Every finding on record at Danville Centre for Health & Rehabilitation

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were allowed to return to the facility for 1 of 5 sampled residents (Resident (R)1). The findings include: Review of the facility's policy titled, Clinical Discharge and Transfer: Transfer/Discharge Notice, revised 02/03/2025, revealed the facility was committed to ensuring all transfers and discharges were conducted in a manner that respected the rights, dignity, and welfare of residents while complying with federal and state regulations. Continued review of the policy revealed it established procedures to ensure appropriate notice, documentation, and support for safe and orderly transitions. Per review of the facility policy, the facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. Further policy review revealed if the facility determined a resident, who was transferred with an expectation of returning to the facility, could not return to the facility, the facility must comply with the (federal regulatory) requirements of 483.15 (c) as they applied to discharges. Review of the facility's policy titled, Clinical Discharge and Transfer: Facility Bed-Hold, revised 02/03/2025, revealed if a resident with a bed-hold was transferred with the expectation of returning to the facility at the time of transfer, and ultimately could not return, the facility was to comply with any applicable discharge rules. Review of the Face sheet for R1 revealed the facility admitted the resident on 08/06/2021, with diagnoses of schizoaffective disorder, dementia, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/2026, revealed the facility assessed R1 as having a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of R1's Care Plan, dated 05/06/2026, revealed the facility identified a problem for the resident as at risk and/or active behaviors such as physically abusive and verbally abusive towards staff related to delusional beliefs that were difficult to redirect. Continued review of the Care Plan revealed the interventions included every 15 minute checks of R1, and to reapproach resident later when he became less agitated. Review of the Progress Note, dated 07/06/2026 at 2:51 PM, written by Licensed Practical Nurse (LPN) 1, revealed R1 had stated, I'm getting out of here one way or another. Continued review of the Progress Note revealed R1 had picked up a chair and started hitting the door and grabbed the wrists of Unit Manager (UM) 1. Further review revealed staff attempted redirection and R1 was given a soft drink and went to his room on the memory care unit. Review of the Progress Note, dated 07/06/2026 at 2:53 PM, written by the UM 1, revealed R1 had been banging on the door to get it open with a chair and when UM 1 came to assist with redirection, the resident grabbed her wrists and squeezed them and was not redirectable. Continued review of the Progress Note revealed staff offered R1 a soda and he went and sat down to watch television. Additionally review revealed, about 30 minutes later, UM 1 was called back to the unit and it was reported R1 had went back to his room to use the bathroom. Further review revealed staff reported hearing a loud noise and when they went to investigate it, they found R1 holding a wheelchair leg rest and a shattered window. ( Review of the Progress Note for R1, dated 07/06/2026 at 2:53 PM, written by Unit Manager (UM) 1, revealed the resident had been found in his room holding a wheelchair leg rest after taking it to the window causing it to shatter. Continued review of the Note revealed 9-1-1 was notified and the hospital was called to give report that R1 was being transferred to them. Per review of the Note, UM 1 had sent over the transfer policy and bed hold policy to the hospital via fax. Review of the Progress Note, dated 07/06/2026 at 3:25 PM, written by Licensed Practical Nurse (LPN) 2, revealed Emergency Medical Services had been at the facility and had transported R1 to the hospital. Review of the facility document titled, Witness Statement, dated 07/06/2026, written by the Administrator, revealed the Administrator spoke with the emergency room (ER) Physician regarding R1's behavior. Continued review of the facility document revealed the Administrator informed the Physician that R1 had displayed behaviors at the facility, which put other residents and staff in danger. Additionally, review revealed the Administrator told the ER Physician R1 had busted out a six-inch window from the memory care unit. However, per review of the witness statement, the ER Physician told the Administrator there was no medical or psychiatric reason for R1 to be admitted to the hospital. Review of the facility's untitled document, dated 07/10/2026, revealed the facility ethics committee held a meeting to discuss