed a check for the facility. She stated she only collected the resident's liability for the room and gave it to the BOM when people would pay at the front desk. She stated she had the receipts in a drawer at the front desk. The SSA Surveyor, on 07/19/2023 at 9:45 AM, requested for the second time from the DON and BOM to view the original receipts for purchases for Resident #14. The SSA also requested the petty cash log and resident advanced checks for the last three (3) months. At that time, the SSA Surveyor saw four (4) packs of thirty-five (35) cans of soda in the BOM's closet. Certified Nursing Assistant (CNA) #15 stated they were for Resident #14 and were stored in the BOM's office. In an interview on 07/19/2023 at 10:10 AM, the Receptionist stated she had cashed two (2) checks for the facility. She stated these were resident advanced checks, and her name was listed as the vendor being called the petty cashier. She stated she cashed the resident advanced check and gave the money to the BOM. She provided a bank check deposit slip, dated 07/11/2023, which was not legible. In an interview on 07/19/2023 at 10:12 AM, Certified Nurse Aide (CNA) #15 stated Resident #14 had soda, popcorn, Coke, and peanut butter crackers that staff got from the BOM's office. The CNA stated the resident got new clothes and new athletic/tennis shoes about a month ago. In an interview on 07/19/2023 at 10:45 AM, the Human Resources Director stated she cashed a check yesterday for $260. She stated this was to replenish the petty cash fund, and she had to cash the check and bring the money back to the facility in all one-dollar bills. In an interview on 07/19/2023 at 1:15 PM, the BOM and the Regional Director of Operations (RDO), MDS Coordinator, and the DON were present. The SSA Surveyor requested clarification for deposits at the same bank that was the BOM's bank and also the RFMS' (Resident Fund Manager Service) bank. The BOM stated the money went into a main account for the RFMS, and then it was distributed into resident accounts from there. The SSA Surveyor asked about the Human Resources Director cashing a $260 check. The BOM stated the residents came to get petty cash, and the facility had the Human Resources Director cash a check to bring the petty cash amount back to $300. In an interview, on 07/20/2023 at 8:00 AM, the Guardian Fiduciary stated that residents' monies were all kept in another city. She stated they would send the residents their $30 to $40 each month. She stated if the residents needed clothes or anything, they would send the facility more money. She stated she did not have any concerns. In an interview on 07/23/2023 at 11:00 AM, Resident #14 stated his/her favorite snacks were popcorn and peanut butter crackers. The resident stated his/her favorite soda was cream soda and Coke. When asked if he/she like honey buns, the resident replied, No. In an interview on 07/24/2023 at 1:31 PM, the Regional Account Manager stated the residents' funds were held by National Data Care which was the RFMS. He said state guidelines determined the amount a resident was allotted each month; however, he did not know the Kentucky amount. He stated unless the resident had an item D expense (not covered by Medicaid or by a third party like Medicare or private insurance), then the state would allot them more money. He stated the maximum amount for a resident trust fund was $2000. During continued interview, he stated there was an exception when residents were able to exceed this amount, which started with the COVID pandemic in March 2020 and ended six (6) months ago. The Regional Account Manager stated the BOM should not handle any purchases for residents. He stated Social Services, Activities, or a responsible party would help spend down the resident's money and should make purchases for residents. He stated each resident had his/her own interest-bearing account. The Regional Account Manager stated there was a master account which received the statement from the bank. He stated each resident had his/her own routing and account number through National Data Care. He stated the BOM did the reconciliation, and it was sent to the regional office for review. In interview, he stated residents could use money for anything they wanted. He stated the Administrator should be the one who cashed checks to replenish petty cash, and this came from the master petty cash account. The Regional Account Manager stated the process for a request for money was the BOM signed the check request and the check recipient, then it would withdraw from the National Data Care system, and the check would be printed in twenty-four (24) hours. He stated the facility could have checks made to employees if the BOM approved. The Regional Account Manager stated for audits they verified: that purchases were signed for; the amount requested was the amount given; interest was provided to accounts; accounts that needed to be closed were closed in thirty (30) days; checked for outstanding checks, or negative accounts. He stated the BOM reviewed returned receipts. He stated if the BOM did shopping for the resident, which should not happen, the Administrator should review the receipts. He stated if something was bought incorrectly on a resident account, the money should be returned immediately. In an interview on 08/01/2023 at 3:20 PM, the Administrator stated each resident's trust fund account must be less than $2000. She stated the resident could delegate how he/she wanted any monies spent that exceeded the $2000 account limit. The Administrator stated the BOM should not do any shopping for the residents. She stated the BOM reviewed receipts. However, she stated if the BOM did any shopping, the Administrator or Human Resources Director would sign off on the receipts. The Administrator stated the only time she had done shopping was for Resident #14's wheelchair. She stated she had to put it on her own personal credit card, because the facility did not have a facility credit card. During continued interview, she stated she did not want her employees to endure the cost on their personal credit card. She stated if a personal item was placed on a resident's account, it should be reimbursed immediately. The Administrator stated if the resident requested a copy of the receipt, the facility would give a copy to him/her or the Power of Attorney or Guardian. She stated a resident's Brief Interview for Mental Status (BIMS) score of greater than eight (8), which meant the resident had moderate cognitive impairment or no cognitive impairment, was acceptable to sign off on his/her cash advances.

Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure residents were free from abuse for two (2) of nineteen (19) sampled residents, Resident #7 and #8. Review of the Facility Reported Incident document, undated, revealed at approximately 11:13 PM on [DATE], CNA #6 noticed Resident #7 in the room of Resident #8. CNA #6 observed Resident #7 sitting on the side of the bed of Resident #8. The CNA entered the room, and observed Resident #7 with his/her hand underneath the shirt of Resident #8, moving his/her hand up and down the torso/chest area of Resident #8. Interview with CNA #3, on [DATE], revealed Resident #8 told the CNA a few days after the incident occurred that a man came into his/her room and sat on the side of his/her bed and rubbed his/her boobs. Record review and interview revealed the facility did not assess Resident #7 or #8 prior to engaging in sexual behaviors or relations for the capacity to consent. Interview on [DATE] at 9:10 AM, with Resident #8's family member (FM) #8, revealed Resident #8 did not have the mental capacity to make decisions to consent to sexual relations. The FM further revealed Resident #8 had not been able to consent for a long time. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at scope and severity (S/S) of J.The facility was notified of the Immediate Jeopardy on [DATE]. An extended survey was conducted on [DATE] through [DATE]. The State Survey Agency validated the facility's Allegation of Compliance/Removal Plan and found the facility had removed the immediacy on [DATE], as alleged prior to exit on [DATE] with remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at scope and severity (S/S) of D while the facility developed and implemented a Plan of Correction and monitored for effectiveness of the systemic changes. Additional deficient practice was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F602 Free from Misappropriation/Exploitation. The findings include: Review of the facility's policy, entitled, Abuse Prevention Program, undated, indicated it was the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident received care and services in a person-centered environment in which all individuals were treated as human beings. Review of the facility's policy, Consent for Sexual Contact, undated, revealed it was the policy of the facility to ensure the residents' needs were met and their Resident Rights were upheld in a safe, comfortable homelike environment. These needs included physical mental, social, spiritual and sexual (as desired and under specific requirement). Interview with the Regional Nurse Consultant (RNC), on [DATE] at 1:15 PM, revealed the facility had recently created a policy related to consent for sexual activity entitled, Consent for Sexual Contact. When asked the date the policy was created, the RNC commented, It was not dated, but it was recently created. The facility provided the resident's Brief Interview for Mental Status (BIMS) assessment from the Resident Assessment Instrument (RAI) as the reference the facility used to determine a resident's capacity to consent. Review of the Abbreviated Instructions for Conducting the BIMS, revised ,d+[DATE], revealed a BIMS'S score range of thirteen (13) to fifteen (15) indicated a resident was cognitively intact, eight (8) to twelve (12) was moderately impaired, and zero (0) to seven (7) was severe impairment. Review of the Mini Mental Status Examination (MMSE), provided by the Family Nurse Practitioner (FNP) #20, revealed the scoring code on the form revealed a twenty-four (24) to thirty (30) indicated no cognitive impairment, eighteen (18) to twenty-three (23) was mild cognitive impairment, and zero (0) to seventeen (17) was severe cognitive impairment. Interview with Family Nurse Practitioner (FNP) #20, on [DATE] at 10:20 AM, revealed she used the Mini Mental State Examination (MMSE) as a reference to determine a resident's capacity to consent to sexual relationships. Review of the Facility Reported Incident (FRI) Investigation document, undated, revealed at approximately 11:13 PM on [DATE], CNA #6 was walking down the hall of the Evergreen Unit when Resident #7, was noticed in the room of Resident #8. CNA #6 noticed Resident #7 sitting on the side of the bed of Resident #8. The CNA entered the room, and noticed Resident #7 with his/her hand underneath the shirt of Resident #8, moving his/her hand up and down the torso/chest area of Resident #8. Record review revealed no evidence the facility had conducted an assessment of Resident #7 or Resident #8 for capacity to consent to sexual relations prior to the incident reported on [DATE]. The first recorded evaluation of Resident #7 and #8, for capacity to consent, was on [DATE]. 1. Record review revealed the facility admitted Resident #7 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission Minimal Data Set (MDS), dated [DATE], revealed the facility assessed Resident #7 to have a Brief Mental Interview Status Score (BIMS) score of ten (10) which determined the resident had moderate cognitive impairment. Record review revealed no evidence the facility assessed Resident #7 for capacity to consent, participate or initiate sexual relations, prior to the incident on [DATE]. Record review of a Psychotherapy Diagnostic Assessment completed by a Licensed Clinical Social Worker, (LCSW) on [DATE], revealed Resident #7 presented with symptoms of confusion and inappropriate sexual behavior. Current risk factors reviewed revealed the resident was not currently a risk to self or others. The treatment plan was to decrease inappropriate behavior by fifty percent. Review of Resident #7's care plan initiated, [DATE], revealed Resident #7 displayed an alteration in cognitive functioning and memory related to a [CONDITION(S)]. The goal was the resident would not have adverse effects of poor decision making initiated. Further review revealed the staff interventions included to provide cueing and prompting as needed. Record review revealed a progress note, dated [DATE] at 1:03 PM, that noted Resident #7 had periods of confusion. Continued record review revealed the facility's first documented assessment for Resident #7's capacity to consent was conducted on [DATE], by Family Nurse Practitioner (FNP). The FNP noted at that time the resident was able to give informed consent regarding consensual sexual activity. Interview on [DATE] at 3:45 PM, with Certified Nursing Assistant (CNA) #6, revealed she was walking down the hall to answer a call light when she saw Resident #7 sitting on the side of Resident #8's bed with his/her hand under Resident #8's shirt. CNA #6 immediately escorted Resident #7 to his/her room and reported the incident to Registered Nurse, (RN) #1. Interview with Resident #7, on [DATE] at 11:30 AM, revealed Resident #8 had asked him/her to come into his/her room. Resident #8 stated, I did touch her breast under her clothing. A woman came down the hall and caught me. He/she (Resident #8) did not tell me to stop. Yes, it was under her clothes I have never done this before and will never do it again. The police came in and talked to me. 2. Review of the clinical record for Resident #8 revealed the facility readmitted the resident from the hospital, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Quarterly Minimum Data Set (MDS) dated [DATE], Section C Cognitive Patterns, revealed the facility assessed Resident #8 to have a Brief Mental Interview Status Score (BIMS) of five (5) out of a total of fifteen (15) which indicated the resident was severely cognitively impaired. Review of the facility's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #8 to be totally dependent on the staff for transfers with two (2) person assist and total dependence to move about the unit with one (1) person assistance. The resident had impairment on one (1) side for upper and lower extremities. Section C of the MDS for cognitive patterns was not completed. Review of the comprehensive care plan for Resident #8, revealed the facility initiated a care plan on [DATE] for displaying an alteration in cognitive function and memory. His/her BIMS fluctuated between five (5) and fourteen (14), required clues and reminders, talked about things in the past that resident believed were current and reality, such as speaking to his/her parents that were deceased . Interventions included provide one (1) on one (1) as needed and staff to provide cueing and prompting as needed. Further review of the Comprehensive Care Plan for Resident #8, revealed the facility initiated a Behavior Problem care plan on [DATE]. The care plane that the resident had a problem of fabricating the truth related to attention seeking behavior. Interventions included encourage resident to not invite others into room that passed by, related to attention seeking. Encourage to not voice acceptance of actions to some and voice disapproval of actions to others in regards to the same occurrence(s) in order to gain attention from the audience in which he/she was entertaining. Record review of the Progress Notes, dated [DATE] at 6:37 PM, revealed Resident #8 displayed behaviors including speaking out loud to his/her deceased parents, frequently speaking of life events as factual, was unable to make his/her needs known, and staff needed to anticipate all the resident needs. Review of the Family Nurse Practitioner (FNP) #20's note, dated [DATE], revealed the facility requested Resident #8 be seen for his/her mental capacity to consent to sexual activity. Continued review of the medical record revealed no evidence of prior assessments for capacity to consent to sexual activity. The FNP assessment noted the resident had been diagnosed with delusions, depression and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Mini Mental State Evaluation (MMSE) was completed with a score of 20, indicating mild cognitive impairment. Continued review of the FNP's notes, revealed the BIMS score previously completed at the facility was documented as low as five (5), however this may need to be reassessed as the resident showed more cognitive ability during exam. Based on the (FNP) evaluation, the resident was able to give informed consent regarding consensual sexual activity. The note further stated the resident had many diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 5:05 PM, observation revealed Resident #8 sitting up in bed in room [ROOM NUMBER]-A on the Evergreen Unit watching television. The resident waved his/her hand for the surveyor to come in and then verbally invited the surveyor to come in. The resident asked the surveyor to open a package of cookies. A staff member immediately entered the room and opened the cookies for the resident. On [DATE] at 1:10 PM when the surveyor was walking down the Evergreen Hall, Resident #8 waved at the surveyor to come into his/her room, (room [ROOM NUMBER]-A). Resident #8 was able to correctly state his/her birthdate and name. When asked if anyone had ever bothered him/her such as touching him/her inappropriately the resident responded, No. On [DATE] at 12:30 PM, during an interview with Resident #8, the resident revealed he/she yelled out a lot because he/she was lonely. Resident #8 said, The man across the hall tells me not to make noise and to be quiet. When asked the name of the man across the hall, the resident answered with the name of a man who had never been a resident at the facility. Resident #8 revealed no one had ever sexually bothered him/her at the nursing home. Resident #8 said, If they did, my Mom & Dad would whoop them. When asked how long he/she had lived at the nursing home the resident responded, About a month or two. The other day I thought I was in a hospital, but the nurse told me I was in a nursing home. I have had two strokes. The resident asked the surveyor when she would come back to visit. Observation on [DATE] at 3:20 PM, revealed Resident #8 was sitting up in bed in his/her room when he/she waved to the surveyor to come in. On [DATE] and [DATE] attempted phone interviews with RN #1, who no longer worked at the facility. Left voice messages. Never received a call back by the end of the survey. Interview with CNA #6 on [DATE] revealed she had worked at the facility for six (6) years, but now was off work on bed rest. She revealed she had often cared for Resident #8. CNA #6 stated she was walking down the hall of the Evergreen Unit when Resident #7, was noticed in the room of Resident #8. Resident #7 was sitting on the side of the bed of Resident #8. The CNA entered the room, and noticed Resident #7 with his/her hand underneath the shirt of Resident #8, moving his/her hand up and down the torso/chest area of Resident #8. A couple of days later resident #8 told her a man was sitting on the side of his/her bed and rubbing her boobs. Interview with the Assistant Director of Nursing, (ADON), on [DATE] at 9:35 AM, revealed the facility used a BIMS's score of eight (8) and above to determine if a resident could give consent. The ADON stated Resident #8 had the ability to consent because he/she had a BIMS of eight (8) or above. Furthermore the ADON stated no one had assessed the resident if she/he wanted to be in a sexual relationship or have sexual contact. Interview with Family Nurse Practitioners (FNP) #20, on [DATE] at 10:20 AM, revealed she conducted telehealth services and was asked to evaluate Resident #8 for mental capacity to determine his/her ability to consent to sexual relationships on [DATE]. The FNP revealed if a resident expressed an interest in a sexual relationship, she used the Mini Mental State Examination (MMSE) to determine if the resident had the mental capacity to consent. Resident #8 scored twenty (20) indicating mild cognitive impairment. The FNP stated, I understand the resident's BIMS score fluctuates, but at the time of my evaluation on [DATE], the resident was able to consent to sexual relationships. It could be he/she had periods of decreased mental capacity. I do not know why he/she has had such low BIMS at times. BIMS can be high one day and not the next day. Lots of factors can change the mental capacity of a person. Telephone interview with the Medical Director, on [DATE] at 4:55 PM, revealed in his opinion Resident #8 was capable of consenting to sexual relationships, because a Score of 20 on the MMSE indicated mild cognitive impairment. The Medical Director stated, Resident #8 sometimes became shy with some people and shut down depending on who the interrogator was. The Medical Director stated he was uncertain when he last saw Resident #8. Interview on [DATE] at 9:10 AM, with Resident #8's family member (FM) #8, revealed, in his/her opinion, Resident #8 did not have the mental capacity to make decisions to consent to sexual relations for a long time. During an interview with the Administrator, on [DATE] at 11:10 AM, revealed the facility realized a resident's BIMS would not always determine whether or not the resident was capable of making a decision to consent to sexual relationships. Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility took the following actions: 1. The Medical Director assessed Resident #8 for capacity to consent to sexual contact. 2. Residents who reside in the facility and who have cognition deficits, based on facility defined parameters were assessed by the Licensed Social Worker (LSD) or Social Services Designee (SSD) by the [NAME] of day [DATE]. Those with a BIMS score of eight (8) or greater who expressed a desire for sexual contact will have interview with physician to validate capacity to consent 3. The DON/Designee/ADON/SSD will monitor ten (10) medical records five (5) days weekly times three (3) months on a rotating basis, (to include any new admissions or re-admissions), to ensure that these residents have had their capacity to consent to sexual contact has been defined per assessment. Afterwards ten (10) medical records will be reviewed weekly on a rotating basis (to include new admissions or re-admissions,) for six (6) months. 4. These residents' care plans will reflect the status of their sexual contact potential. Afterwards, 10 medical records will be reviewed weekly on a rotating basis, (to include any new admissions or re-admissions), for 6 months to ensure ongoing compliance. 5. The CQI (Clinical Quality Indicator) morning meetings, held M-F, any residents admitted or readmitted since the prior CQI morning meeting, will be reviewed and an assessment as to their capacity to consent to sexual contact will be scheduled. This assessment will be completed and care planned within the first fourteen (14) days of admission or re-admission. This will be an ongoing part of the CQI meeting agenda. This practice will be ongoing. This issue will also be reviewed at the quarterly care plan conferences or upon request of a resident. Residents with a BIMS of 8 or greater who express a desire, per assessment for sexual contact with another consenting adult, will be further assessed by a face-to-face interview with a physician to validate the resident's capacity to consent to sexual contact with another consenting adult. Family and POA will provide input as indicated. 