discharging R1 from the facility on 07/06/2026. Review of the hospital ER General Exam Note, dated 07/06/2026, written by the ER Physician, revealed the Physician consulted psychiatry services who evaluated R1. Per review of the Note, psychiatry services deemed there was no psychiatric benefit for hospital admission and R1 should return to the facility. Review of the Hospital Behavioral Health Services (BHS) Intake Assessment documentation, dated 07/06/2026 at 4:37 PM, written by the BHS intake nurse, revealed R1 had told her he got upset that his sitter did not show up and so he broke a window at the facility. Continued review of the Intake Assessment documentation revealed R1 had been alert and oriented times four (oriented to person, place, time, and situation). Per review, R1 had been logical with no hallucinations or delusions, and had good judgement. Additionally, review revealed R1 denied wanting to hurt himself or others. Further review of the Intake Assessment revealed R1 had not met criteria for (hospital) admission and was to be referred back to the facility. Review of the Hospital Progress Note, dated 07/06/2026 at 6:55 PM, written by Registered Nurse (RN) 3, revealed she had spoken with the facility's Administrator regarding R1's return to the facility. Review revealed however, RN 3 had been told R1 could not return to the facility. Review of the Hospital Progress Note, dated 07/06/2026 at 7:30 PM, written by RN 4, revealed R1 had been cleared and had no medical or psychiatric qualifiers for (hospital) admission. Continued review of the Progress Note revealed the Administrator of the facility denied abandoning R1. Further review of the Note revealed RN 4 noted however, the facility did not have a room for R1, as the broken window was to be fixed the next day. Review of the Hospital Progress Note, dated 07/07/2026 at 7:49 AM, written by RN 1, revealed facility staff told the hospital staff the window would be fixed by 12:00 PM that day. Review of the Hospital Progress Note, dated 07/07/2026 at 2:04 PM, written by the Hospital Case Manager (CM), revealed the facility community liaison came to the hospital and saw R1 and was told by hospital staff, and was told the resident would not be admitted to the hospital. Continued review of the Note revealed facility staff were told by the Hospital CM R1 could not stay at the hospital long term and had been discharged for about 22 hours with zero aggression noted and was directable. Review of the Hospital Progress Note, dated 07/07/2026 at 2:07 PM, written by the hospital ER Unit Facilitator, revealed the facility's administration was refusing to take R1 back at the facility. Further review of the Note revealed the facility's administration told the Facilitator R1 was unsafe to return to the facility. In interview with the Ombudsman on 07/16/2026 at 11:12 AM, she stated she had been called with a report saying the facility had dumped R1 and refused to take him back. The Ombudsman stated she talked to the facility's Administrator and told him he had to find a place for R1 to be sent, but she did not think the facility tried to find a safe place for R1. She stated the facility had not done a 30 day bed hold with notice of discharge and had not attempted to get a 202A involuntary hold order (process for involuntary hospitalization and evaluation) as per her recommendation. The Ombudsman stated she worried that that type of illegal discharge would occur again if something was not done. She stated she thought when the facility transferred R1 on 07/06/2026, they had no plan to take R1 back as a resident in the facility. In interview with the State Guardian of R1 on 07/16/2026 at 11:32 AM, she stated the facility sent R1 to the hospital; however, she never could get a clear issue of why the sent the resident to the hospital from the facility. She stated she was not aware of any combative behavior regarding R1. The State Guardian stated the hospital staff called her and reported R1 had a psychiatric evaluation and a full medical evaluation. She stated the hospital staff told her there was no reason for R1 to be admitted to the hospital, but the facility refused to take the resident back. The State Guardian stated she called and spoke with the facility's Administrator and told him the facility could not discharge R1 to a hospital setting and he (R1) had to be returned to the facility, but the facility refused to take the resident back. In interview with the ER Physician on 07/17/2026 at 11:25 AM, he stated R1 had a full medical evaluation which had been clear and the resident had also been seen by a Psychiatric Intake Nurse and did not meet criteria for admission to the hospital. He stated R1 was well known to them and he may be a pain in the butt; however, the resident was a ward of the state