6. A Regional Team member will review the afore mentioned monitoring audits of assessments weekly times three (3) months. Any concerns will be addressed if found. The State Survey Agency validated the facility took the following actions: 1. Review of medical records revealed Resident #8 and Resident #9 were assessed by FNP #20 on [DATE]. The Medical Director oversaw the FNP and determined both residents had the capacity to consent to sexual contact. 2. Interview revealed residents in the facility were assessed for cognitive deficits by the end of the day [DATE]. Residents with a BIMS of eight (8) or greater where assessed by physician for capacity to consent to sexual activity. Record review revealed four (4) residents were assessed by a physician as indicated. 3. Interview with the ADON revealed record reviews occurred as indicated. Record review revealed record audits completed as indicated. 4. Record review revealed resident care plans updated as indicated. 5. Interview with the ADON and the Administrator on [DATE] at 2:10 PM revealed they both attend the CQI (Clinical Quality Indicator) morning meetings, held Monday through Friday. Review of CQI meeting notes revealed new and readmissions, capacity to consent to sexual relationship assessment, and care plans were discussed each morning 6. Interview with the ADON and Administrator revealed the Regional Nurse Consultant (RNC) #18 was reviewing the monitoring audits weekly of the assessments to consent to sexual contact.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop a person centered care plan with measurable interventions for one (1) of three (3) sampled residents (Resident #1). On 09/01/2020 at 4:49 PM, Resident #1 was located near an exterior door, and informed staff he/she wanted to go home. Facility staff completed an elopement risk assessment, which determined Resident #1 was at high risk for elopement with a score of thirteen (13). Facility staff applied a wander guard device to Resident #1 on 09/01/2020. On 09/01/2020, the facility developed a care plan for Resident #1 for elopement with interventions which included wander guard placement, close supervision, and regular compliance rounds when Resident #1 was in his/her room. On 09/02/2020 at 4:00 AM, during a fire drill, the facility staff became aware Resident #1 had eloped from the facility. Resident #1 had removed the windowpane from his/her room to exit the building. The facility camera footage revealed Resident #1 had eloped from the facility at 2:34 AM. Resident #1 walked eleven blocks to his/her apartment. The facility's failure to ensure the resident's care plan was developed to minimize elopement risk had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/16/2020 and determined to exist on 09/02/2020. The facility was notified of the Immediate Jeopardy on 10/16/2020. An acceptable Allegation of Compliance was received, on 10/23/2020, which alleged removal of the Immediate Jeopardy on 09/02/2020. The State Survey Agency verified the facility implemented corrective actions and was in compliance, on 09/02/2020, as alleged, prior to the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings included: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 09/2017, revealed care plans were to be person centered with measurable interventions, timetables, and revised as needed. The IDT (Interdisciplinary Team) in the morning CQI (Continuous Quality Improvement) meetings reviewed the care plans and revised for any resident changes. Further review of the policy revealed nurses and nursing management were also responsible for the initiation and revisions to the care plans if revisions were required on the weekends. The facility did not have a policy related to making rounds. Review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed elopement interventions would be included in the care plan for an at risk resident. Record review revealed the facility admitted Resident #1 on 08/25/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's care plan, initiated on 09/01/2020 by Licensed Practical Nurse (LPN) #6, revealed interventions for wandering and elopement. Further review of the care plan revealed interventions that included Wanderguard placement, close supervision, and regular compliance rounds when Resident #1 was in his/her room. Review of the facility's investigation dated 09/02/2020 revealed Resident #1 exited the building at 2:34 AM as seen on recorded camera footage. Interview with CNA #4, on 10/02/2020 at 3:07 PM, revealed the nurse aides accessed resident care plans to determine what interventions were in place. She stated Resident #1's care plan for elopement would direct facility staff to round more frequently. According to Resident #1's care plan, CNA #4 stated the intervention for close supervision and regular rounding did not include a specific, measurable time. Further interview with CNA #4 revealed the increased frequency for supervision and rounding could range from twenty (20) minutes to the routine every two (2) hours. Interview with Licensed Practical Nurse (LPN) #6, on 10/02/2020 at 7:15 PM, revealed the care plans did not have templates and interventions were entered by staff. She stated care plans were developed for the individual resident. LPN #6 stated care plans were revised by facility nurses and members of the Interdisciplinary (IDT) team. LPN#6 stated she did not remember revising Resident #1's care plan on 09/01/2020 to address elopement. She stated the intervention to closely supervise and perform rounds directed staff to round more frequently. However, LPN #6 could not define more frequently, she stated it could be every fifteen minutes. Interview with LPN #3, on 10/02/2020 at 2:30 PM, revealed Resident #1's care plan intervention of close supervision and compliance rounds directed staff to monitor Resident #1 more closely, but it did not include a measurable period of time. She stated staff were to round more frequently than the routine two (2) hours, but she could not give a definite time. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 7:03 PM, revealed Resident #1's care plan included interventions for close supervision and regular compliance rounds meant staff would round more frequently. RN #1 stated rounds could range from fifteen (15) minutes up to hourly. She stated it was important for staff to have knowledge of Resident #1's location at all times. Interview with the Minimum Data Set (MDS) Coordinator, on 10/02/2020 at 2:07 PM, revealed she assisted with care plan development and could not give a definition of close supervision and compliance rounds on Resident #1's care plan. Interview with the Director of Nursing, on 10/02/2020 at 1:37 PM, revealed the facility did not have a policy related to making rounds. She stated care plans were important because it provided a person-centered plan of care for the residents. During the daily CQI meetings, the DON stated she reviewed the care plans for revisions due to any resident changes in the past twenty-four (24) hours. The DON stated it was to ensure proper interventions were initiated or revised. She stated staff were contacted for any concerns related to care plans. Interview with the Administrator, on 10/02/2020 at 9:40 AM, revealed the facility staff were responsible for ensuring Resident #1's care plan included appropriate interventions and was communicated among staff to prevent elopement. NEED INTERVIEWS RELATED TO CARE PLANS **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 09/02/2020, the facility provided one to one supervision on 09/02/2020 until Resident #1 was discharged . 2. On 09/02/2020, the facility performed Elopement Risk Assessments on all residents. The facility reviewed the elopement binder and care plans for at risk residents. 3. The facility held an Ad Hoc QAPI meeting on 09/03/2020, discussed Resident #1's elopement incident, and developed a plan of correction. 4. The Maintenance Director audited all facility windows on 09/02/2020 and bolted the windows shut. On 09/14/2020, the facility changed the window bolts to allow the windows to open three (3) inches with an additional bolt to prevent removal of the window panel from the window tract and installed window alarms on all windows in resident rooms and resident assessable areas. 5. The Maintenance Director conducted an Elopement Drill on 09/02/2020. 6. By 09/11/2020, all staff including prn and agency staff were in serviced on the Elopement Policy by the Administrator and Director of Nursing (DON) with a pretest and posttest. 7. The DON monitored new admissions, re-admissions, and residents with changes in condition discussed in the morning CQI meetings for identification of exit seeking behaviors and ensured care plans were updated with appropriate interventions. 8. The DON/ADON reviewed five (5) charts three (3) days weekly to monitor for exit seeking behaviors. The monitoring will continue until four (4) consecutive weeks with zero negative findings. Five (5) charts were reviewed weekly for six (6) months to assess ongoing compliance. 9. The Administrator/designee audited resident and like resident area windows twice weekly for four (4) consecutive weeks until no negative findings were revealed. The facility audited the windows weekly for at least six (6) months to ensure compliance. 10. The facility presented monitoring audits during monthly QAPI meetings with any concerns addressed. The committee developed an Action Plan for any concerns with weekly monitoring until the concern was resolved. The SSA validated the facility implemented the following actions: 1. Review of the One to One (1:1) Checks document revealed Resident #1 was under one (1) to one (1) supervision from 7:30 AM until 2:00 PM on 09/02/2020. Interview with the Activities Aide on 10/30/2020 at 10:00 AM, the SSD on 10/30/2020 at 10:20 AM, and the Physical Therapist on 10/30/2020 at 11:08 AM, revealed participation in one (1) to one (1) supervision of Resident #1 on 09/02/2020 from 9:00 AM to 11:15 AM. Interview with the DON, on 10/30/2020 at 3:32 PM, revealed participation in supervision of Resident #1. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed he provided observation of Resident #1 from 7:30 AM to 9:00 AM and from 2:00 PM until the time of discharge at 6:40 PM. On 10/30/2020 at 10:00 AM, interviewed the Physical Therapist, SSD, Activities Aide #1, DON, and Administrator regarding (1) to one (1) supervision of Resident #1 on 09/02/2020 from 7:30 AM to 2:00 PM. WHAT DID THEY DO? 2. Record review revealed the facility conducted elopement risk assessments on all residents in the facility on 09/02/2020. Review of the wander guard binder revealed resident information for four (4) residents at risk for elopement. Interview with the Director of Nursing (DON), on 10/30/2020 at 3:32 PM, revealed the Minimum Data Set (MDS) Coordinator and Licensed Practical Nurse (LPN) #4 assisted in assessment of all residents for elopement. The DON stated staff reviewed the care plans and the wander guard binder for the residents at high risk for elopement. 3. Record review revealed an Ad Hoc QAPI meeting on 09/03/2020 with a plan of correction documented. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed the facility held an Ad Hoc QAPI meeting on 09/03/2020 and discussed a plan of correction. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she attended an Ad Hoc QAPI meeting on 09/03/2020 during which they discussed the elopement incident and developed a plan of correction. 4. Review of the window audits performed by the Administrator revealed documentation the facility windows were checked and secured. The Maintenance Director documented on 09/14/2020 the installation of an additional bolt in the top window track and alarm installation to the windows. Observed three (3) residents' rooms windows and a lobby window on 10/30/2020 at 2:00 PM for functioning alarms and presence of bolt in windowpane track. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed the residents' windows were modified to bolt the windows shut on 09/02/2020. He stated all windows in the facility had alarms installed with an additional bolt to the top of the windowpane track to prevent removal of windowpane. 5. Record review revealed an elopement drill was performed on 09/02/2020. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed he conducted an elopement drill on 09/02/2020. 6. Education record review, dated 09/02/2020 through 09/11/2020, revealed reeducation of all facility staff including agency on elopement with a graded pretest and posttest. Interview with the Director of Nursing (DON), on 10/30/2020 at 3:32 PM, revealed she reeducated staff on elopement. She and the Administrator administered the pre and posttest for the elopement education. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed he assisted with the elopement reeducation of facility staff and administration of pre and posttests. 7. Record review revealed daily CQI minutes documented by the DON addressed any concerns of the residents in the facility. Interview with the DON, on 10/30/2020 at 3:32 PM, revealed CQI meeting minutes in which she monitored and documented new admits, re admits, and residents with a change in condition or exit seeking behaviors and updated care plans as needed. 8. Record review revealed five (5) chart audits were conducted three days weekly for four (4) weeks and five charts weekly. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she audited five (5) charts three (3) days weekly for four (4) weeks and five (5) charts weekly thereafter. 9. Record review revealed window audit documentation by the Maintenance Director twice weekly for four (4) weeks and weekly thereafter. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she attended a QAPI meeting on 10/29/2020 and they discussed audits of charts, windows, and alarms. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed window and alarm inspections were performed twice weekly for four weeks then weekly for 6 months. 10. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed a QAPI meeting was held on 10/29/2020. She stated elopement was discussed during the meeting.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide adequate supervision to prevent accidents and hazards for one (1) of three (3) sampled residents (Resident #1). On 09/01/2020, Resident #1 exhibited exit seeking behaviors and verbalized wanting to go home and attempted to exit the building. Resident #1 was assessed at that time to be at risk for elopement, and a wander guard (a system designed for residents to keep them safe while wandering throughout the facility) was applied. Additionally, the facility revised the resident's care plan to increase close monitoring and supervision related to Elopement (exit the facility without staff knowledge). On 09/02/2020, at approximately 4:00 AM, during a scheduled fire drill, staff were unable to locate Resident #1. Review of the facility's security cameras revealed Resident #1 exited the facility on 09/02/2020 at 2:34 AM. Continued review of the security cameras revealed the resident exited the facility by removing his/her windowpane in his/her room. The resident then climbed over the window and walked approximately eleven (11) blocks from the facility. The resident was returned by staff at 7:30 AM, approximately five (5) hours from which the resident was unaccounted for and unsupervised. The facility's failure to ensure adequate supervision was provided to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. The facility was notified of the Immediate Jeopardy on 10/16/2020. Immediate Jeopardy was identified on 10/16/2020 and determined to exist on 09/02/2020. An acceptable Allegation of Compliance was received, on 10/23/2020, which alleged removal of the Immediate Jeopardy on 09/11/2020. The State Survey Agency verified the facility implemented corrective actions and was in compliance, on 09/11/2020, as alleged, prior to the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed the facility's staff provided adequate supervision for residents at high risk for elopement. The policy stated environmental safety precautions included at least one of the following: door alarms on facility exits, staff supervision directly or by video camera, or a personal safety device to alarm staff when residents attempted to exit the building. Review of the job description titled, Security First Landmark of River City, undated, revealed the security officer's responsibility included monitoring the closed circuit television (CCTV) both inside and outside the building. The job description revealed the security officer monitored movement of staff and residents in the facility. Per interview with the Administrator, on 10/09/2020 at 10:10 AM, the video footage from the resident exiting the facility on 09/02/2020 was unavailable because the video recording was on a seven (7) day loop, which reset every seven (7) days. Review of Resident #1's closed record revealed the facility admitted Resident #1 on 08/25/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of eight (8), indicating the resident's cognition was moderately impaired. Review of the Elopement Risk Review, dated 09/01/2020 at 3:14 PM, revealed Resident #1 had a score of thirteen (13), indicating the resident was a high risk for elopement. Review of Resident #1's care plan initiated on 08/25/2020 and revised on 09/01/2020 revealed the resident's goal was for Resident #1 to remain safe in the facility. The care plan interventions included elopement assessment, documentation of exit seeking behaviors, redirection, ensure proper functioning with application of a wander guard device, supervise closely, and perform regular rounds. Review of the care plan further revealed interventions which required staff to provide close supervision and rounding on Resident #1, when he/she was in his/her room. Per interview with the Director of Nursing (DON), on 10/02/2020 at 1:37 PM, the facility did not have a policy related to making rounds, or a tool used to document rounding of the residents. Review of the resident's physician's orders [REDACTED]. Review of the Progress Notes for August and September of 2020, revealed Resident #1 was discovered beyond an inner door on 09/01/2020 at 4:49 PM, which was normally locked, and attempted to exit a locked exterior door. Further review of the Progress Notes revealed Licensed Practical Nurse (LPN) #3, applied a wander guard to Resident #1 at that time. Continued review of the Progress Notes revealed Resident #1 exited the facility through his/her room window at approximately 2:34 AM on 09/02/2020, and returned unharmed to the facility by staff on the same day at approximately 7:30 AM. Review of the Treatment Administration Record (TAR) for August and September of 2020, revealed staff were to check the Wanderguard for function during the 6:00 AM to 6:00 PM and the 6:00 PM to 6:00 AM shifts. Further review of the TAR revealed documentation on 09/01/2020 on the 6:00 PM to 6:00 AM shift, where Registered Nurse (RN) #1 initialed that she had checked the functioning of the resident's Wanderguard. Phone interview with Resident #1 was attempted, on 10/08/2020 at 12:09 PM and on 10/12/2020 at 9:00 AM. The State Survey Agency (Surveyor) was unable to leave a message and the resident did not answer the call. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 10:01 AM, revealed she observed Resident #1 on 09/01/2020 in the afternoon, in the hall, pass an unlocked inner door. LPN #3 stated Resident #1 told her that he/she wanted to go home. She stated she informed Resident #1 they would speak with the physician in the morning. LPN #3 stated the resident agreed to the placement of the Wanderguard device. Interview with LPN #2, on 09/30/2020 at 3:07 PM, revealed she observed on 09/01/2020 at approximately 3:30 PM, that Resident #1 was located beyond an inner facility door with a broken keypad lock. Further interview revealed the resident stood at the locked exterior door, and verbalized wanting to leave. She stated she notified the Maintenance Director immediately of the broken keypad lock. Interview with Certified Nursing Assistant (CNA) #4, on 10/02/2020 at 3:07 PM, revealed during report on 09/01/2020 at 10:30 PM, she was informed by the previous CNA of Resident #1's exit seeking behavior on 09/01/2020 and the Wanderguard placement. She stated her routine consisted of every two (2) hour rounds, but she would increase the frequency of rounds to twenty (20) minutes or more frequently depending on the resident. Per interview, CNA #4 stated she observed Resident #1 at the nurse's station at approximately 1:30 AM asking for ice water. She stated when performing rounds that night, Resident #1's door was open and he/she was sitting on the bed watching television. Interview with LPN #3, on 10/01/2020 at 10: 01 AM, revealed the resident's care plan was developed to include elopement intervention which added close monitoring of Resident #1. LPN #3 stated she reported to RN #1 during shift report regarding the events of the afternoon and the Wanderguard placement on Resident #1. She stated Resident #1 walked eleven (11) blocks through the inner city at night on 09/02/2020 which could have resulted in an injury. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 7:03 PM, revealed LPN #3 did not inform her of Resident #1's exit seeking behaviors on 09/01/2020. Per interview, RN#1 stated she was unaware of the resident having a Wanderguard device and she did not know the resident had a physician's orders [REDACTED].#1 stated she became aware of the resident's Wanderguard and physician's orders [REDACTED]. However, review of the facility's Treatment Administration Record (TAR) dated, August and September of 2020, revealed RN #1 initialed she had checked the resident's wander guard for function and placement. Additionally, RN #1 stated had she known about the resident's exit seeking behaviors, she would have communicated the updated information to CNA #4, to ensure she was aware of the resident's location at all times. She stated she would have increased her rounds anywhere from every fifteen (15) minutes to hourly for Resident #1's elopement risk. RN #1 could not define in specific terms what supervise closely and regular compliance rounds as listed in Resident #1's care plan. Interview with LPN #4, on 10/01/2020 at 3:00 PM, revealed she was working the unit as a floor nurse on 09/02/2020. LPN #4 revealed the night shift supervisor, was not aware Resident #1 was an elopement risk, or that he/she attempted to leave on 09/01/2020. She stated she was unaware Resident #1 was wearing a Wanderguard until after the resident could not be located during the fire drill. Per interview, at the time the resident went missing, staff referred to the Wanderguard binder at the nurses station to determine if the resident was an elopement risk. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed staff notified him on 09/01/2020 at approximately 4:00 PM, of the broken keypad lock to the inner door Resident #1 had opened. Continued interview with the Maintenance Director revealed he conducted a fire drill on 09/02/2020 around 4:30 AM. Additionally, he stated the facility's staff could not locate Resident #1 during the fire drill and began a search. Further interview revealed, the windows in the residents' rooms opened side to side which had a bolt mechanism that prevented the windows from opening more than three (3) inches. The Maintenance Director stated Resident #1 removed the windowpane from the track and exited the building on 09/02/2020. Interview with the Security Guard, on 10/15/2020 at 6:27 AM, revealed his responsibility at the facility was to screen incoming visitors and staff. Further interview revealed he monitored the closed circuit cameras inside and outside of the facility. He further stated he managed the door access to the building. The Security Guard stated, in reviewing the facility's security cameras, he did not see Resident #1 exit the facility. Additionally, the Security Guard stated he reviewed the facility's security cameras to investigate how the resident exited the facility. He stated the resident was observed exiting the facility by going out of his/her window. Further interview revealed that due to COVID-19 restrictions, he did not make his walking rounds throughout the facility, as per the facility's policy. Interview with the Interim Assistant Director of Nursing (IADON), on 10/02/2020 at 8:52 AM, revealed an elopement was defined as, when a resident leaves the building unknowingly or knowingly. She stated the Wanderguard device alarmed when the wearer exited the facility via a door, but it did not alarm with exiting through the window. Per interview, the IADON stated, anything could happen to the resident during an elopement. Interview with the Director of Nursing (DON), on 10/02/2020 at 1:37 PM, revealed Resident #1's elopement could have resulted in physical injury such as a fall, physical assault, or motor vehicle accident. The DON stated the priority was Resident #1's safety. Interview with the Administrator, on 10/09/2020 at 10:10 AM, revealed Resident #1 was located at his/her apartment, which was eleven (11) blocks away from the facility. The Administrator stated it was the responsibility of the facility to keep Resident #1 safe. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 09/02/2020, the facility provided one to one supervision on 09/02/2020 until Resident #1 was discharged . 2. On 09/02/2020, the facility performed Elopement Risk Assessments on all residents. The facility reviewed the elopement binder and care plans for at risk residents. 3. The facility held an Ad Hoc QAPI meeting on 09/03/2020, discussed Resident #1's elopement incident, and developed a plan of correction. 4. The Maintenance Director audited all facility windows on 09/02/2020 and bolted the windows shut. On 09/14/2020, the facility changed the window bolts to allow the windows to open three (3) inches with an additional bolt to prevent removal of the window panel from the window tract and installed window alarms on all windows in resident rooms and resident assessable areas. 5. The Maintenance Director conducted an Elopement Drill on 09/02/2020. 6. By 09/11/2020, all staff including prn and agency staff were in serviced on the Elopement Policy by the Administrator and Director of Nursing (DON) with a pretest and posttest. 7. The DON monitored new admissions, re-admissions, and residents with changes in condition discussed in the morning CQI meetings for identification of exit seeking behaviors and ensured care plans were updated with appropriate interventions. 8. The DON/ADON reviewed five (5) charts three (3) days weekly to monitor for exit seeking behaviors. The monitoring will continue until four (4) consecutive weeks with zero negative findings. Five (5) charts were reviewed weekly for six (6) months to assess ongoing compliance. 9. The Administrator/designee audited resident and like resident area windows twice weekly for four (4) consecutive weeks until no negative findings were revealed. The facility audited the windows weekly for at least six (6) months to ensure compliance. 10. The facility presented monitoring audits during monthly QAPI meetings with any concerns addressed. The committee developed an Action Plan for any concerns with weekly monitoring until the concern was resolved. The SSA validated the facility implemented the following actions: 1. Review of the One to One (1:1) Checks document revealed Resident #1 was under one (1) to one (1) supervision from 7:30 AM until 2:00 PM on 09/02/2020. Interview with the Activities Aide on 10/30/2020 at 10:00 AM, the SSD on 10/30/2020 at 10:20 AM, and the Physical Therapist on 10/30/2020 at 11:08 AM, revealed participation in one (1) to one (1) supervision of Resident #1 on 09/02/2020 from 9:00 AM to 11:15 AM. Interview with the DON, on 10/30/2020 at 3:32 PM, revealed participation in supervision of Resident #1. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed he provided observation of Resident #1 from 7:30 AM to 9:00 AM and from 2:00 PM until the time of discharge at 6:40 PM. On 10/30/2020 at 10:00 AM, interviewed the Physical Therapist, SSD, Activities Aide #1, DON, and Administrator regarding one (1) to one (1) supervision of Resident #1 on 09/02/2020 from 7:30 AM to 2:00 PM. Staff interviews revealed they accompanied with Resident #1 throughout the facility or in the areas documented on the one (1) to one (1) record. 2. Record review revealed the facility conducted elopement risk assessments on all residents in the facility on 09/02/2020. Review of the wander guard binder revealed resident information for four (4) residents at risk for elopement. Interview with the Director of Nursing (DON), on 10/30/2020 at 3:32 PM, revealed the Minimum Data Set (MDS) Coordinator and Licensed Practical Nurse (LPN) #4 assisted in assessment of all residents for elopement. The DON stated staff reviewed the care plans and the wander guard binder for the residents at high risk for elopement. 3. Record review revealed an Ad Hoc QAPI meeting on 09/03/2020 with a plan of correction documented. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed the facility held an Ad Hoc QAPI meeting on 09/03/2020 and discussed a plan of correction. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she attended an Ad Hoc QAPI meeting on 09/03/2020 during which they discussed the elopement incident and developed a plan of correction. 4. Review of the window audits performed by the Administrator revealed documentation the facility windows were checked and secured. The Maintenance Director documented on 09/14/2020 the installation of an additional bolt in the top window track and alarm installation to the windows. Observed three (3) residents' rooms windows and a lobby window on 10/30/2020 at 2:00 PM for functioning alarms and presence of bolt in windowpane track. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed the residents' windows were modified to bolt the windows shut on 09/02/2020. He stated all windows in the facility had alarms installed with an additional bolt to the top of the windowpane track to prevent removal of windowpane. 5. Record review revealed an elopement drill was performed on 09/02/2020. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed he conducted an elopement drill on 09/02/2020. 6. Education record review, dated 09/02/2020 through 09/11/2020, revealed reeducation of all facility staff including agency on elopement with a graded pretest and posttest. Interview with the Director of Nursing (DON), on 10/30/2020 at 3:32 PM, revealed she reeducated staff on elopement. She and the Administrator administered the pre and posttest for the elopement education. Interview with the Administrator, on 10/30/2020 at 3:15 PM, revealed he assisted with the elopement reeducation of facility staff and administration of pre and posttests. 7. Record review revealed daily CQI minutes documented by the DON addressed any concerns of the residents in the facility. Interview with the DON, on 10/30/2020 at 3:32 PM, revealed CQI meeting minutes in which she monitored and documented new admits, re admits, and residents with a change in condition or exit seeking behaviors and updated care plans as needed. 8. Record review revealed five (5) chart audits were conducted three days weekly for four (4) weeks and five charts weekly. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she audited five (5) charts three (3) days weekly for four (4) weeks and five (5) charts weekly thereafter. 9. Record review revealed window audit documentation by the Maintenance Director twice weekly for four (4) weeks and weekly thereafter. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed she attended a QAPI meeting on 10/29/2020 and they discussed audits of charts, windows, and alarms. Interview with the Maintenance Director, on 10/01/2020 at 8:35 AM, revealed window and alarm inspections were performed twice weekly for four weeks then weekly for 6 months. 10. Interview with the DON, on 10/30/2020 at 3:34 PM, revealed a QAPI meeting was held on 10/29/2020. She stated elopement was discussed during the meeting.

Based on interview, record review, and facility policy review it was determined the facility failed to have an effective system to ensure the comprehensive care plans were reviewed and revised to address the frequency of monitoring residents who were identified by the facility as an elopement risk for one (1) of eight (8) sampled residents (Resident #1). The facility failed to revise the care plan for Resident #1 to ensure the staff were clearly directed on the frequency of resident checks for safety needs. On 10/20/13 at 5:37:21 (from the WanderGuard report) Resident #1 exited the facility without staff knowledge when the security guard entered an over ride code to open the front entrance door and allowed the resident to leave the facility. Resident #1 was found by a staff member ambulating on a sidewalk in front of a fast food restaurant 0.3 miles from the facility in a heavy traffic, four (4) lane street and was returned to the facility unharmed at approximately 8:29 AM on 10/20/13, approximately two (2) hours and fifty-two (52) minutes after he/she left the facility. Review of the National Weather Service archive temperature log revealed the temperature on 10/20/13 was 39 degrees Fahrenheit. Resident #1 was assessed by the facility as having no injuries. (Refer to F323) The facility's failure to ensure the care plan was reviewed and revised, placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment or death to a resident. The facility was notified of the Immediate Jeopardy on 10/24/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/30/13 alleging Immediate Jeopardy was removed on 10/25/13. The State Survey Agency verified removal of Immediate Jeopardy on 10/25/13 as alleged, prior to exit on 11/01/13 with remaining non-compliance at a scope and severity lowered to a "D", while the facility develops and implements the quality assurance measures to establish and maintain an effective system to ensure care plans are revised to address the care needs of the residents. The findings include: Review of the facility's policy regarding Care Plans, revised 01/23/12, revealed the resident's care plan provided guidance to all staff caring for the resident and communicated changes in care to all direct care staff. The identified rule revealed under updating the care plan: the Interdisciplinary Care Plan was to be reviewed; revised; and updated quarterly and more frequently if warranted by a change in the resident's condition. Review of the facility's policy regarding Elopement, not dated, revealed through assessment, the staff were to identify residents at risk for elopement or unsafe wandering. The facility would enhance staff awareness of residents at risk and educate them in approaches/interventions for those residents. The procedure noted, at risk residents for Elopement/Wandering would be addressed on the care plan with individualized interventions. Patterns, if identified, and causes of this behavior would be addressed. Review of the facility's investigation, dated 10/24/13, revealed on 10/20/13 Resident #1 exited the front door at the facility's entrance at 5:37 AM. The resident was returned to the facility at 8:29 AM, and was assessed with [REDACTED]. The root cause was determined to be Security Guard #6 thought the resident was a visitor and let the him/her out the front entrance. An interview conducted by the Administrator and the corporate Director of Clinical Services (DCS) with Security Guard #6 revealed the door did alarm when the resident approached the door; however, the security guard keyed in the over ride code to release the lock and let the resident exit the building. Review of the clinical record for Resident #1, revealed the facility initially admitted the resident on 11/29/12 and the facility assessed the resident as having a cognition score of four (4) on the Minimum Data Set (MDS) indicating a moderate impairment of cognition. Review of the physician orders [REDACTED]. Review of the care plan, dated 01/28/13, for Resident #1 revealed the facility had identified the resident at risk for elopement due to the resident making statements of wanting to leave the building. The care plan identified the approaches as: the resident was to use a WanderGuard bracelet; the resident's picture would be displayed in the elopement book; approach the resident in a calm manner; redirect the resident to another location; walk with the resident in the direction he/she was going, then gradually assume leadership; direct the resident to an area of greater safety; and check WanderGuard placement every shift and function every week. The care plan did not give guidance to the staff on the frequency of checking the resident for safety related issues. Review of the Risk of Elopement/Wandering Review, revealed the resident was assessed on 01/28/13, 04/01/13, 06/10/13, and 09/10/13 for potential risk factors. Assessments dated 01/28/13 and 09/10/13 revealed the resident had verbally expressed the desire to go home and was exit seeking. Further review of the care plan revealed it did not direct staff as to how frequently to monitor the resident for safety related to the resident's exit seeking behavior. No guidance or direction to monitor the resident was identified in any of the resident's identified care areas. Interview with the Director of Clinical Services, on 10/24/13 at 3:55 PM, revealed it was the facility's standard of practice to monitor the residents every two hours. She stated it should have been identified in the incontinence care plan, at least. She reviewed Resident #1's care plan and stated there was no direction to monitor the resident every two hours; however, per interview staff should have revised the care plan to direct the staff in monitoring the resident every two hours. Telephone interview with CNA (Certified Nursing Assistant) #1 on 10/22/13 at 2:01 PM, revealed she was assigned to Resident #1 from 6:45 PM 10/19/13 to 7:00 AM on 10/20/13. The CNA stated the staff should check the residents every two (2) hours. Per interview she saw Resident #1 at 12:00 AM; however, she did not check on the resident again until 5:30 AM when she changed the resident, five (5) and a half hours later. She further stated during the change of shifts, she and the on-coming staff were to do a physical walk around and report what was going on with each resident they were assigned. However, on 10/20/13 she had twenty-five (25) residents to care for and get up and the oncoming staff did not want to do a walking round report. The CNA stated she was aware the resident was an elopement risk and was exit seeking; however, checking residents every two (2) hours was not on the plan of care. Telephone interview with CNA #2, on 10/23/13 at 10:42 AM, revealed she was in the facility on 10/20/13 at 6:45 AM. She stated she was supposed to do a walk through with the off-going CNA; receive a report on each resident; and see each resident. However, a walk through was not conducted on 10/20/13 and CNA #1 had reported to her that everyone was fine. In addition, they were to round every two (2) hours on the residents. She stated she went to get Resident #1 up, about 7:30 AM and he/she was not in his/her bed. CNA #2 knew the resident was exit seeking and wanted to leave the facility. She stated the resident would have been identified as missing earlier if they had done the safety rounds as required. Telephone interview with LPN (Licensed Practical Nurse) #1, on 10/22/12 at 4:04 PM, revealed she had last seen Resident #1 during the end of her medication pass about 5:38 AM. The on-coming nurse declined to do a walk around because she was not feeling well. LPN #1 stated the frequency to check on the resident and/or shift change rounds was not on the care plan for Resident #1 even though she knew the resident was exit seeking and an elopement risk. Telephone interview with LPN #2, on 10/22/13 at 3:25 PM, revealed she was the first shift nurse for Resident #1, the morning he/she had left the building. She stated they sometimes did a walking round with the off-going or on-coming staff; however, the morning the resident had left the building they did not do a walking round and she only received a verbal report. LPN #2 stated even though the resident was exit seeking, the care plan did not indicate every two hour checks or the shift change rounds to check on the resident. Interview, on 10/25/13 at 1:21 PM, with RN #2 the Minimum Data Set (MDS) Coordinator, revealed the Social Services staff completed the wandering section of the care plan assessments; however, the Social Services staff had recently resigned. She stated she reviewed the nurses notes or clinical documentation to support exit seeking behaviors for the care plan. However, she did not initiate the care plan for Resident #1 and could not state how the information was obtained for the assessment. Further interview revealed even though the care plan for Resident #1 did not say to monitor the resident, the residents should be checked every 2 hours. She stated there should be some direction in the care plan as to how staff were to monitor the resident and provide care. Interview with the Director of Clinical Services, on 10/24/13 at 4:10 PM, revealed the care plan was the tool used to inform staff of the resident's needed care and services. The nurses were responsible to update, revise, and develop the care plan as needed; however, the MDS staff were to initiate the care plan based on the Care Area Assessment (CAA) to include the monitoring of residents at risk for elopement. The previous Social Services staff was not available for interview. Review of the acceptable AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. A facility wide search and resident census was taken by the charge nurse immediately on 10/20/13 at 7:30 AM, to determine if Resident #1 was missing and all other residents were present. The Administrator, DON, police, physician and family of Resident #1 were all notified by telephone. 2. After Resident #1's return to the facility at 8:29:31 AM by CNA #4, the DON and LPN #2 assessed the resident. They assigned a LPN to complete a check on the resident and CNA sitter every fifteen (15) minutes for twenty-four (24) hours. On 10/21/13 the Administrator and the Director of Nursing (DON) directed the assigned staff to check on the resident every thirty (30) minutes for twenty-four (24) hours. 3. An investigation was initiated by the DON and the Administrator, on 10/20/13 at approximately 8:45 AM with interviews of staff on duty and telephone interviews with staff from the previous shift, and review of the video-surveillance tape. All exit doors were checked for functionality by the Maintenance Supervisor on 10/20/13 and all exit doors alarming appropriately. The DON notified the physician and assessed the resident along with LPN #2. 4. On 10/20/13, after review of the surveillance video revealed the Security Guard #6, had entered the bypass code and allowed Resident #1 to exit the building, unsupervised. The Administrator contacted the Security Agency to obtain contact information for Security Guard #6. The facility notified the Security Agency on 10/20/13 that effective immediately Security Guard #6 was no longer authorized to work at the facility. 5. On 10/20/13, after Resident #1's elopement from the facility, the Administrator determined the Security Communication binder and Elopement at Risk binder was in place and up-to-date as of 10/20/13 with all identifying information and a current photo in the binder for the five (5) residents (to include Resident #1) who had been assessed as being at risk for elopement. On 10/20/13 the DON checked the five (5) residents who had been assessed as being at risk for elopement with WanderGuard bracelets to ensure the bracelets' placement and functionality. The Administrator and the DON had identified the same five (5) at risk residents of the seventy-eight (78) residents assessed. The Director of Clinical Services, the DON, and RN #1 reassessed all seventy-eight (78) residents for their elopement risks on 10/20-21/13. 6. The Administrator and the Director of Clinical Services determined which security guards were scheduled to work from 10/20/13 and subsequent shifts and re-educated them on the policies related to elopement and completed a competency quiz with a score of 100% before allowing them to work any further shifts. The competency quiz was administered to all two (2) security guards scheduled to work by the DCS on 10/21/13. 7. A minimum of every two hour facility safety rounds were continued by the staff to ensure resident safety. Corrective action was issued to all nursing staff members with responsibility for caring for the resident during third shift on 10/19/13 and first shift 10/20/13; up to and including termination of employment. On 10/21/13 directives by the Administrator and DON and the QA Committee for all nursing staff that safety rounds must be conducted for all shift changes. To ensure this standard of walking rounds at shift change is met the nursing staff must provide the DON a mutually-signed copy of the staff member's care records for their shift. 8. All seventy-eight (78) resident's elopement assessments were reviewed or reassessed by the DON, Unit Managers, and the Director of Clinical Services, and reviewed on 10/20/13 the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. In addition, all residents' admission assessments, care plans, CNA care records, assignment sheets, elopement, fall and smoking at risk assessments beginning on 10/20/13 and completed on 10/24/13 with revisions as indicated. 9. On 10/20/13 and 10/21/13, all current staff (with the exception of as-needed staff or those on an approved leave) were re-educated by a Unit Manager and the Director of Clinical Services on facility policies for: door alarm, door check, missing person, elopement, falls and smoking schedules for residents which included a post-test to ensure competency. The Administrator assured as needed staff or those that were on approved leave were called via telephone on 10/20/13 to inform them that they were not to work any further shifts until they were trained on the policies and must meet with the supervisor at the beginning of a scheduled shift. 10. On 10/21/13 the Administrator directed that a representative of the manufacturer of the Center's WanderGuard system be contacted for an onsite visit to re-check the functionality of all applicable doors and adjust the monitoring of sensitivity if needed. The testing and subsequent work was completed on 10/23/13 with the authorization to purchase an additional sensor on one interior door to heighten staff awareness to potential elopement in the corridor leading to the main entry door. 11. The Administrator conducted a Quality Assurance meeting on 10/21/13 to review the investigation findings and actions taken by the facility. The QA meeting included the Administrator, Medical Director, DON, Unit Manager, and the Director of Clinical Services. Audits were developed and directives were given to ensure compliance. The Elopement at Risk binders would be audited weekly by the Unit Manager. Documentation of the correct placement and functionality of all WanderGuard devices in use would be audited weekly by a licensed nurse. Ten percent of the resident elopement assessments would be audited weekly by the Unit Manager or DON. The DON or Unit Manager would ensure the care plan would be reviewed and revised as needed to reflect if a resident was found to be at risk for elopement. The Maintenance Director would audit all exit doors for function with a WanderGuard four (4) times weekly. All staff responsible for conducting the audits was trained as of 10/21/13. 12. All licensed nurses were educated on 10/21/13 by the DON that the WanderGuard computer monitor's volume level was not to be adjusted for any reason and was not to be turned off. The ability to change the monitor volume and the ability to turn the monitor on and off was disabled on 10/24/13 by the Senior Executive Director. The security staff would be audited three (3) times weekly by the Administrator on their competency and knowledge of the facility's door alarm and locking policy as well as all job-related requirements involving the use of the Elopement at Risk binder. 13. All audits listed which were developed on 10/21/13 would be gathered by the Unit Manager weekly and submitted to and reviewed by the DON. The DON will report the findings of the audits to the Administrator. The Administrator will present the audit results to the Quality Assurance Committee monthly for twelve (12) months. The Senior Executive Director will review the Quality Assurance minutes monthly and attend the QA meeting on a quarterly basis to monitor compliance. 14. The Unit Manager educated their total nursing staff of twenty-four (24) on 10/24/13 in person and via telephone on the revised Care Plan Revision Policy and Procedure. Unit Managers will audit care plans for correct revision five (5) days weekly based on new physician orders [REDACTED]. This will be a part of the daily clinical review meeting. Corrections needed would be made at that time. The DON will review the findings of these audits with the Administrator who will present the results to the QA committee. 15. The Senior Executive Director educated the Administrator on 10/24/13 of the Administrator's job responsibilities, duties and roles along with the company's Quality Assessment and Assurance policy to assure ongoing knowledge and performance of duties and responsibilities. The State Survey Agency validated through record review and interview the Immediate Jeopardy was removed as follows: 1. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she was notified by the DON at approximately 8:00 AM by telephone on 10/20/13 of the elopement of Resident #1 after a facility wide search and determination Resident #1 was missing from the facility and immediate grounds. Interview with the DON, on 10/25/13 at 10:29 AM, revealed she was notified by RN #1 by telephone at approximately 7:50 AM on 10/20/13 of the elopement of Resident #1. Interview with RN #1, on 10/23/13 at 9:24 AM, LPN #2, on 10/22/13 at 3:25 PM, and LPN #3, on 10/23/13 at 2:12 PM, revealed they were directed to complete an accountability check for each resident on 10/20/13. Review of the nursing notes for 10/20/13 revealed the family and physician were notified by the DON at 8:50 AM. 2. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had directed a nurse to complete a fifteen (15) minute check on the resident and CNA sitter every fifteen minutes for twenty-four hours and then for staff to check the resident every thirty (30) minutes for twenty-four (24) hours. Review of the Check sheet dated 10/20/13 and 10/21/13, revealed staff monitored Resident #1 as directed. Review of the nursing documentation on 10/20/13, revealed LPN #2 documented the events from notification of resident missing to the resident's return and assessment completed. 3. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed an investigation was initiated by herself and the Director of Clinical Services. Review of the information gathered and documented interviews revealed the investigation had been initiated and was on-going. Review of the facility's investigation into Resident #1's elopement on 10/22/13, revealed staff interviews were done timely. Review of the Maintenance Supervisor report revealed all exit doors had been checked for function on 10/20/13 with no problems identified. 4. Review of the facility's video-surveillance tape and interview with Administrator, on 10/22/13 at 8:15 AM, revealed the Security Guard #6 had entered a bypass code at the front entrance (known as Main Street 2), on 10/20/13 at 5:37:21 AM, and allowed Resident #1 to exit the facility unsupervised. Review of the e-mail dated 10/23/13 from the facility to the Security Provider revealed the provider was informed of the termination of Security Guard #6 at the facility. 5. Record review and interview with the Administrator and the DON, on 10/22/13 at 8:15 AM, revealed they had checked the elopement at risk binder at the nursing station, on 10/20/13 to ensure all identifying information and a current photo was in the binder for the five (5) residents (to include Resident #1) who had been assessed at being at risk for elopement. Review of the facility's elopement binder on 10/22/13 revealed all residents who were at risk for elopement had their identifying information in the Security Communication binder. Record review on 10/22/13 revealed seventy-eight (78) residents had been reassessed for their elopement risks by the DON, Director of Clinical Services, and Unit Managers. Review of the Maintenance door check lists revealed the doors were checked weekly without concerns identified. Review of the TARs revealed the WanderGuards were checked daily for placement and weekly for function. 6. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had identified the security guards scheduled to work and immediately in-serviced them on the policy and procedures to include the Elopement at Risk binder. She stated a post-test was completed and they had to pass with 100 percent. Review of the POS [REDACTED]'s test was administered on 10/21/13 with both scoring 100%. 7. Record review and interview with the Administrator, on 10/24/13 at 3:30 PM, revealed corrective action was issued to LPN's #1 and #2, and CNAs #1 and #2 for failure to complete safety rounds as required. LPN #8 was terminated for turning off the computer monitor. Record review for the employees revealed the written reprimands were placed in the employee files, signed by the employees. Interviews with LPN # 8 revealed she had been terminated for turning off the computer monitor. Review of shift change walking rounds report completed by the LPN's at shift change on 11/01/13 revealed they were signed off by both staff indicating the walking round had been completed and all residents were accounted for. Interviews with CNA #5, on 10/31/13 at 12:50 AM, CNA #6, on 10/31/13 at 1:25 PM, LPN #1, on 10/22/13 at 3:57 PM,and LPN #2, on 10/22/13 at 3:25 PM, revealed the staff was to complete safety rounds at shift change and every two hours to ensure the residents were safe or if any care was needed. 8. Record review and interview with the Administrator and the Director of Clinical Services, on 11/01/13 at 11:00 AM revealed the DON, Unit Managers, Director of Clinical Services, and the Administrator had reviewed on 10/20/13, the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct with signatures and dates of the DON, Director of Clinical Services and Administrator. Interview with the Director of Clinical Services (DCS), on 11/01/13 at 11:00 PM, revealed the rest of the seventy-eight (78) residents' documents were reviewed with the Administrator and revisions were made as necessary. Review of the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement on 10/20/13 revealed signatures and dates of review and revision by the DCS, DON, and the Administrator. Additional review of all the resident's admission assessments and care plans, CNA care records, assignment sheets, elopement, fall, and smoking at risk assessments began on 10/20/13 and completed on 10/24/13 were done. 9. Record review and interview with the DON, on 10/25/13 at 10:29 AM, revealed she had provided the in-services regarding facility policies for: elopement risk/assessment; interventions; and steps to be taken during an incident of a missing resident; door alarms; door checks; falls; and smoking schedules; which included a post-test to ensure the staff's competency. Interview with CNA #5, on 10/31/13 at 12:50 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident, falls, door check, smoking policy, safety rounds, which included a post-test on 10/20/13. Interview with CNA #6, on 10/31/13 at 1:25 PM, LPN #1, on 10/22/13 at 3:57 PM, and LPN #2, on 10/22/13 at 3:25 PM, revealed they received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident falls, door check, smoking policy, safety rounds, which included a post-test to ensure competency on 10/20/13. All in-service training content and staff sign-in sheets were reviewed on 10/31/13 to ensure all nursing staff had been re-trained per the AOC. 10. Record review and interview with the manufacturer's representative of the Center's WanderGuard system revealed an on-site visit was made to verify the function of all exit doors and adjust the monitoring of sensitivity. Interview with Representative, on 10/22/13 at 11:15 AM, revealed he was contacted by the Administrator on 10/20/13, of the resident elopement and the Maintenance Director was in the facility to check all exit doors. He stated he had checked all exit doors on 10/21/13 and they were working appropriately. He stated the inner door was working and he had added an extra sensor. He stated the inner door was not an exit; however, it was to make staff aware of resident's going through the door. 11. Record review and interview with the Administrator, on 11/01/13 at 8:30 AM, revealed a Quality Assurance (QA) meeting included the Medical Director, DON, Unit Managers, Director of Clinical Services, and Administrator on 10/21/13. She stated audits were developed and directives were given to ensure removal of Immediate Jeopardy. Review of the Elopement at Risk binders on 10/22-24/13 and 10/30-11/01/13, revealed they had been reviewed and updated with resident census and appointments. No additional residents had been identified at risk for elopement. Review of the facility's audit forms and interview with the DON, on 11/01/13 at 11:50 AM, revealed audits were developed for nursing to ensure walking rounds were done; audits to verify the function and placement of WanderGuards; resident elopement assessments; and care plan audits would be completed by the Nurse Managers and/or DON and given to the DON weekly. She stated she would review all information and report to the Administrator and QA. Interview with the Administrator, on 11/01/13 at 8:30 AM, revealed she would be auditing the Security Guards three (3) times a week to ensure competency and knowledge of the door alarm and locking requirements, and use of the Elopement Risk binder. She stated the Maintenance Director would continue to complete audits on the exit doors to ensure they were functioning appropriately. 12. Record review and interview with the DON on 10/31/13 at 11:50 AM, revealed she had in-serviced all nurses regarding the use of the computer monitor and to not touch or change the volume of the monitor system, on 10/24/13. She stated the computer's on/off button was covered by the Executive Director to prevent the staff from turning it off. Interview with LPN #7, on 10/31/13 at 12:54 PM, and RN #3 at 1:12 PM, revealed they had been in-serviced on the purpose and use of the computer monitor and they were not allowed to adjust the volume or turn the monitor off. They said the alarm system on the doors was in place to keep residents safe and nurses had to verify the placement of the resident's WanderGuard and check the function of the WanderGuard weekly. 13. Record review and interview with the DON, on 10/31/13 at 1:18 AM, revealed she had in-serviced the Nurse Managers on the use and purpose of the audits developed to ensure on-going compliance with the facility policy's for: residents' elopement risks assessments; updating; and reviewing the Elopement binder. She stated she would gather all audits from the Unit Nurse Managers to review and submit to the Administrator. She stated the results of the information would be presented at the monthly QA meetings. 14. Record review of all in-service training content and staff sign-in sheets and interview with LPN #1, on 10/22/13 at 3:57 PM, LPN #2, on 10/22/13 at 3:25 PM, and RN #1 on 11/01/13 at 11:20 AM, revealed they were in-serviced on the revised care plan policy and assisted with the in-servicing of all the nurses. They were to review all new physician orders [REDACTED]. They stated the audits would go to the DON and QA. 15. Interview with the Administrator, on 11/01/13 at 1:30 PM, revealed she did have a job performance review with the Executive Director on 10/24/13 of the job responsibilities, duties and roles along with the company's Quality Assessment and Assurance policy to assure ongoing knowledge and performance of duties and responsibilities.

Based on interview, record review and review of the facility's policy, investigation, observation Flow Sheet, video surveillance, and WanderGuard Activities Report, it was determined the facility failed to have an effective system to ensure the provision of adequate supervision to prevent accidents for one (1) of eight (8) sampled residents, Resident #1. The facility failed to supervise residents at risk for elopement, failed to ensure the security guard's competency of the security system, failed to ensure the security system monitor was functioning at all times, and failed to ensure staff conducted safety rounds. On 10/20/13 at 5:37:21 (from the WanderGuard report) Resident #1 exited the facility without staff knowledge when the security guard entered an over ride code to open the front entrance door and allowed the resident to leave the facility. Resident #1 was found by a staff member ambulating on a sidewalk in front of a fast food restaurant 0.3 miles from the facility in a heavy traffic, four (4) lane street and was returned to the facility unharmed at approximately 8:29 AM on 10/20/13, approximately two (2) hours and fifty-two (52) minutes after he/she left the facility. Review of the National Weather Service archive temperature log revealed the temperature on 10/20/13 was 39 degrees Fahrenheit. Resident #1 was assessed by the facility as having no injuries. The facility's failure to have an effective system to ensure the provision of adequate supervision for residents assessed at risk for elopement placed residents in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/24/13 and determined to exist on 10/20/13. The facility was notified on 10/24/13 of the Immediate Jeopardy and Substandard Quality of Care. An acceptable Allegation of Compliance (AOC) was received on 10/30/13 which alleged the Immediate Jeopardy was removed on 10/25/13. The State Survey Agency validated the removal of Immediate Jeopardy on 10/25/13 as alleged, prior to exit on 11/01/13. The scope and severity was lowered to a "D" while the facility develops and implements a Plan of Correction and the facility's Quality Assurance program monitors the effectiveness of systemic changes to achieve and maintain substantial compliance. The findings include: Review of the facility's policy regarding Procedure for Door Alarm/Lock Policy (not dated) revealed all staff had the responsibility to assure that residents who wander would not leave the building unescorted. Staff was directed to respond when a door alarm sounds. The WanderGuard computer located at the nurse's station were not to be touched unless authorized. All staff that was in close proximity was responsible for going to the WanderGuard computer when an alarm sounds to alert others as to which door was alarming. Staff was directed that at no time were authorized personnel allowed to place a door alarm on bypass/silence. Unit Managers, DON, Maintenance and Administrator were the only ones authorized. Review of the facility's Elopement Policy (not dated) revealed the residents at risk for elopement or unsafe wandering would be identified through assessment. The facility would enhance staff awareness of residents at risk and educate them in approaches and interventions for those residents. Interview with the Administrator revealed the facility did not identify the required safety rounds of residents as a policy, but it was the facility's standard of practice for Certified Nursing Assistants and Nurses to perform walking safety rounds at the beginning and end of the shift to assure resident safety. Review of the clinical record revealed Resident #1 had been assessed by the facility to be at risk for elopement and had a WanderGuard bracelet on his/her right wrist. On 10/20/13 at approximately 7:30 AM, Resident #1 was discovered missing from the facility during the morning tray pass. Resident #1 was found by a staff member ambulating on a sidewalk in front of a fast food restaurant 0.3 miles from the facility in a heavy traffic four (4) lane street and was returned to the facility unharmed at approximately 8:29 AM on 10/20/13. Review of the National Weather Service archive temperature log revealed the temperature on 10/20/13 was 39 degrees Fahrenheit. Review of the facility's investigation, dated 10/20/13, revealed upon return to the facility Resident #1 was wearing a WanderGuard, which alarmed as he/she entered the facility. The investigation revealed all exit doors and WanderGuard system had been checked to ensure they were operating properly. During the process of gathering statements, the facility received a return call from the security guard who was on duty from 11:00 PM - 7:00 AM. During the interview he informed the Director of Clinical Services and the Administrator that he had let someone out of the facility that appeared to be a visitor. Review of the facility's investigation also revealed print-out logs of documentation for the date/time/location of exit doors and WanderGuard bracelet numbers that indicated if a resident with a WanderGuard bracelet had exited an alarmed door, or if a resident with a WanderGuard bracelet had been near an alarmed exit door. Review of WanderGuard Activities Report for 10/20/13 indicated Resident #1 was near the Main Street 2 Exit at 5:36:49 and 5:37:09 and caused the door to alarm at 5:37:21 AM and 5:37:35 AM. Resident #1's WanderGuard did not indicate activity on the system again until 8:29:31 AM at the Main Street 2 Exit when the resident returned to the facility. Review of the facility's video-surveillance tape for 10/20/13 at 5:37:35 AM, revealed Resident #1 was observed to walk through opened doors and go down the facility's main hallway towards the facility's front door. The resident wore a short sleeve T-shirt, jeans, ballcap, and shoes. The resident walked to the entrance door and pushed on the door, turned away and began to walk back towards the unit. Resident #1 was observed to turn his/her neck to the left, a man identified as Security Guard #6 walked to the door and was observed to push buttons on the key pad, he pushed the buttons again releasing the lock, opening the facility's front door and allowed Resident #1 to exit the building. Telephone interview with Security Guard #6, on 10/23/13 at 10:51 AM, revealed he had seen the resident on the nursing unit sitting on a couch about 11:30 PM the evening of 10/19/13, and again around 1:00 AM on 10/20/13. He stated he thought it was about 2:00 to 3:00 AM, when he saw the resident again. He stated the resident punched the door to get out. He said he asked Resident #1 if he/she wanted to go out and the resident shook his/her head yes, but the resident never said anything to him. He stated the alarm sounded and he had to enter the code again to release the lock and let the resident leave the facility. Per interview, he was supposed to look at the Security Communication book and check it every so often for pictures and demographic data on elopement risks, appointments and who would transport the resident, and current census; however, he had not reviewed the book for 4-5 weeks. He revealed he did not recognize the person as a resident because the resident had on regular clothes, a blue outfit, pants, shoes, shirt and the resident looked like he/she was waiting for somebody. He did not notify the nursing staff of the resident leaving the building, and he did not verify if the resident was a visitor by comparing the sign in/out sheet as he was trained. He stated he accepted the responsibility, that he let Resident #1 exit the building unsupervised. Review of the clinical record for Resident #1 revealed the facility initially admitted the resident on 11/29/12 and the facility assessed the resident as having a cognition score of four (4) on the Minimum Data Set (MDS) indicating a moderate impairment of cognition. Review of the physician orders, dated 10/01/13 to 10/31/13, and the face sheet revealed [DIAGNOSES REDACTED]. Review of the Risk of Elopement/Wandering Review, dated 01/28/13, revealed the facility assessed Resident #1 for elopement due to the resident verbalizing the expressed desire to go home, wandering aimlessly in the facility, and the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave. Review of the Comprehensive Care Plan initiated on 01/28/13 to address the problem of Resident #1 as at risk for elopement revealed a goal the resident would not exit the center unattended. The approach was for the resident to use a WanderGuard bracelet, a picture was to be displayed in the Elopement Book, and staff was to observe potential exit seeking activity. Staff was to approach the resident in a calm manner, redirect the resident to another location, walk with the resident in the direction he/she was going and assume leadership of direction back to area of greater safety. Additional approach was to check placement of the WanderGuard every shift and the function every week. Resident #1 was reassessed on 04/01/13, 06/10/13, and 09/10/13 for his/her risk of elopement/wandering behavior. The facility identified the resident as a continued elopement risk due to expressions to leave facility unattended and walking towards exit doors. There was no direction to staff as to the frequency of monitoring Resident #1. Telephone interview with Certified Nursing Assistant (CNA) #1, on 10/22/13 at 2:01 PM, revealed she was assigned to Resident #1 from 6:45 PM on 10/19/13 to 7:00 AM on 10/20/13. CNA #1 indicated the staff had to check the residents every two (2) hours and she had seen the resident at 12:00 AM in the rotunda (an area adjacent to the nurses' station with two recliners and a small couch). She took the resident to his/her room to ensure he/she was clean and dry, and then the resident went to bed in his/her clothes. However, she did not check on the resident again until approximately 5:30 AM when she changed him/her, and the resident walked out of the bedroom as if he/she was going to the rotunda. Further interview revealed during the change of shifts, she and the on-coming staff was to do a physical walk