and the facility basically made him homeless. In interview with the Director of Nursing (DON) on 07/17/2026 at 2:23 PM, she stated she had been out of the facility getting lunch on 07/06/2026 and got a call telling her R1 had busted a window in the facility. She stated upon her return to the facility from lunch she had been told R1 was being sent to the hospital. The DON stated R1 had not been safe to return to the facility. In interview with the Administrator on 07/17/2026 at 2:38 PM, he stated when R1 had been sent to the hospital (on 07/06/2026), his thought process was R1 would be admitted to the hospital. He stated he could not understand why R1 had not met hospitalization admission criteria. The Administrator stated he never agreed to take R1 back regardless of the window having been broken. However, the Administrator kept repeating R1 had been a transfer, not a discharge. He stated the Ombudsman told him the facility could not dump a resident, but he felt he had to protect the other residents and staff at the facility.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for 1 of 6 sampled residents, Resident (R) 1. The facility failed to administer R1's scheduled monthly invega sustenna injection (an antipsychotic medication used to treat schizophrenia) on 04/19/2026. Additionally, the facility failed to notify the resident's physician or guardian at the time of the missed medication. R1 had increased behaviors in April and May 2026, which resulted in multiple transfers to the local hospital, and an admission to the state psychiatric facility from 05/08/2026 until 05/21/2026. R1 was last admitted to the local hospital's behavioral unit related to psychotic behaviors and psychosis on 05/31/2026 and remained in the hospital during the Survey.The findings include:Review of the facility's policy titled, Notification of Change of Condition, reviewed 01/31/2026, revealed the facility must inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. Further review revealed documentation of notification or notification attempts should be recorded in the resident's electronic medical record (EMR). Continued review revealed the resident and/or representative and medical provider should be notified of a change in condition and the medical provider would provide guidance related to the change in condition. Review of the facility's policy titled, Medication Administration, dated 07/2018, revealed medications were administered as prescribed in accordance with the manufacturers' specifications and good nursing principles and practices. Further review revealed medications were to be administered within 60 minutes of the scheduled time.Review of R1's Face Sheet, located in the electronic medical record (EMR), revealed the facility admitted the resident on 08/06/2021 with diagnoses which included schizoaffective disorder, dementia with behavioral disturbance, and cognitive communication disorder. Review of R1's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status of five out of 15 indicating severe cognitive impairment.Review of R1's Physician's Orders, dated 04/2026, revealed orders for invega sustenna 234 milligrams (mg) (the maximum dosage) once monthly. This medication was initiated 09/19/2025.Review of the website:www.mentalhealthdaily.com, revealed quitting invega cold turkey might leave the person's neurotransmission and nervous system in a state of chaotic disarray. Additional review revealed possible withdrawal symptoms included agitation, anger, anxiety, confusion, hallucinations, hot flashes, irritability, memory problems, mood swings, and sweating. Review of R1's Comprehensive Care Plan Communication, dated 05/05/2025, revealed a focus area that R1 was under state appointed guardianship and required notification to the guardian for decision-making. Further review revealed a goal to maintain effective communication with the state guardian for guardianship notification to promote the resident's well-being. Continued review revealed approaches which included to notify the resident's medical guardian with change in condition.Review of R1's Medication Administration Record (MAR), dated April 2026, revealed the facility scheduled R1's monthly dose of invega sustenna for 04/19/2026. Licensed Practical Nurse (LPN) 2 charted the medication was unavailable on that date. Further review of the MAR revealed there was no documented evidence the invega sustenna medication was administered during the month of April 2026.Review of the facility's investigation, undated, revealed the facility determined Licensed Practical Nurse (LPN) 2 did not administer R1's scheduled invega on 04/19/2026. Additional review revealed the facility did not administer R1's invega until 05/06/2026.Additional review of R1's Electronic Medical Record (EMR), revealed there