around and report what was going on with each resident they were assigned. However, CNA #2 did not want to do a walk through the morning of 10/20/13 at approximately 6:45 AM. CNA #1 further revealed the resident had a WanderGuard on and any resident with a WanderGuard on who tried to open an exit door would cause the door to lock and alarm, and someone would have to physically put in a code. She stated she did not hear any alarms sounding the morning of 10/20/13. Telephone interview with LPN (Licensed Practical Nurse) #1, on 10/22/12 at 4:04 PM, revealed she had last seen Resident #1 during the end of her medication pass about 5:38 AM on 10/20/13. She had turned the light on at the desk and was charting when she saw Resident #1 walking up the hallway toward the nursing station. Per interview, it was not unusual to see Resident #1 ambulating in the rotunda and he/she would sit down. She stated the resident had a WanderGuard on and when staff was at the desk they could hear the alarms loud and clear. LPN #1 indicated it was her understanding the exit doors would alarm if a resident with a WanderGuard bracelet got near an exit door, and it was also her understanding the WanderGuard alarms on the exit doors would help the staff keep the residents safe. However, she did not hear an alarm sound the morning of 10/20/13. LPN #1 further stated she did not do a walking round with on-coming nurse LPN #2, on 10/20/13; LPN #2 declined to do a walk around because she was not feeling well. When LPN #1 left the facility at 6:40 AM, LPN #1 was not aware Resident #1 had left the building. Telephone interview with LPN #2, on 10/22/13 at 3:25 PM, revealed she was the first shift nurse for Resident #1, the morning he/she had left the building. Per interview, nurses sometimes did a walking round with the off-going or on-coming staff; however, the morning the resident had left the building they did not do a walking round and she only received a verbal report from LPN #1. CNA #2 had notified her that she was unable to locate Resident #1; a search was initiated; and, she called RN #1 to report the missing resident. LPN #2 stated she had not heard any alarms that morning. Telephone interview with CNA #2, on 10/23/13 at 10:42 AM, revealed she was in the facility on 10/20/13 at 6:45 AM. She stated she was supposed to do a walk through with the off-going CNA and receive a report on each resident and visually see the residents. However, she did not do a walk through on 10/20/13 and CNA #1 had reported that everyone was fine. Further interview revealed it was not normal practice to see the residents on a walk through, but they were supposed to. In addition, they were to round every two (2) hours on the residents. Per interview, CNA #2 went to get Resident #1 up, about 7:30 AM, and the resident was not in his/her bed. The resident's bed was made, and she assumed Resident #1 was up front in a chair. The CNA indicated the resident was not there and she began to look around and then told the nurses and other CNAs. She stated a search to find Resident #1 began and the resident was found right away. The resident had a WanderGuard on his/her wrist. CNA #1 revealed the resident was confused; however, he/she was easily redirected. She stated the resident would have been identified as missing earlier if they had done the safety rounds as required. Telephone interview with CNA #4, on 10/24/13 at 8:30 AM, revealed he found Resident #1 walking in front of a nearby fast food restaurant. He stated the resident and he walked to the pawn shop and he called for staff to pick them up. The resident was cold and he placed his jacket on the resident. He revealed the resident had a short sleeve T-shirt and blue jeans on, with a ball cap, shoes and socks. When they returned to the facility, staff put a blanket around the resident, escorted the resident to his/her bedroom, where the nursing staff assessed the resident. Further interview with LPN #2 revealed Resident #1 was confused, and the resident reported he/she was cold when returned to the facility. She assessed the resident upon return with no injuries. Review of the National Weather Service archive temperature log revealed the temperature on 10/20/13 was 39 degrees Fahrenheit. Further review of the video-surveillance tape revealed on 10/19/13 at approximately 7:42 PM, a nurse (identified by facility staff as LPN #8) was observed in the nurses station and as she walked by the computer monitor she turned it off. The monitor was observed on the video-surveillance tape to be off until a nurse (identified by facility staff as LPN #3) observed the monitor and turned it on at approximately 7:51 AM on 10/20/13. Interview with LPN #8 on 10/25/13 at 8:33 AM revealed on 10/19/13 at approximately 7:42 PM she reset the monitor at the nurses station because an alarm had sounded. She pushed the button on the monitor twice and did not realize the monitor had not come back on. She revealed it was her mistake not to stay by the monitor until it rebooted. Due to the monitor being turned off, the alarm system did not sound at the nurses station on 10/20/13 at 5:36:49 AM, 5:37:09 AM, 5:37:21 AM and 5:37:35 AM per the facility's WanderGuard Activities Report. Per interview, LPN #1 and CNA #1 stated they did not hear alarms sound the morning of 10/20/13, and interview with LPN #1 and LPN #2 revealed they did not notice the monitor was turned off. Interview with the Maintenance Supervisor on 10/23/13 at 3:06 PM, revealed he was called to the facility on [DATE] after Resident #1's elopement from the facility. He stated he checked the doors five days a week. He stated there were no problems and they were working correctly prior to the weekend and on 10/20/13. He stated the nurses checked the transmitters daily to ensure they were working appropriately. He stated the overhead alarm sounds through the computer monitor and it would have alerted staff of the resident exiting the building. If staff entered a reset code the system would not have alarmed overhead. He stated if the computer was turned off, the transmitter and everything would work appropriately. Additionally, he stated the alarm system sounds at the computer/monitor terminal at the nurses' station, and if it were turned off staff would not be alerted if a resident was to exit the building. Interview with the Director of Nursing (DON), on 10/25/13 at 10:29 AM, revealed she was notified about 7:50 AM on Sunday morning (10/20/13) by LPN #2 of Resident #1 being missing. She arrived to the facility about 8:15 AM and directed staff to notify the police and family and she called the Administrator and left to search the area for the resident. She stated she received a call from LPN #3 who reported the resident had been found. She and LPN #2 assessed Resident #1 upon his/her return to the facility and the resident was found with no injury; however, the resident reported being "cold". Further interview revealed she had viewed the monitor and had seen some alerts were still blinking where staff had not addressed them. She stated after the alarms sounded the nurse had to walk to the monitor to reset it. She stated staff was taught how to read the monitor to identify when someone was at the door and how to reset it. She stated the door alarm system had worked appropriately; however, the monitor had been turned off and staff could not hear the alarms sounding. She stated staff was to sign off on the CNA assignment sheets to verify they had visually seen the resident. Per interview, she did not think she had to monitor the nurses to ensure they did their rounds; however, staff could have found the resident earlier if they had completed the walking safety rounds and identified him/her as missing. She revealed she did not know how the resident exited until they reviewed the video-surveillance tape and discovered the Security Guard had let the resident out of the building. Interview with the Administrator, on 10/22/13 at 8:15 AM, revealed review of the video surveillance tape revealed the Security Guard had entered the reset code which allowed Resident #1, who was wearing a WanderGuard to exit the building, without sounding the alarm. She stated the Security Guard thought the resident was a visitor and failed to contact the nurse or review the elopement binder, prior to letting the resident exit the building. She stated during the time the monitor was disabled staff would not have heard any alarms to notify them of a resident wearing a WanderGuard trying to exit the facility. The Administrator stated the purpose of the WanderGuard alarm system on the exit doors and the contracted Security Guards was to assist in keeping the residents safe. In addition, she stated staff was to complete walking rounds and visualize each resident during shift change. She stated the staff's failure to do safety rounds at shift change to visualize each resident caused a delay in initiating a search for the resident. She further stated it was ultimately her responsibility to ensure the contracted providers, such as the Security Guards, were informed of the facility policies and procedures and trained regarding residents at risk for elopement. Review of the acceptable AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. A facility wide search and resident census was taken by the charge nurse immediately on 10/20/13 at 7:30 AM, to determine if Resident #1 was missing and all other residents were present. The Administrator, DON, police, physician and family of Resident #1 were all notified by telephone. 2. After Resident #1's return to the facility at 8:29:31 AM by CNA #4, the DON and LPN #2 assessed the resident. They assigned a LPN to complete a check on the resident and CNA sitter every fifteen (15) minutes for twenty-four (24) hours. On 10/21/13 the Administrator and the Director of Nursing (DON) directed the assigned staff to check on the resident every thirty (30) minutes for twenty-four (24) hours. 3. An investigation was initiated by the DON and the Administrator, on 10/20/13 at approximately 8:45 AM with interviews of staff on duty and telephone interviews with staff from the previous shift, and review of the video-surveillance tape. All exit doors were checked for functionality by the Maintenance Supervisor on 10/20/13 and all exit doors alarming appropriately. The DON notified the physician and assessed the resident along with LPN #2. 4. On 10/20/13, after review of the surveillance video revealed the Security Guard #6, had entered the bypass code and allowed Resident #1 to exit the building, unsupervised. The Administrator contacted the Security Agency to obtain contact information for Security Guard #6. The facility notified the Security Agency on 10/20/13 that effective immediately Security Guard #6 was no longer authorized to work at the facility. 5. On 10/20/13, after Resident #1's elopement from the facility, the Administrator determined the Security Communication binder and Elopement at Risk binder were in place and up-to-date as of 10/20/13 with all identifying information and a current photo in the binder for the five (5) residents (to include Resident #1) who had been assessed as being at risk for elopement. On 10/20/13 the DON checked the five (5) residents who had been assessed as being at risk for elopement with WanderGuard bracelets to ensure the bracelets' placement and functionality. The Administrator and the DON had identified the same five (5) at risk residents of the seventy-eight (78) residents assessed. The Director of Clinical Services, the DON, and RN #1 reassessed all seventy-eight (78) residents for their elopement risks on 10/20-21/13. 6. The Administrator and the Director of Clinical Services determined which security guards were scheduled to work from 10/20/13 and subsequent shifts and re-educated them on the policies related to elopement and completed a competency quiz with a score of 100% before allowing them to work any further shifts. The competency quiz was administered to all two (2) security guards scheduled to work by the Director of Clinical Services on 10/21/13. 7. A minimum of every two hour facility safety rounds were continued by the staff to ensure resident safety. Corrective action was issued to all nursing staff members with responsibility for caring for the resident during third shift on 10/19/13 and first shift 10/20/13; up to and including termination of employment. On 10/21/13 directives by the Administrator and DON and the QA Committee for all nursing staff that safety rounds must be conducted for all shift changes. To ensure this standard of walking rounds at shift change is met the nursing staff must provide the DON a mutually-signed copy of the staff member's care records for their shift. 8. All seventy-eight (78) resident's elopement assessments were reviewed or reassessed by the DON, Unit Managers, and the Director of Clinical Services, and reviewed on 10/20/13 the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. In addition, all residents' admission assessments, care plans, CNA care records, assignment sheets, elopement, fall and smoking at risk assessments beginning on 10/20/13 and completed on 10/24/13 with revisions as indicated. 9. On 10/20/13 and 10/21/13, all current staff (with the exception of as-needed staff or those on an approved leave) were re-educated by a Unit Manager and the Director of Clinical Services on facility policies for: door alarm, door check, missing person, elopement, falls and smoking schedules for residents which included a post-test to ensure competency. The Administrator assured as needed staff or those that were on approved leave were called via telephone on 10/20/13 to inform them that they were not to work any further shifts until they were trained on the policies and must meet with the supervisor at the beginning of a scheduled shift. 10. On 10/21/13 the Administrator directed that a representative of the manufacturer of the Center's WanderGuard system be contacted for an onsite visit to re-check the functionality of all applicable doors and adjust the monitoring of sensitivity if needed. The testing and subsequent work was completed on 10/23/13 with the authorization to purchase an additional sensor on one interior door to heighten staff awareness to potential elopement in the corridor leading to the main entry door. 11. The Administrator conducted a Quality Assurance meeting on 10/21/13 to review the investigation findings and actions taken by the facility. The QA meeting included the Administrator, Medical Director, DON, Unit Manager, and the Director of Clinical Services. Audits were developed and directives were given to ensure compliance. The Elopement at Risk binders would be audited weekly by the Unit Manager. Documentation of the correct placement and functionality of all WanderGuard devices in use would be audited weekly by a licensed nurse. Ten percent of the resident elopement assessments would be audited weekly by the Unit Manager or DON. The DON or Unit Manager would ensure the care plan would be reviewed and revised as needed to reflect if a resident was found to be at risk for elopement. The Maintenance Director would audit all exit doors for function with a WanderGuard four (4) times weekly. All staff responsible for conducting the audits was trained as of 10/21/13. 12. All licensed nurses were educated on 10/21/13 by the DON that the WanderGuard computer monitor's volume level was not to be adjusted for any reason and was not to be turned off. The ability to change the monitor volume and the ability to turn the monitor on and off was disabled on 10/24/13 by the Senior Executive Director. The security staff would be audited three (3) times weekly by the Administrator on their competency and knowledge of the facility's door alarm and locking policy as well as all job-related requirements involving the use of the Elopement at Risk binder. 13. All audits listed which were developed on 10/21/13 would be gathered by the Unit Manager weekly and submitted to and reviewed by the DON. The DON will report the findings of the audits to the Administrator. The Administrator will present the audit results to the Quality Assurance Committee monthly for twelve (12) months. The Senior Executive Director will review the Quality Assurance minutes monthly and attend the QA meeting on a quarterly basis to monitor compliance. 14. The Unit Manager educated their total nursing staff of twenty-four (24) on 10/24/13 in person and via telephone on the revised Care Plan Revision Policy and Procedure. Unit Managers will audit care plans for correct revision five (5) days weekly based on new physician orders [REDACTED]. This will be a part of the daily clinical review meeting. Corrections needed would be made at that time. The DON will review the findings of these audits with the Administrator who will present the results to the QA committee. 15. The Senior Executive Director educated the Administrator on 10/24/13 of the Administrator's job responsibilities, duties and roles along with the company's Quality Assessment and Assurance policy to assure ongoing knowledge and performance of duties and responsibilities. The State Survey Agency validated through record review and interview the Immediate Jeopardy was removed as follows: 1. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she was notified by the DON at approximately 8:00 AM by telephone on 10/20/13 of the elopement of Resident #1 after a facility wide search and determination Resident #1 was missing from the facility and immediate grounds. Interview with the DON, on 10/25/13 at 10:29 AM, revealed she was notified by RN #1 by telephone at approximately 7:50 AM on 10/20/13 of the elopement of Resident #1. Interview with RN #1, on 10/23/13 at 9:24 AM, LPN #2, on 10/22/13 at 3:25 PM, and LPN #3, on 10/23/13 at 2:12 PM, revealed they were directed to complete an accountability check for each resident on 10/20/13. Review of the nursing notes for 10/20/13 revealed the family and physician were notified by the DON at 8:50 AM. 2. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had directed a nurse to complete a fifteen (15) minute check on the resident and CNA sitter every fifteen minutes for twenty-four hours and then for staff to check the resident every thirty (30) minutes for twenty-four (24) hours. Review of the Check sheet dated 10/20/13 and 10/21/13, revealed staff monitored Resident #1 as directed. Review of the nursing documentation on 10/20/13, revealed LPN #2 documented the events from notification of resident missing to the resident's return and assessment completed. 3. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed an investigation was initiated by herself and the Director of Clinical Services. Review of the information gathered and documented interviews revealed the investigation had been initiated and was on-going. Review of the facility's investigation into Resident #1's elopement on 10/22/13, revealed staff interviews were done timely. Review of the Maintenance Supervisor report revealed all exit doors had been checked for function on 10/20/13 with no problems identified. 4. Review of the facility's video-surveillance tape and interview with Administrator, on 10/22/13 at 8:15 AM, revealed the Security Guard #6 had entered a bypass code at the front entrance (known as Main Street 2), on 10/20/13 at 5:37:21 AM, and allowed Resident #1 to exit the facility unsupervised. Review of the e-mail dated 10/23/13 from the facility to the Security Provider revealed the provider was informed of the termination of Security Guard #6 at the facility. 5. Record review and interview with the Administrator and the DON, on 10/22/13 at 8:15 AM, revealed they had checked the elopement at risk binder at the nursing station, on 10/20/13 to ensure all identifying information and a current photo was in the binder for the five (5) residents (to include Resident #1) who had been assessed at being at risk for elopement. Review of the facility's elopement binder on 10/22/13 revealed all residents who were at risk for elopement had their identifying information in the Security Communication binder. Record review on 10/22/13 revealed seventy-eight (78) residents had been reassessed for their elopement risks by the DON, Director of Clinical Services, and Unit Managers. Review of the Maintenance door check lists revealed the doors were checked weekly without concerns identified. Review of the TARs revealed the WanderGuards were checked daily for placement and weekly for function. 6. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had identified the security guards scheduled to work and immediately in-serviced them on the policy and procedures to include the Elopement at Risk binder. She stated a post-test was completed and they had to pass with 100 percent. Review of the post-test for Security Guard #5, revealed the test had been administered on 10/20/13 and Security Guard #9's test was administered on 10/21/13 with both scoring 100%. 7. Record review and interview with the Administrator, on 10/24/13 at 3:30 PM, revealed corrective action was issued to LPN's #1 and #2, and CNA's #1 and #2 for failure to complete safety rounds as required. LPN #8 was terminated for turning off the computer monitor. Record review for the employees revealed the written reprimands were placed in the employee files, signed by the employees. Interviews with LPN # 8 revealed she had been terminated for turning off the computer monitor. Review of shift change walking rounds report completed by the LPN's at shift change on 11/01/13 revealed they were signed off by both staff indicating the walking round had been completed and all residents were accounted for. Interviews with CNA #

Based on interview, record review, and review of facility's policies, investigation, and WanderGuard system, it was determined the facility's Administration failed to have an effective system to ensure policies were implemented related to the WanderGuard system and contracted security staff was educated on the policies. Interview with Administration revealed education of contract staff was the responsibility of the contract company, not the facility. There was no evidence the facility had a system in place to monitor and ensure the contracted staff was following facility policies. This failure affected (1) of eight (8) sampled residents, Resident #1. On 10/20/13 at 5:37:21 (from the WanderGuard report) Resident #1 exited the facility without staff knowledge when the security guard entered an over ride code to open the front entrance door and allowed the resident to leave the facility. Resident #1 was found by a staff member ambulating on a sidewalk in front of a fast food restaurant 0.3 miles from the facility in a heavy traffic, four (4) lane street and was returned to the facility unharmed at approximately 8:29 AM on 10/20/13, approximately two (2) hours and fifty-two (52) minutes after he/she left the facility. Review of the National Weather Service archive temperature log revealed the temperature on 10/20/13 was 39 degrees Fahrenheit. Resident #1 was assessed by the facility as having no injuries. (Refer to F280 and F323) The facility's failure to have an effective system to ensure its resources were used effectively and efficiently placed residents' at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 10/24/13 of the Immediate Jeopardy. An acceptable Allegation of Compliance (AOC) was received on 10/30/13 which alleged the Immediate Jeopardy was removed on 10/25/13. The State Survey Agency validated the removal of Immediate Jeopardy on 10/25/13 as alleged, prior to exit on 11/01/13 and the scope and severity lowered to a "D" while the facility develops and implements a Plan of Correction and the facility's Quality Assurance program monitors the effectiveness of systemic changes to achieve and maintain substantial compliance. The findings include: Review of the facility's policy regarding Procedure for Door Alarm/Lock Policy (not dated) revealed all staff had the responsibility to assure that residents who wander would not leave the building unescorted. Staff was directed to respond when a door alarm sounds. The WanderGuard computer located at the nurse's station was not to be touched unless authorized. All staff that was in close proximity was responsible for going to the WanderGuard computer when an alarm sounded to alert others as to which door was alarming. Staff was directed that at no time was authorized personnel allowed to place a door alarm on bypass/silence. Unit Managers, DON, Maintenance and Administrator were the only ones authorized. Interview and record review revealed Security Guard #6 entered a code to over ride the door alarm on 10/20/13 at approximately 5:37 AM and allowed Resident #1 to leave the facility unsupervised. Telephone interview with Security Guard #6, on 10/23/13 at 10:51 AM, revealed he did not recognize the person as a resident. He stated Resident #1 had on regular clothes, a blue outfit, pants, shoes, shirt and looked like he/she was waiting for somebody. He revealed he did not review the elopement binder, he did not notify the nursing staff of the resident leaving the building as he was trained, and he did not verify if the resident was a visitor by comparing the sign in/out sheet. He further stated he was supposed to look at the elopement book and check it every so often; however, he had not reviewed the elopement binder for 4-5 weeks. Per interview, he accepted the responsibility, that he let Resident #1 exit the building unsupervised. Review of the Elopement at Risk binder revealed two (2) in-service sheets had been signed by Security Guard #6, on 05/26/13 and 07/04/13 as directed by the Contracted Security Provider, indicating he was educated on the elopement at risk binder and was to check the elopement at risk binder daily. Review of the daily shift report completed by Security Guard #6, dated 10/19/13, revealed he was in the facility at 7:00 PM and out at 7:15 AM on 10/20/13. Review of the visitors log sign in/out sheet revealed the second shift visitors had signed out at 7:46 PM on 10/19/13, with no visitors again until 10/20/13 at 9:12 AM. Interview with the Administrator, on 10/22/13 at 8:15 AM, revealed review of the video surveillance tape disclosed Security Guard #6 had entered the reset code which allowed Resident #1, who was wearing a WanderGuard, to exit the building without supervision and without sounding the alarm. She stated Security Guard #6 thought the resident was a visitor and failed to contact the nurse or review the elopement binder, prior to letting the resident exit the building. Per interview, the facility did not provide education to the contracted security guards regarding facility policies and had left this responsibility up to the contract company. However, she stated it was her responsibility to ensure the contracted providers were informed of the facility policies and procedures regarding residents at risk for elopement and to ensure the safety of the residents in the facility. However, interview with a Corporate Executive Director, on 10/23/13 at 2:00 PM, revealed the security company was ultimately responsible to train the security guards. He stated the facility provided the materials, and the "Elopement at Risk" binder to ensure they were aware of the expectations. He stated the facility did not monitor the contracted agency; the security company supervisors were to ensure their guards were complying with the facility requirements. Interview with the Owner and Partner of the Security Company, on 10/23/13 at 12:40 PM, revealed the company only received the Elopement binder from the facility, and did not receive any policies related to the WanderGuard system. Per interview, the Elopement binder contained a list of elopement risk residents with a picture, appointments, census, and a signature sheet of acknowledgement that the guard had read and understood the facility's expectations. Review of the signature sheet revealed Security Guard #6 signed on 05/31/13 and again on 07/06/13. The Owner/Partner stated the guard was supposed to check the Elopement book each shift. In addition, the interview revealed a supervisor made daily rounds at the facility but this was to make sure the guard was on duty and to check if issues needed to be addressed. Review of the acceptable AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. A facility wide search and resident census was taken by the charge nurse immediately on 10/20/13 at 7:30 AM, to determine if Resident #1 was missing and all other residents were present. The Administrator, DON, police, physician and family of Resident #1 were all notified by telephone. 2. After Resident #1's return to the facility at 8:29:31 AM by CNA #4, the DON and LPN #2 assessed the resident. They assigned a LPN to complete a check on the resident and CNA sitter every fifteen (15) minutes for twenty-four (24) hours. On 10/21/13 the Administrator and the Director of Nursing (DON) directed the assigned staff to check on the resident every thirty (30) minutes for twenty-four (24) hours. 3. An investigation was initiated by the DON and the Administrator, on 10/20/13 at approximately 8:45 AM with interviews of staff on duty and telephone interviews with staff from the previous shift, and review of the video-surveillance tape. All exit doors were checked for functionality by the Maintenance Supervisor on 10/20/13 and all exit doors alarming appropriately. The DON notified the physician and assessed the resident along with LPN #2. 4. On 10/20/13, after review of the surveillance video revealed the Security Guard #6, had entered the bypass code and allowed Resident #1 to exit the building, unsupervised. The Administrator contacted the Security Agency to obtain contact information for Security Guard #6. The facility notified the Security Agency on 10/20/13 that effective immediately Security Guard #6 was no longer authorized to work at the facility. 5. On 10/20/13, after Resident #1's elopement from the facility, the Administrator determined the Security Communication binder and Elopement at Risk binder was in place and up-to-date as of 10/20/13 with all identifying information and a current photo in the binder for the five (5) residents (to include Resident #1) who had been assessed as being at risk for elopement. On 10/20/13 the DON checked the five (5) residents who had been assessed as being at risk for elopement with WanderGuard bracelets to ensure the bracelets' placement and functionality. The Administrator and the DON had identified the same five (5) at risk residents of the seventy-eight (78) residents assessed. The Director of Clinical Services, the DON, and RN #1 reassessed all seventy-eight (78) residents for their elopement risks on 10/20-21/13. 6. The Administrator and the Director of Clinical Services determined which security guards were scheduled to work from 10/20/13 and subsequent shifts and re-educated them on the policies related to elopement and completed a competency quiz with a score of 100% before allowing them to work any further shifts. The competency quiz was administered to all two (2) security guards scheduled to work by the DCS on 10/21/13. 7. A minimum of every two hour facility safety rounds were continued by the staff to ensure resident safety. Corrective action was issued to all nursing staff members with responsibility for caring for the resident during third shift on 10/19/13 and first shift 10/20/13; up to and including termination of employment. On 10/21/13 directives by the Administrator and DON and the QA Committee for all nursing staff that safety rounds must be conducted for all shift changes. To ensure this standard of walking rounds at shift change is met the nursing staff must provide the DON a mutually-signed copy of the staff member's care records for their shift. 8. All seventy-eight (78) resident's elopement assessments were reviewed or reassessed by the DON, Unit Managers, and the Director of Clinical Services, and reviewed on 10/20/13 the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. In addition, all residents' admission assessments, care plans, CNA care records, assignment sheets, elopement, fall and smoking at risk assessments beginning on 10/20/13 and completed on 10/24/13 with revisions as indicated. 9. On 10/20/13 and 10/21/13, all current staff (with the exception of as-needed staff or those on an approved leave) were re-educated by a Unit Manager and the Director of Clinical Services on facility policies for: door alarm, door check, missing person, elopement, falls and smoking schedules for residents which included a post-test to ensure competency. The Administrator assured as needed staff or those that were on approved leave were called via telephone on 10/20/13 to inform them that they were not to work any further shifts until they were trained on the policies and must meet with the supervisor at the beginning of a scheduled shift. 10. On 10/21/13 the Administrator directed that a representative of the manufacturer of the Center's WanderGuard system be contacted for an onsite visit to re-check the functionality of all applicable doors and adjust the monitoring of sensitivity if needed. The testing and subsequent work was completed on 10/23/13 with the authorization to purchase an additional sensor on one interior door to heighten staff awareness to potential elopement in the corridor leading to the main entry door. 11. The Administrator conducted a Quality Assurance meeting on 10/21/13 to review the investigation findings and actions taken by the facility. The QA meeting included the Administrator, Medical Director, DON, Unit Manager, and the Director of Clinical Services. Audits were developed and directives were given to ensure compliance. The Elopement at Risk binders would be audited weekly by the Unit Manager. Documentation of the correct placement and functionality of all WanderGuard devices in use would be audited weekly by a licensed nurse. Ten percent of the resident elopement assessments would be audited weekly by the Unit Manager or DON. The DON or Unit Manager would ensure the care plan would be reviewed and revised as needed to reflect if a resident was found to be at risk for elopement. The Maintenance Director would audit all exit doors for function with a WanderGuard four (4) times weekly. All staff responsible for conducting the audits was trained as of 10/21/13. 12. All licensed nurses were educated on 10/21/13 by the DON that the WanderGuard computer monitor's volume level was not to be adjusted for any reason and was not to be turned off. The ability to change the monitor volume and the ability to turn the monitor on and off was disabled on 10/24/13 by the Senior Executive Director. The security staff would be audited three (3) times weekly by the Administrator on their competency and knowledge of the facility's door alarm and locking policy as well as all job-related requirements involving the use of the Elopement at Risk binder. 13. All audits listed which were developed on 10/21/13 would be gathered by the Unit Manager weekly and submitted to and reviewed by the DON. The DON will report the findings of the audits to the Administrator. The Administrator will present the audit results to the Quality Assurance Committee monthly for twelve (12) months. The Senior Executive Director will review the Quality Assurance minutes monthly and attend the QA meeting on a quarterly basis to monitor compliance. 14. The Unit Manager educated their total nursing staff of twenty-four (24) on 10/24/13 in person and via telephone on the revised Care Plan Revision Policy and Procedure. Unit Managers will audit care plans for correct revision five (5) days weekly based on new physician orders [REDACTED]. This will be a part of the daily clinical review meeting. Corrections needed would be made at that time. The DON will review the findings of these audits with the Administrator who will present the results to the QA committee. 15. The Senior Executive Director educated the Administrator on 10/24/13 of the Administrator's job responsibilities, duties and roles along with the company's Quality Assessment and Assurance policy to assure ongoing knowledge and performance of duties and responsibilities. The State Survey Agency validated through record review and interview the Immediate Jeopardy was removed as follows: 1. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she was notified by the DON at approximately 8:00 AM by telephone on 10/20/13 of the elopement of Resident #1 after a facility wide search and determination Resident #1 was missing from the facility and immediate grounds. Interview with the DON, on 10/25/13 at 10:29 AM, revealed she was notified by RN #1 by telephone at approximately 7:50 AM on 10/20/13 of the elopement of Resident #1. Interview with RN #1, on 10/23/13 at 9:24 AM, LPN #2, on 10/22/13 at 3:25 PM, and LPN #3, on 10/23/13 at 2:12 PM, revealed they were directed to complete an accountability check for each resident on 10/20/13. Review of the nursing notes for 10/20/13 revealed the family and physician were notified by the DON at 8:50 AM. 2. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had directed a nurse to complete a fifteen (15) minute check on the resident and CNA sitter every fifteen minutes for twenty-four hours and then for staff to check the resident every thirty (30) minutes for twenty-four (24) hours. Review of the Check sheet dated 10/20/13 and 10/21/13, revealed staff monitored Resident #1 as directed. Review of the nursing documentation on 10/20/13, revealed LPN #2 documented the events from notification of resident missing to the resident's return and assessment completed. 3. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed an investigation was initiated by herself and the Director of Clinical Services. Review of the information gathered and documented interviews revealed the investigation had been initiated and was on-going. Review of the facility's investigation into Resident #1's elopement on 10/22/13, revealed staff interviews were done timely. Review of the Maintenance Supervisor report revealed all exit doors had been checked for function on 10/20/13 with no problems identified. 4. Review of the facility's video-surveillance tape and interview with Administrator, on 10/22/13 at 8:15 AM, revealed the Security Guard #6 had entered a bypass code at the front entrance (known as Main Street 2), on 10/20/13 at 5:37:21 AM, and allowed Resident #1 to exit the facility unsupervised. Review of the e-mail dated 10/23/13 from the facility to the Security Provider revealed the provider was informed of the termination of Security Guard #6 at the facility. 5. Record review and interview with the Administrator and the DON, on 10/22/13 at 8:15 AM, revealed they had checked the elopement at risk binder at the nursing station, on 10/20/13 to ensure all identifying information and a current photo was in the binder for the five (5) residents (to include Resident #1) who had been assessed at being at risk for elopement. Review of the facility's elopement binder on 10/22/13 revealed all residents who were at risk for elopement had their identifying information in the Security Communication binder. Record review on 10/22/13 revealed seventy-eight (78) residents had been reassessed for their elopement risks by the DON, Director of Clinical Services, and Unit Managers. Review of the Maintenance door check lists revealed the doors were checked weekly without concerns identified. Review of the TARs revealed the WanderGuards were checked daily for placement and weekly for function. 6. Record review and interview with the Administrator, on 10/22/13 at 8:15 AM, revealed she had identified the security guards scheduled to work and immediately in-serviced them on the policy and procedures to include the Elopement at Risk binder. She stated a post-test was completed and they had to pass with 100 percent. Review of the POS [REDACTED]'s test was administered on 10/21/13 with both scoring 100%. 7. Record review and interview with the Administrator, on 10/24/13 at 3:30 PM, revealed corrective action was issued to LPN's #1 and #2, and CNAs #1 and #2 for failure to complete safety rounds as required. LPN #8 was terminated for turning off the computer monitor. Record review for the employees revealed the written reprimands were placed in the employee files, signed by the employees. Interviews with LPN # 8 revealed she had been terminated for turning off the computer monitor. Review of shift change walking rounds report completed by the LPN's at shift change on 11/01/13 revealed they were signed off by both staff indicating the walking round had been completed and all residents were accounted for. Interviews with CNA #5, on 10/31/13 at 12:50 AM, CNA #6, on 10/31/13 at 1:25 PM, LPN #1, on 10/22/13 at 3:57 PM,and LPN #2, on 10/22/13 at 3:25 PM, revealed the staff was to complete safety rounds at shift change and every two hours to ensure the residents were safe or if any care was needed. 8. Record review and interview with the Administrator and the Director of Clinical Services, on 11/01/13 at 11:00 AM revealed the DON, Unit Managers, Director of Clinical Services, and the Administrator had reviewed on 10/20/13, the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct with signatures and dates of the DON, Director of Clinical Services and Administrator. Interview with the Director of Clinical Services (DCS), on 11/01/13 at 11:00 PM, revealed the rest of the seventy-eight (78) residents' documents were reviewed with the Administrator and revisions were made as necessary. Review of the elopement assessments and care plans of the five (5) residents the facility had assessed as being at risk for elopement on 10/20/13 revealed signatures and dates of review and revision by the DCS, DON, and the Administrator. Additional review of all the resident's admission assessments and care plans, CNA care records, assignment sheets, elopement, fall, and smoking at risk assessments began on 10/20/13 and completed on 10/24/13 were done. 9. Record review and interview with the DON, on 10/25/13 at 10:29 AM, revealed she had provided the in-services regarding facility policies for: elopement risk/assessment; interventions; and steps to be taken during an incident of a missing resident; door alarms; door checks; falls; and smoking schedules; which included a post-test to ensure the staff's competency. Interview with CNA #5, on 10/31/13 at 12:50 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident, falls, door check, smoking policy, safety rounds, which included a post-test on 10/20/13. Interview with CNA #6, on 10/31/13 at 1:25 PM, LPN #1, on 10/22/13 at 3:57 PM, and LPN #2, on 10/22/13 at 3:25 PM, revealed they received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident falls, door check, smoking policy, safety rounds, which included a post-test to ensure competency on 10/20/13. All in-service training content and staff sign-in sheets were reviewed on 10/31/13 to ensure all nursing staff had been re-trained per the AOC. 10. Record review and interview with the manufacturer's representative of the Center's WanderGuard system revealed an on-site visit was made to verify the function of all exit doors and adjust the monitoring of sensitivity. Interview with Representative, on 10/22/13 at 11:15 AM, revealed he was contacted by the Administrator on 10/20/13, of the resident elopement and the Maintenance Director was in the facility to check all exit doors. He stated he had checked all exit doors on 10/21/13 and they were working appropriately. He stated the inner door was working and he had added an extra sensor. He stated the inner door was not an exit; however, it was to make staff aware of resident's going through the door. 11. Record review and interview with the Administrator, on 11/01/13 at 8:30 AM, revealed a Quality Assurance (QA) meeting included the Medical Director, DON, Unit Managers, Director of Clinical Services, and Administrator on 10/21/13. She stated audits were developed and directives were given to ensure removal of Immediate Jeopardy. Review of the Elopement at Risk binders on 10/22-24/13 and 10/30-11/01/13, revealed they had been reviewed and updated with resident census and appointments. No additional residents had been identified at risk for elopement. Review of the facility's audit forms and interview with the DON, on 11/01/13 at 11:50 AM, revealed audits were developed for nursing to ensure walking rounds were done; audits to verify the function and placement of WanderGuards; resident elopement assessments; and care plan audits would be completed by the Nurse Managers and/or DON and given to the DON weekly. She stated she would review all information and report to the Administrator and QA. Interview with the Administrator, on 11/01/13 at 8:30 AM, revealed she would be auditing the Security Guards three (3) times a week to ensure competency and knowledge of the door alarm and locking requirements, and use of the Elopement Risk binder. She stated the Maintenance Director would continue to complete audits on the exit doors to ensure they were functioning appropriately. 12. Record review and interview with the DON on 10/31/13 at 11:50 AM, revealed she had in-serviced all nurses regarding the use of the computer monitor and to not touch or change the volume of the monitor system, on 10/24/13. She stated the computer 's on/off button was covered by the Executive Director to prevent the staff from turning it off. Interview with LPN #7, on 10/31/13 at 12:54 PM, and RN #3 at 1:12 PM, revealed they had been in-serviced on the purpose and use of the computer monitor and they were not allowed to adjust the volume or turn the monitor off. They said the alarm system on the doors was in place to keep residents safe and nurses had to verify the placement of the resident's WanderGuard and check the function of the WanderGuard weekly. 13. Record review and interview with the DON, on 10/31/13 at 1:18 AM, revealed she had in-serviced the Nurse Managers on the use and purpose of the audits developed to ensure on-going compliance with the facility policy's for: residents' elopement risks assessments; updating; and reviewing the Elopement binder. She stated she would gather all audits from the Unit Nurse Managers to review and submit to the Administrator. She stated the results of the information would be presented at the monthly QA meetings. 14. Record review of all in-service training content and staff sign-in sheets and interview with LPN #1, on 10/22/13 at 3:57 PM, LPN #2, on 10/22/13 at 3:25 PM, and RN #1 on 11/01/13 at 11:20 AM, revealed they were in-serviced on the revised care plan policy and assisted with the in-servicing of all the nurses. They were to review all new physician orders [REDACTED]. They stated the audits would go to the DON and QA. 15. Interview with the Administrator, on 11/01/13 at 1:30 PM, revealed she did have a job performance review with the Executive Director on 10/24/13 of the job responsibilities, duties and roles along with the company's Quality Assessment and Assurance policy to assure ongoing knowledge and performance of duties and responsibilities.