was no documented evidence the facility notified the resident's guardian or physician that the invega sustenna medication was not administered as ordered.Review of R1's Progress Notes, dated 04/20/2026 at 1:55 PM, revealed LPN3 documented R1 refused his oral medications. Continued review revealed on 04/21/2026 at 12:46 AM, Registered Nurse (RN)3 documented R1 refused his bedtime medications. However, there was no documented evidence the physician or guardian was notified at the time, of the missed medication administrations. Review of R1's Progress Notes, dated 05/03/2026 at 12:13 AM, revealed LPN2 documented R1 had increased anxiety and agitation. However, there was no documented evidence LPN2 notified the physician or guardian.Review of R1's Progress Notes, dated 05/05/2026 at 7:06 PM, revealed the facility transferred the resident to the hospital as the resident was attempting to leave the unit and became physically aggressive with staff. Further review of R1's Progress Notes, dated 05/05/2026 at 11:18 PM, revealed R1 returned to the facility and was placed on 15-minute checks.Review of R1's Progress Notes, dated 05/06/2026 at 5:28 PM, written by Psychiatric Advanced Practice Registered Nurse (APRN) 2, revealed following medication review, it was noted R1 did not receive his invega injection for 04/19/2026 and suspect likely reason of behavioral change. Review of R1's May 2026 MAR, revealed the facility administered invega sustenna 234 mg to R1 on 05/06/2026, 17 days after it should have been administered.Review of R1's Progress Notes, dated 05/08/2026 at 7:58 AM, revealed the resident was verbally aggressive to staff, the Physician was notified. Orders were received to send R1 to the emergency room (ER).Review of R1's Progress Notes, dated 05/11/2026 at 8:45 AM, written by the Social Services Director (SSD), revealed R1 had been transferred to a state psychiatric facility related to behavioral health needs. Review of R1's Progress Notes, dated 05/21/2026 at 9:12 PM, revealed R1 returned to the facility at 9:00 PM.Review of R1's Progress Notes, dated 05/31/2026 at 10:19 AM, revealed R1 pushed a staff member through the secure unit exit and exited the unit into the lobby. The facility called 911 for assistance related to R1's behavior escalation and law enforcement arrived to talk with R1. R1 was transported to the hospital by Emergency Medical Service (EMS) for further evaluation.Review of R1's Progress Notes, dated 05/31/2026 at 12:41 PM, revealed R1 had been admitted to the local hospital's behavioral unit related to psychotic behaviors and psychosis.In an interview, on 06/01/2026 at 4:24 PM, R1's State Guardian (SG) stated she had been his guardian for approximately a year and a half. The SG stated the facility provided psychiatric services and started R1 on invega injections. The SG stated she did not receive a phone call when the facility did not administer R1's invega in April, nor did the facility notify her of any increased behaviors. In continued interview, on 06/01/2026 at 4:24 PM, R1's SG stated the first time she was made aware of any increased behavior was when the local hospital called asking her for permission to transfer R1 to a state psychiatric facility. She stated the state psychiatric facility asked the facility when the last dose was received and it was determined R1 did not receive the medication in April. The SG stated it was her understanding that missing the invega was likely the reason for R1's increased behaviors. Messages were left for LPN2, on 06/02/2026 at 8:04 AM and 06/03/2026 at 8:20 AM. However, no return calls were received from LPN2. During an interview, on 06/02/2026 at 2:51 PM, Unit Manager (UM) 1 stated she was unsure if anyone had notified the Physician that R1's invega sustenna was not administered on 04/19/2026. UM1 stated she would not typically notify the physician if medication was unavailable if the medication could be given within 24 hours.During an interview, on 06/02/2026 at 3:04 PM, the Director of Nursing (DON) stated R1 began having increased behaviors and was transferred to the local hospital on [DATE] for evaluation. She stated R1 was later transferred to a state psychiatric facility. The DON stated LPN2 had not documented notification to the physician or guardian at the time of the missed invega sustenna medication.During an interview, on 06/03/2026 at 11:13 AM, APRN 1 stated R1 exhibited increased behaviors and aggression after missing his April Invega Sustenna injection. Additionally, APRN 1 stated it was her expectation the facility notify her of any missed medication. She stated she could not make any decisions regarding appropriate medication orders if she was unaware the medication was not administered.During an interview, on 06/03/2026 at 3:28 PM, the Medical Director stated he was not notified when R1 did not receive the invega sustenna medication. He further stated he was available 24 hours a day for calls, and it was his expectation the facility notify him or the APRN of any missed medications.During an interview, on 06/03/2026 at 8:05 AM, the Administrator stated he expected staff to follow all facility policies and procedures including notification of physicians and guardians.

Based on interview and record review, the facility failed to provide routine drugs to its residents as ordered or obtain them for one (1) of six (6) sampled residents, Resident (R) 1. The facility failed to administer R1's scheduled monthly invega sustenna injection (an antipsychotic medication used to treat schizophrenia) on 04/19/2026 and did not promptly notify the pharmacy that the medication was unavailable. R1 did not receive his scheduled invega sustenna injection until 05/06/2026, 17 days later, resulting in increased behaviors in April and May 2026. R1 was admitted to the state psychiatric facility from 05/08/2026 until 05/21/2026. Additionally, on 05/31/2026, R1 was admitted to the local hospital's behavioral unit related to psychotic behaviors and psychosis and remained there during the Survey.The findings include: Review of the facility's policy titled, Medication Administration, dated 07/2018, revealed medications were administered as prescribed in accordance with the manufacturers' specifications and good nursing principles and practices. Further review revealed medications were to be administered within 60 minutes of the scheduled time. Review of the facility's policy titled, Ordering and Receiving Non-Controlled Medications, dated 01/2025, revealed all medication order changes must be communicated to the pharmacy timely, in order to provide the correct quantities and accurate labeling. Further review revealed a licensed nurse or appropriate personnel as required by law should promptly report any discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. Review of R1's Face Sheet, located in the electronic medical record (EMR), revealed the facility admitted R1 on 08/06/2021. R1's diagnoses included schizoaffective disorder, dementia with behavioral disturbance, and cognitive communication disorder. Review of R1's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 5 out of 15. This score indicated severe cognitive impairment. Review of R1's Comprehensive Care Plan, dated 01/30/2024, revealed a focus of at risk and/or active behavioral problems which included hallucinations, paranoia, and delusional behaviors at times. The goal stated the resident would have fewer episodes during the review period. Interventions included administering and monitoring the effectiveness and side effects of medications as ordered and intervening as needed to protect the rights and safety of others. Review of R1's Physician's Orders, dated 04/2026, revealed the physician ordered invega sustenna 234 milligrams (mg) (the maximum dosage) once monthly. This medication was first ordered 09/19/2025. Review of the website: www.mentalhealthdaily.com revealed quitting Invega cold turkey might leave the person's neurotransmission and nervous system in a state of chaotic disarray. Further review revealed possible withdrawal symptoms included agitation, anger, anxiety, confusion, hallucinations, hot flashes, irritability, memory problems, mood swings, and sweating. Review of R1's March 2026 Medication Administration Record (MAR), revealed the facility administered R1's monthly invega sustenna 234 mg dose on 03/19/2026. Review of R1's April 2026 MAR, revealed the facility scheduled R1 to receive his monthly dose of invega sustenna on 04/19/2026. However, Licensed Practical Nurse (LPN)2 documented on the MAR, that the medication was unavailable. Additional review of the MAR revealed there was no documented evidence the facility administered R1's invega sustenna during the month of April 2026. Review of R1's Progress Notes, dated 04/29/2026 at 4:14 PM, revealed the facility documented R1 had a reddened face, complained of being hot, and was noted to have delusions during the shift. Review of R1's Progress Notes, dated 05/03/2026 at 12:13 AM, revealed LPN2 documented R1 had increased anxiety and agitation. Review of R1's Progress Notes, dated 05/05/2026 at 7:02 PM, revealed the Director of Nursing (DON) documented R1 was transferred to the local hospital. Further review of R1's Progress Notes, dated 05/05/2026 at 7:06 PM, revealed the DON documented R1 was attempting to leave the unit and became physically aggressive with staff. Further review revealed Advanced Practice Registered Nurse (APRN) 1 was notified with orders to send R1 to the local hospital via Emergency Medical Services (EMS) for evaluation. Review of R1's Progress Notes, dated 05/05/2026 