Based on interview, record review and review of the facility's policy, investigation, Observation Flow Sheet, and Code Alert Activities Report, it was determined the facility failed to have an effective system to ensure the resident's environment remained free of accident/hazards for one (1) of seven (7) sampled residents (Resident #1). Resident #1 had been assessed by the facility to be at risk for elopement, was on every fifteen (15) minute checks, and had a Code Alert bracelet on his/her ankle. On 08/15/12 the facility's Code Alert Activities Report (a computerized report which tracks residents wearing a Code Alert bracelet when the resident comes within five (5) feet of the exit door) indicated Resident #1 was near the following exits at the times listed: Evergreen Court 6:14:56 & 6:15:52 PM, the Dining Room Exit 6:21:03 & 6:21:37 PM, and Maple Boulevard Exit 6:33:06 & 6:33:17 PM. Interviews with facility staff revealed they failed to observe Resident #1 on the unoccupied and unsupervised hallway of Maple Boulevard on that date during the 15 minute checks. On 08/15/12 at approximately 7:15 PM, Resident #1 was discovered missing from the facility. Resident #1 was found by the local police ambulating on a sidewalk approximately thirteen (13) city blocks from the facility in a heavily trafficked urban area and was returned to the facility unharmed at 8:34:49 PM on 08/15/12. Resident #1's Code Alert did not indicate activity on the system from 6:33:17 PM until 8:34:49 PM, when the resident was returned to the facility through the Main Street 1 Exit. In addition, the facility failed to identify an inconsistently alarming exit door which was to assist in the prevention of resident elopement. The facility exit doors were to alarm if a resident, who wore a Code Alert bracelet, attempted to exit the facility. However, the exit door on Maple Boulevard was not alarming inconsistently. Resident #1 was discharged to a local Veteran's hospital, later the evening of 08/15/12, upon family request and physician's orders [REDACTED]. The facility's failure to supervise residents at risk for elopement and to identify an exit door alarm which was not alarming properly placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/23/12 of the Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). An acceptable Allegation of Compliance (AOC) was received on 08/27/12 which alleged the Immediate Jeopardy was removed on 08/25/12. However, the State Survey Agency determined the facility had not trained the agency nursing staff until 08/30/12, therefore Immediate Jeopardy was determined to be removed on 08/31/12 prior to exit. The scope and severity for Substandard Quality of Care at 42 CFR 483.25 Quality of Care F323 Accidents and Supervision was lowered to a "D" while the facility develops and implements a plan of correction to achieve substantial compliance with regulation, and while the facility's Quality Assurance program continues to monitor the effectiveness of staff education, effectiveness of resident assessments and care planning, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility's policy regarding Procedure for Code Alert Alarms (undated) revealed when the resident approached an exit door, the alarm would sound and the door would lock. The procedure also revealed staff would check exits and server computer to identify the resident and the exit door. Staff was to proceed to the identified exit and redirect the resident. If the resident was not seen, staff was to check the area and outside to assure the resident had not exited. Review of Code Alert Activities Report for 08/15/12 indicated Resident #1 near the following exits at the times listed: Evergreen Court 6:14:56 & 6:15:52 PM, the Dining Room Exit 6:21:03 & 6:21:37 PM, and Maple Boulevard Exit 6:33:06 & 6:33:17 PM. Resident #1's Code Alert did not indicate activity on the system again until 8:34:49 PM at the Main Street 1 Exit. Record review revealed Resident #1 was initially admitted to the facility on [DATE] and the facility assessed the resident as having a cognition score of ten (10) on the Minimum Data Set (MDS) indicating a moderate impairment of cognition. Review of the nursing notes, dated 07/30/12, revealed Resident #1 attempted to elope from the facility on 07/30/12 and was discharged to a psychiatric hospital on [DATE] for an evaluation. Review of a discharge summary from the psychiatric hospital dated 08/15/12 revealed Resident #1 had no exit seeking behavior for the previous forty-eight (48) hours. The resident was re-admitted to the facility on [DATE] at 3:00 PM. Review of the nursing admission elopement assessment, dated 08/15/12 and timed 3:00 PM, revealed Resident #1 triggered as an elopement risk due to his/her being ambulatory, having a history of wandering and having a [DIAGNOSES REDACTED].#1 was a risk for elopement, the goal listed was to decrease the risk for elopement and one intervention for the prevention of elopement was to apply a Code Alert bracelet. Review of an every fifteen (15) minute observation document revealed Resident #1 was not located in the facility at 7:15 PM. Review of the facility's investigation, dated 08/15/12, revealed a check of the Maple Boulevard exit door by the Director of Clinical Services (DCS) on 08/15/12 prior to Resident #1's return indicated inconsistent alarming of the Maple Boulevard exit door. The facility investigation included an interview with Resident #1, upon return to the facility, during which Resident #1 stated he/she left the facility out a back door. Further review of the facility's investigation revealed Resident #1 was wearing a Code Alert bracelet upon return to the facility and the Code Alert bracelet did cause the exit doors to alarm when checked by the Maintenance Supervisor. Review of the Maintenance Supervisor's maintenance log sheet revealed all of the exit door alarms had been functional when checked on 08/10/12. Review of the door alarm company's representative's report on 08/16/12 revealed the exit door on Maple Boulevard did not shut completely and needed repair; however, if shut completely the door did lock properly and all functions were working for the Code Alert system. Interview with the Maintenance Supervisor, on 08/20/12 at 3:50 PM, revealed he was called to the facility on [DATE] at approximately 8:30 PM after Resident #1's elopement from the facility. He stated his initial assessment of the eleven (11) alarmed exit doors revealed they were all working correctly. However, another assessment of the eleven (11) alarmed exit doors revealed the exit door on Maple Boulevard was alarming inconsistently. He stated he discovered the exit door on Maple Boulevard was not shutting properly and he thought this might have contributed to the inconsistent alarming of that door. He further stated administrative staff took turns manning the Maple Boulevard exit door until a security guard came to work at 11:00 PM to man the door to ensure the safety of all residents. The Maintenance Supervisor indicated he checked the alarming exit doors bi-monthly prior to Resident #1's elopement from the facility; however, he was now checking the doors daily to ensure their functionality. He stated it was his understanding the alarms on the doors would sound when a resident wearing a Code Alert bracelet attempted to exit one of the doors. He stated there was no manufacturer's recommendation or facility policy as to how often to check the alarms on exit doors and he checked them as they were checked at another company's facility. Record review of the manufacture's recommendation revealed no recommendations to the frequency of door alarm checks. Interview with CNA (Certified Nursing Assistant) #4, on 08/21/12 at 11:45 AM, revealed she was assigned to Resident #1 on the evening shift of 08/15/12 and LPN #5 was assigned to observe Resident #1 every fifteen (15) minutes and document the same. She stated she saw Resident #1 at about 6:30 PM on 08/15/12 in his/her room and further stated she had not seen the resident ambulating on Maple Boulevard prior to his/her elopement. CNA #4 stated she had not heard any exit door alarms in the facility the evening of 08/15/12. CNA #4 stated she had been trained on the Code Alert door alarm system on hire and her understanding was the exit doors would alarm when a resident wearing a Code Alert bracelet attempted to go out an exit door. She stated the computer at the nurses station had a facility diagram on the screen which would show a blinking light at the exit door which was alarming. CNA #4 indicated the Code Alert door alarms would help the staff know if a resident wearing a Code Alert bracelet attempted to go out an exit door. Interview with LPN (Licensed Practical Nurse) #5, on 08/21/12 at 11:00 AM, revealed she had been assigned to do the every fifteen (15) minute observations of Resident #1 and she stated she had seen the resident at 6:30 PM, 6:45 PM and 7:00 PM. However, she stated Resident #1 was not in his/her room at 7:15 PM and could not be located in the facility. She stated she did not hear an exit door alarm during the evening shift of 08/15/12 until the Maintenance Supervisor and administrative staff arrived and began checking the exit door alarms. She also stated no alarms or indicators went off on the computer schematic diagram of the facility to indicate any alarming exit door. LPN #5 indicated she had been trained on the Code Alert alarm system on hire and she understood the exit doors would alarm if a resident actually attempted to exit an alarmed door and that alarm would help the staff keep the residents safe. Interview with LPN #5, on 08/23/12 at 4:00 PM, revealed she had not seen Resident #1 on Maple Boulevard on 08/15/12; however, the Code Alert log had placed the resident on the unoccupied wing at approximately 6:33 PM. Review of the resident's Observation Flow Sheet revealed documentation that Resident #1 was seen at the nurse's station at 6:30 PM and 6:45 PM, and in his/her room at 7:00 PM. Interview with LPN #6, on 08/21/12 at 3:15 PM, revealed she was the admitting nurse for Resident #1 on 08/15/12 but she was working on another hall that evening. She stated she was aware Resident #1 was placed on every fifteen (15) minute observations which were to be done by LPN #5. She stated she did not hear any exit door alarms that evening, she had been trained on the Code Alert door alarm system on hire, and she was aware the computer at the nurses station would indicate which exit door was alarming. LPN #6 indicated it was her understanding the exit doors would alarm if a resident with a Code Alert bracelet got 'near' an exit door, and it was also her understanding the Code Alert alarms on the exit doors would help the staff keep the residents safe. Interview with the Director of Nursing (DON), on 8/21/12 at 11:30 AM, revealed she was present in the facility on 08/15/12 and had made the determination to place Resident #1 on every fifteen (15) minute observations by LPN #5. She stated she made this determination based on the documentation from the psychiatric hospital which stated Resident #1 had not had exit-seeking behaviors there for forty-eight (48) hours prior to discharge. She stated the nursing staff had no responsibility to check exit doors for alarming function or monitoring of the computer screen at the nurses station except when an alarm was sounding. The DON stated she thought Resident #1 eloped from the facility through an exit door which was not alarming properly although the purpose of the alarms on the exit doors was to assist the staff in keeping the residents safe. Interview with the Administrator, on 08/22/12 at 3:45 PM, revealed there was no policy on how often the door alarm system should be checked and no policy regarding utilization of the Code Alert computer information. The Administrator stated the purpose of the Code Alert alarm system on the exit doors was to assist in keeping the residents safe. She further stated it was ultimately her responsibility to ensure adequate assistance devices (door alarms) to ensure the safety of the residents in the facility. Review of the acceptable AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. A facility wide search and resident census was taken by the charge nurse immediately to determine if Resident #1 was missing and all other residents were present. The Administrator, DON, police, physician and family of Resident #1 were all notified by telephone. 2. All exit doors were checked for functionality by the Maintenance Supervisor at approximately 8:40 PM on 08/15/12 with the exit door on Maple Boulevard alarming inconsistently. Administrative staff monitored the exit door on Maple Boulevard until 11:00 PM when the security guard came on duty. 3. After Resident #1's return to the facility at 8:34:49 PM by the local police, the resident was placed on one-to-one (1:1) supervision by the Social Services Director to ensure his/her safety until Resident #1's transfer out of the facility to the local veteran's hospital. 4. On 08/15/12, after Resident #1's elopement from the facility, LPN #6 checked all seven (7) residents (remaining in the facility) who had been assessed as being at risk for elopement with Code Alert bracelets to ensure the bracelets' placement and functionality. 5. On 08/15/12, the DON checked the Elopement at Risk binder at the nursing station to ensure all identifying information and a current photo was in the binder for the eight (8) residents (to include Resident #1) who had been assessed as being at risk for elopement. 6. The DON initiated the facility's investigation into Resident #1's elopement from the facility, on 08/15/12 at 9:00 PM, with interviews of the staff on duty. 7. The Administrator and the Director of Clinical Services (DCS) reviewed the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement on 08/15/12 at 10:00 PM and determined those assessments and documents were correct. The Administrator and the DCS also reviewed all residents' admission assessments, care plans, CNA care records, assignment sheets, elopement, fall and smoking at risk assessments beginning on 08/15/12 and completed on 08/16/12 with revisions as indicated. 8. A minimum of every two hours facility supervision rounds were continued by on duty staff to ensure resident safety. 9. On 08/20/12, all current staff were re-in-serviced on elopement risk/assessment, interventions and steps taken during an incident and missing residents which included a post test to ensure competency. The in-services was conducted by the Director of Nurses. 10. All interdisciplinary team members and licensed nurses were to be re-in-serviced on the facility's policy regarding Care Plans beginning on 08/23/12, by the Staff Development Nurse. All interdisciplinary team members and licensed nurses were to be re-in-serviced on that policy prior to beginning their next shift or giving care with the date of compliance of 08/25/12. Review of in-service training sheets and interview revealed all nurses were not trained by 08/25/12 with seven (7) agency nurses having worked 08/23/12 through 08/29/12 prior to re-in-service on the Care Plan policy. All nursing staff were re-in-serviced by 08/30/12 on the policy: Care Plan which changed the facility date of compliance to 08/30/12. 11. On 08/24/12 regulatory guidelines and facility policies were reviewed with the Administrator by the Vice President of Older Adults Communities to ensure resident care was provided in accordance with accurate comprehensive care plans and safety through supervision. On 08/24/12 the Administrator reviewed and re-signed her job description to assure ongoing knowledge and acceptance of duties and responsibilities. The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1. The State Survey Agency validated through record review and interview with the Administrator, on 08/20/12 at 3:15 PM, she was notified by LPN #5 at approximately 7:30 PM by telephone on 08/15/12 of the elopement of Resident #1 after a facility wide search and determination Resident #1 was missing from the facility and immediate grounds. Interview with the DON, on 08/20/12 at 4:15 PM, revealed she was notified by LPN #5 by telephone at approximately 7:35 PM on 08/15/12 of the elopement of Resident #1. Review of documents provided labeled, Exhibit #5 Evergreen nurse report sheet and Exhibit #7 Lakeview nurse report sheet, revealed a resident head count had been conducted by the charge nurses on each of those halls on 08/15/12 at 7:30 PM. 2. The State Survey Agency validated through record review and interview with the Director of Clinical Services, on 08/21/12 at 5:35 PM, she monitored the exit door on Maple Boulevard from 8:40 PM until 10:00 PM on 08/15/12. Interview with the DON, on 08/21/12 at 11:30 AM, revealed she monitored the Maple Boulevard exit door from 10:00 PM until 11:00 PM on 08/15/12. Interview with the security guard, on 08/23/12 at 6:00 AM, revealed he was assigned to monitor the Maple Boulevard exit door on 08/15/12 from 11:00 PM until 6:45 AM. Interview with Housekeeper #1, on 08/22/12 at 2:10 PM, revealed he was assigned to monitor the Maple Boulevard exit door on 08/16/12 at 6:45 AM until the Code Alert company representative arrived to check the exit doors Code Alert alarm system at approximately 12:00 Noon. 3. The State Survey Agency validated through record review and interview with the Social Services Director, on 08/20/12 at 4:30 PM, she did provide 1:1 supervision to Resident #1 from 8:35 PM on 08/15/12 until his/her discharge from the facility at 10:15 PM. Review of the nursing notes in the record, dated 08/15/12 at 8:30 PM, revealed Resident #1 was placed on 1:1 supervision upon return to the facility until discharge at 10:15 PM. 4. The State Survey Agency validated through record review and interview with LPN #6, on 08/22/12 at 1:50 PM, she checked the seven (7) remaining residents with Code Alert bracelets to ensure the bracelets' placement and functionality on 08/15/12 at approximately 9:00 PM. Review of a twenty-four (24) hour nursing document for 08/15/12 evening shift on 08/29/12 revealed LPN #6 documented the checking of the remaining seven (7) residents with Code Alert bracelets to ensure the Code Alert bracelets' placement and functionality. 5. The State Survey Agency validated through record review and interview with the DON, on 08/20/12 at 4:15 PM, she checked the elopement at risk binder at the nursing station, on 08/15/12 at approximately 8:45 PM, to ensure all identifying information and a current photo was in the binder for the eight (8) residents (to include Resident #1) who had been assessed at being at risk for elopement. Review of the facility's elopement binder on 08/29/12 revealed all residents' at risk for elopement identifying information was in the binder. 6. The State Survey Agency validated through record review and interview with the DON, on 08/20/12 at 4:15 PM, she started the facility investigation of the elopement at 9:00 PM on 08/15/12 with staff interviews (who were on duty at the time of Resident #1's elopement). Interview with CNA #4 on 08/31/12 at 10:10 AM (assigned to Resident #1 at the time of the resident's elopement) revealed she was interviewed regarding Resident #1's elopement from the facility. Review of the facility's investigation into Resident #1's elopement on 08/29/12 revealed staff interviews were done timely. 7. The State Survey Agency validated through record review and interview with the Administrator, on 08/20/12 at 3:15 PM, she had reviewed, on 08/15/12 at 10:00 PM, the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. She also indicated revisions were made to the other documents reviewed as necessary. Interview with the Director of Clinical Services (DCS), on 08/21/12 at 5:35 PM, revealed she had assisted the Administrator, on 08/15/12 at 10:00 PM, in reviewing the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. She further stated the other residents' documents were reviewed with the Administrator and revisions were made as necessary. Review of the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement on 08/30/12 revealed signatures/dates of review and revision by the DCS and the Administrator. 8. The State Survey Agency validated through record review and interview with CNA #3, on 08/21/12 at 3:15 PM, she checked on her assigned residents at least every two (2) hours and it was her understanding this was the facility's practice. Interview with CNA #4, on 08/21/12 at 11:45 AM, revealed the facility's practice was to check on her assigned residents at a minimum of every two hours and she continued to do so after Resident #1's elopement from the facility on 08/15/12. Interview with the DON, on 08/20/12 at 4:15 PM, revealed it was the facility's practice to check on all residents at least every two (2) hours and that was also standard practice. The DON stated the nursing staff had access to up-to-date nursing standards of practice via the computers at the nursing station and a review of that standard of practice was done in nursing orientation. Review of a nursing orientation worksheet on 08/30/12 revealed every two (2) hour checking on residents was discussed in the orientation. 9. The State Survey Agency validated through record review and interview with the Staff Development nurse, on 08/30/12 at 9:15 AM, she had provided the in-services regarding elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure staff competency. Interview with CNA #4, on 08/21/12 at 11:45 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test on 08/16/12. Interview with CNA #3, on 08/21/12 at 3:15 PM, revealed he received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test on 08/15/12. Interview with LPN #1, on 08/21/12 at 11:00 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure competency on 08/17/12. Interview with LPN #5, on 08/21/12 at 11:00 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure competency on 08/15/12. All in-service training content and staff sign-in sheets were reviewed on 08/30/12 to ensure all nursing staff had been re-trained per the AOC. 10. The State Survey Agency validated through record review and interview with LPN #2, on 08/29/12 at 4:30 PM, she had not been re-in-serviced on the Care Plan policy prior to starting her shift and giving resident care at 2:30 PM. Interview with LPN #1, on 08/30/12 at 8:00 AM, revealed he had worked two (2) shifts prior to having a re-in-service on the policy, Care Plans which he received via telephone on 08/29/12. Interview with the DON, on 08/30/12 at 8:30 AM, revealed she placed an in-service binder at the nurses station for the agency nurses to read and sign for the re-in-service on the Care Plan policy. However, she stated that was a new procedure for the facility and the agency nurses were not told to read/sign the in-service prior to starting their shifts. The DON stated it was an oversight and the agency was notified on 08/27/12 to have the agency nurses read/sign the in-service binder which was two (2) days after the alleged date of compliance. Review of all in-service content and agency nurse re-training sign-in sheets were reviewed on 08/30/12 to ensure compliance with the AOC. 11. The State Survey Agency validated through record review and interview with the Administrator, on 08/29/12 at 4:00 PM, she did have a job performance review with the Vice President of Older Adults Communities on 08/24/12 and she did re-sign her job description indicating understanding of same. Interview with the Vice President of Older Adults Communities, on 08/30/12 at 5:00 PM, revealed the Administrator was re-educated on her job duties.

Based on interview, record review, and review of facility's policies, investigation, and Code Alert system, it was determined the facility failed to have an effective system to ensure its resources were used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of seven (7) sampled residents, Resident #1. The facility failed to ensure policies were developed and/or implemented related to the Code Alert system. The facility failed to utilize a computerized program, which would detect when residents with Code Alert bracelets were within five (5) feet of an exit door, and failed to identify an inconsistently alarming exit door. On 08/15/12 Resident #1 eloped from the facility without staff knowledge and was discovered missing from the facility at 7:15 PM. Resident #1 was found by the local police ambulating on a sidewalk approximately thirteen (13) city blocks from the facility in a heavily trafficked urban area and was returned to the facility unharmed at 8:34:49 PM on 08/15/12. The facility's failures to be administered effectively and efficiently placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/23/12 of the Immediate Jeopardy in 42 CFR 483.75 Administration (F490). The facility's failure to supervise residents at risk for elopement and to identify an exit door alarm which was not alarming properly placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/23/12 of the Immediate Jeopardy at 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance (AOC) was received on 08/27/12 which alleged the Immediate Jeopardy was removed on 08/25/12. However, the State Survey Agency determined the facility had not trained the agency nursing staff until 08/30/12, therefore Immediate Jeopardy was determined to be removed on 08/31/12 prior to exit. The scope and severity at 42 CFR 483.75 Administration (F490) was lowered to a "D" while the facility develops and implements a plan of correction to achieve substantial compliance with regulation, and while the facility's Quality Assurance program continues to monitor the effectiveness of staff education, effectiveness of resident assessments and care planning, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility's policy regarding Procedure for Code Alert Alarms (undated) revealed when the resident approaches an exit door, an alarm will sound and the door will lock. The procedure also revealed staff will check exits and the server computer to identify the resident and the exit door. Staff are to proceed to the identified exit, redirect the resident, if the resident is not seen, check the area and outside to assure the resident has not exited. Review of Code Alert activities report for 08/15/12 indicated Resident #1 near the following exits at the times listed: Evergreen Court 6:14:56 & 6:15:52 PM, the Dining Room Exit 6:21:03 & 6:21:37 PM, and Maple Boulevard Exit 6:33:06 & 6:33:17 PM. Resident #1's Code Alert did not indicate activity on the system again until 8:34:49 PM at the Main Street 1 Exit. Review of the facility's investigation, dated 08/15/12, revealed a check of the Maple Boulevard exit door by the Director of Clinical Services (DCS) on 08/15/12, prior to Resident #1's return, which indicated inconsistent alarming of the Maple Boulevard exit door. The facility's investigation included an interview with Resident #1, upon return to the facility, during which Resident #1 stated he/she left the facility out a back door. Further review of the facility's investigation revealed Resident #1 was wearing a Code Alert bracelet upon return to the facility and the Code Alert bracelet did cause the exit doors to alarm when checked by the Maintenance Supervisor. Review of the facility's investigation also revealed print-out logs of documentation for the date/time/location of exit doors/Code Alert bracelet number which indicated if a staff had exited an alarmed door, if a resident with a Code Alert bracelet had exited an alarmed door, or if a resident with a Code Alert bracelet had been 'near' an alarmed exit door. Review of the computer print-out logs revealed Resident #1 had been 'near' the Maple Boulevard exit door at 6:33:06 & 6:33:17 PM on 08/15/12. Review of the report revealed Resident #1's Code Alert was not logged again until 8:34:49 PM, when the resident was returned to the facility through the Main Street 1 Exit. Review of the Maintenance Supervisor's maintenance log sheets for July 2012 and August 2012 revealed all of the exit door alarms had been functional bi-monthly in July and on 08/10/12. Review of the door alarm company's representative's report on 08/16/12 revealed the exit door on Maple Boulevard did not shut completely and needed repair. Interview with the Maintenance Supervisor, on 08/20/12 at 3:50 PM, revealed he was called to the facility on [DATE] at approximately 8:30 PM he discovered the exit door on Maple Boulevard was alarming inconsistently. He stated he discovered the exit door on Maple Boulevard was not shutting properly and he thought this might have contributed to the inconsistent alarming of that door. The Maintenance Supervisor stated he was aware the Code Alert computer system could monitor and log an exit from all alarmed doors and could also monitor and log the presence of a resident with a Code Alert bracelet when that resident was 'near' an alarmed exit door. However, he stated this information was not being utilized to his knowledge. He stated 'near' meant within five (5) feet of an exit door. The Maintenance Supervisor stated there was no facility policy regarding how often to check the alarms on the exit doors. He stated it was his understanding the alarms on the doors would sound when a resident wearing a Code Alert bracelet attempted to exit one of the doors. Interview with LPN (Licensed Practical Nurse) #5, on 08/21/12 at 11:00 AM, revealed during the evening shift of 08/15/12 no alarms or indicators went off on the computer schematic diagram of the facility to indicate any alarming exit door. Further interview with LPN #5, on 08/23/12 at 4:00 PM, revealed she had not seen Resident #1 on Maple Boulevard on 08/15/12; however, the Code Alert log had placed the resident on the unoccupied wing at approximately 6:33 PM. Interview with LPN #6, on 08/21/12 at 3:15 PM, revealed she did not hear any exit door alarms the evening of 08/15/12. LPN #6 indicated it was her understanding the exit doors would alarm if a resident with a Code Alert bracelet got 'near' an exit door and it was also her understanding the Code Alert alarms on the exit doors would help the staff keep the residents safe. Interview with the Director of Nursing (DON), on 08/21/12 at 11:30 AM, revealed the nursing staff had no responsibility to check exit doors for alarming function or monitoring of the computer screen at the nurses station except when an alarm was sounding. The DON stated she thought Resident #1 eloped from the facility through an exit door which was not alarming properly although the purpose of the alarms on the exit doors was to assist staff in keeping the residents safe. The DON further stated she was aware the computer system for the Code Alert could monitor and log each of the alarmed exit doors for exit and the presence of a resident with a Code Alert bracelet when that resident was 'near' an alarmed exit door. She stated the logs of that information were not monitored or used for resident safety to her knowledge. Interview with the Administrator, on 08/22/12 at 3:45 PM, revealed there was no policy on how often the door alarm system should be checked and no policy regarding utilization of the Code Alert computer information. The Administrator stated she was aware the Code Alert computer system could monitor and log by date and time which facility doors were exited, if staff or a resident with a Code Alert bracelet (assigned by code to individual residents) exited an alarmed door, or if a resident with a Code Alert bracelet was 'near' an exit door. She stated the purpose of the Code Alert alarm system on the exit doors was to assist in keeping residents safe. She further stated the computer system logs had not been used previously to assist in keeping residents safe; however, it was ultimately her responsibility to ensure adequate assistance devices (door alarms or computer systems) were utilized to ensure the safety of the residents in the facility. Review of the acceptable AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. A facility wide search and resident census was taken by the charge nurse immediately to determine if Resident #1 was missing and all other residents were present. The Administrator, DON, police, physician and family of Resident #1 were all notified by telephone. 2. All exit doors were checked for functionality by the Maintenance Supervisor at approximately 8:40 PM on 08/15/12 with the exit door on Maple Boulevard alarming inconsistently. Administrative staff monitored the exit door on Maple Boulevard until 11:00 PM when the security guard came on duty. 3. After Resident #1's return to the facility at 8:34:49 PM by the local police, the resident was placed on one-to-one (1:1) supervision by the Social Services Director to ensure his/her safety until Resident #1's transfer out of the facility to the local veteran's hospital. 4. On 08/15/12, after Resident #1's elopement from the facility, LPN #6 checked all seven (7) residents (remaining in the facility) who had been assessed as being at risk for elopement with Code Alert bracelets to ensure the bracelets' placement and functionality. 5. On 08/15/12, the DON checked the Elopement at Risk binder at the nursing station to ensure all identifying information and a current photo was in the binder for the eight (8) residents (to include Resident #1) who had been assessed as being at risk for elopement. 6. The DON initiated the facility's investigation into Resident #1's elopement from the facility, on 08/15/12 at 9:00 PM, with interviews of the staff on duty. 7. The Administrator and the Director of Clinical Services (DCS) reviewed the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement on 08/15/12 at 10:00 PM and determined those assessments and documents were correct. The Administrator and the DCS also reviewed all residents' admission assessments, care plans, CNA care records, assignment sheets, elopement, fall and smoking at risk assessments beginning on 08/15/12 and completed on 08/16/12 with revisions as indicated. 8. A minimum of every two hours facility supervision rounds were continued by on duty staff to ensure resident safety. 9. On 08/20/12, all current staff were re-in-serviced on elopement risk/assessment, interventions and steps taken during an incident and missing residents which included a post test to ensure competency. The in-services was conducted by the Director of Nurses. 10. All interdisciplinary team members and licensed nurses were to be re-in-serviced on the facility's policy regarding Care Plans beginning on 08/23/12, by the Staff Development Nurse. All interdisciplinary team members and licensed nurses were to be re-in-serviced on that policy prior to beginning their next shift or giving care with the date of compliance of 08/25/12. Review of in-service training sheets and interview revealed all nurses were not trained by 08/25/12 with seven (7) agency nurses having worked 08/23/12 through 08/29/12 prior to re-in-service on the Care Plan policy. All nursing staff were re-in-serviced by 08/30/12 on the policy: Care Plan which changed the facility date of compliance to 08/30/12. 11. On 08/24/12 regulatory guidelines and facility policies were reviewed with the Administrator by the Vice President of Older Adults Communities to ensure resident care was provided in accordance with accurate comprehensive care plans and safety through supervision. On 08/24/12 the Administrator reviewed and re-signed her job description to assure ongoing knowledge and acceptance of duties and responsibilities. The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1. The State Survey Agency validated through record review and interview with the Administrator, on 08/20/12 at 3:15 PM, she was notified by LPN #5 at approximately 7:30 PM by telephone on 08/15/12 of the elopement of Resident #1 after a facility wide search and determination Resident #1 was missing from the facility and immediate grounds. Interview with the DON, on 08/20/12 at 4:15 PM, revealed she was notified by LPN #5 by telephone at approximately 7:35 PM on 08/15/12 of the elopement of Resident #1. Review of documents provided labeled, Exhibit #5 Evergreen nurse report sheet and Exhibit #7 Lakeview nurse report sheet, revealed a resident head count had been conducted by the charge nurses on each of those halls on 08/15/12 at 7:30 PM. 2. The State Survey Agency validated through record review and interview with the Director of Clinical Services, on 08/21/12 at 5:35 PM, she monitored the exit door on Maple Boulevard from 8:40 PM until 10:00 PM on 08/15/12. Interview with the DON, on 08/21/12 at 11:30 AM, revealed she monitored the Maple Boulevard exit door from 10:00 PM until 11:00 PM on 08/15/12. Interview with the security guard, on 08/23/12 at 6:00 AM, revealed he was assigned to monitor the Maple Boulevard exit door on 08/15/12 from 11:00 PM until 6:45 AM. Interview with Housekeeper #1, on 08/22/12 at 2:10 PM, revealed he was assigned to monitor the Maple Boulevard exit door on 08/16/12 at 6:45 AM until the Code Alert company representative arrived to check the exit doors Code Alert alarm system at approximately 12:00 Noon. 3. The State Survey Agency validated through record review and interview with the Social Services Director, on 08/20/12 at 4:30 PM, she did provide 1:1 supervision to Resident #1 from 8:35 PM on 08/15/12 until his/her discharge from the facility at 10:15 PM. Review of the nursing notes in the record, dated 08/15/12 at 8:30 PM, revealed Resident #1 was placed on 1:1 supervision upon return to the facility until discharge at 10:15 PM. 4. The State Survey Agency validated through record review and interview with LPN #6, on 08/22/12 at 1:50 PM, she checked the seven (7) remaining residents with Code Alert bracelets to ensure the bracelets' placement and functionality on 08/15/12 at approximately 9:00 PM. Review of a twenty-four (24) hour nursing document for 08/15/12 evening shift on 08/29/12 revealed LPN #6 documented the checking of the remaining seven (7) residents with Code Alert bracelets to ensure the Code Alert bracelets' placement and functionality. 5. The State Survey Agency validated through record review and interview with the DON, on 08/20/12 at 4:15 PM, she checked the elopement at risk binder at the nursing station, on 08/15/12 at approximately 8:45 PM, to ensure all identifying information and a current photo was in the binder for the eight (8) residents (to include Resident #1) who had been assessed at being at risk for elopement. Review of the facility's elopement binder on 08/29/12 revealed all residents' at risk for elopement identifying information was in the binder. 6. The State Survey Agency validated through record review and interview with the DON, on 08/20/12 at 4:15 PM, she started the facility investigation of the elopement at 9:00 PM on 08/15/12 with staff interviews (who were on duty at the time of Resident #1's elopement). Interview with CNA #4 on 08/31/12 at 10:10 AM (assigned to Resident #1 at the time of the resident's elopement) revealed she was interviewed regarding Resident #1's elopement from the facility. Review of the facility's investigation into Resident #1's elopement on 08/29/12 revealed staff interviews were done timely. 7. The State Survey Agency validated through record review and interview with the Administrator, on 08/20/12 at 3:15 PM, she had reviewed, on 08/15/12 at 10:00 PM, the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. She also indicated revisions were made to the other documents reviewed as necessary. Interview with the Director of Clinical Services (DCS), on 08/21/12 at 5:35 PM, revealed she had assisted the Administrator, on 08/15/12 at 10:00 PM, in reviewing the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement and determined those assessments and documents were correct. She further stated the other residents' documents were reviewed with the Administrator and revisions were made as necessary. Review of the elopement assessments and care plans of the eight (8) residents the facility had assessed as being at risk for elopement on 08/30/12 revealed signatures/dates of review and revision by the DCS and the Administrator. 8. The State Survey Agency validated through record review and interview with CNA #3, on 08/21/12 at 3:15 PM, she checked on her assigned residents at least every two (2) hours and it was her understanding this was the facility's practice. Interview with CNA #4, on 08/21/12 at 11:45 AM, revealed the facility's practice was to check on her assigned residents at a minimum of every two hours and she continued to do so after Resident #1's elopement from the facility on 08/15/12. Interview with the DON, on 08/20/12 at 4:15 PM, revealed it was the facility's practice to check on all residents at least every two (2) hours and that was also standard practice. The DON stated the nursing staff had access to up-to-date nursing standards of practice via the computers at the nursing station and a review of that standard of practice was done in nursing orientation. Review of a nursing orientation worksheet on 08/30/12 revealed every two (2) hour checking on residents was discussed in the orientation. 9. The State Survey Agency validated through record review and interview with the Staff Development nurse, on 08/30/12 at 9:15 AM, she had provided the in-services regarding elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure staff competency. Interview with CNA #4, on 08/21/12 at 11:45 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test on 08/16/12. Interview with CNA #3, on 08/21/12 at 3:15 PM, revealed he received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test on 08/15/12. Interview with LPN #1, on 08/21/12 at 11:00 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure competency on 08/17/12. Interview with LPN #5, on 08/21/12 at 11:00 AM, revealed she received the facility in-service on elopement risk/assessment, interventions and steps to be taken during an incident of a missing resident which included a post test to ensure competency on 08/15/12. All in-service training content and staff sign-in sheets were reviewed on 08/30/12 to ensure all nursing staff had been re-trained per the AOC. 10. The State Survey Agency validated through record review and interview with LPN #2, on 08/29/12 at 4:30 PM, she had not been re-in-serviced on the Care Plan policy prior to starting her shift and giving resident care at 2:30 PM. Interview with LPN #1, on 08/30/12 at 8:00 AM, revealed he had worked two (2) shifts prior to having a re-in-service on the policy, Care Plans which he received via telephone on 08/29/12. Interview with the DON, on 08/30/12 at 8:30 AM, revealed she placed an in-service binder at the nurses station for the agency nurses to read and sign for the re-in-service on the Care Plan policy. However, she stated that was a new procedure for the facility and the agency nurses were not told to read/sign the in-service prior to starting their shifts. The DON stated it was an oversight and the agency was notified on 08/27/12 to have the agency nurses read/sign the in-service binder which was two (2) days after the alleged date of compliance. Review of all in-service content and agency nurse re-training sign-in sheets were reviewed on 08/30/12 to ensure compliance with the AOC. 11. The State Survey Agency validated through record review and interview with the Administrator, on 08/29/12 at 4:00 PM, she did have a job performance review with the Vice President of Older Adults Communities on 08/24/12 and she did re-sign her job description indicating understanding of same. Interview with the Vice President of Older Adults Communities, on 08/30/12 at 5:00 PM, revealed the Administrator was re-educated on her job duties.