at 11:18 PM, revealed Registered Nurse (RN)3 documented R1 had returned from the hospital. The facility placed R1 on every 15-minute checks. Review of R1's Progress Notes, dated 05/06/2026 at 5:28 PM, revealed Psychiatric APRN 2 documented that after a med review, it was noted R1 had not received his invega injection for 04/19/2026 and suspect likely reason of behavioral change. Review of R1's May 2026 MAR, revealed the facility administered the invega sustenna 234 mg to R1 on 05/06/2026. Further review revealed this was 17 days after it should have been administered. However, review of the invega sustenna package insert revealed if a maintenance dose of 234 mg was missed more than six (6) weeks, the injection should be restarted by giving an injection of 156 mg as soon as possible, followed by another 156 mg injection one week later. Continued review revealed there was no documented evidence the facility administered this dosage although it was 6 weeks and 6 days between R1's injections. Review of R1's Progress Notes, dated 05/08/2026 at 7:58 AM, revealed Unit Manager (UM) 1 documented R1 was verbally aggressive to staff. Further review revealed the physician was notified with an order to send R1 to the emergency room (ER). Review of R1's Progress Notes, dated 05/11/2026 at 8:45 AM, revealed the Social Services Director (SSD) documented R1 had been transferred to a state psychiatric facility related to behavioral health needs. Review of R1's Progress Notes, dated 05/21/2026 at 9:12 PM, revealed RN4 documented R1 had returned to the facility at 9:00 PM. Review of the state psychiatric hospital's Discharge Summary, dated 05/21/2026, revealed the hospital admitted R1 on 05/08/2026 and discharged him on 05/21/2026 with diagnoses which included major neurocognitive disorder and schizoaffective disorder by history. Further review revealed an order for invega sustenna 234 mg every 28 days, beginning on 06/04/2026, for psychosis. Continued review revealed R1 was admitted to the psychiatric facility on a 72-hour court order from the local hospital for increasingly violent behavior and threatening to kill and assaulting staff members at the local facility. Additionally, the local facility staff stated they had missed R1's 04/19/2026 Invega injection, caught it and gave it on 05/06/2026, but at that time he was already having symptom burden return (meaning the Invega needed to be received monthly for maximum symptom relief, and, since the medication was not given in over a month, R1's symptoms were beginning to return). Review of R1's Progress Notes, dated 05/31/2026 at 10:19 AM, revealed LPN4 documented R1 pushed a staff member through the secure unit exit and exited the unit into the lobby. Further review revealed the facility called 911 for assistance related to R1's behavior escalation and law enforcement arrived to talk with R1. Continued review revealed R1 was transported to the hospital by EMS for further evaluation. Review of R1's Progress Notes, dated 05/31/2026 at 12:41 PM, revealed LPN4 documented R1 had been admitted to the local hospital's behavioral unit related to psychotic behaviors and psychosis. Review of the facility's investigation, undated, revealed the facility determined Licensed Practical Nurse (LPN) 2 did not administer R1's scheduled invega medication on 04/19/2026, and corrective action was given regarding failure to follow policy. During an interview, on 06/01/2026 at 11:17 AM, the Assistant Director of Nursing (ADON) stated the facility's pharmacy delivered medications twice a day, and the pharmacy could deliver the medication within four (4) hours if they were needed between the twice daily deliveries. During an interview, on 06/01/2026 at 4:24 PM, R1's State Guardian (SG) stated she had been his guardian for approximately a year and a half. She further stated R1 started to have increased exit seeking behavior around Thanksgiving (November 2025) and thought the Federal Bureau of Investigation (FBI) was coming to get him. She stated the facility provided psychiatric services and had started R1 on invega injections. The SG stated it was her understanding that missing the invega was likely the reason for R1's increased behaviors. During an interview, on 06/02/2026 at 10:32 AM, Registered Nurse (RN)2 stated she typically worked on R1's unit. She further sated he had schizophrenia with delusional thinking, often geared toward women and things he heard on the television. RN 2 stated she had never seen R1 become aggressive and grab staff until May 2026. She stated R1 had started to refuse medications which was not typical for him. During an interview, on 06/02/2026 at 2:51 PM, Unit Manager (UM) 1 stated R1 was not aggressive or did not attempt to elope until recently. She stated she thought the nurse (LPN2) tried to reorder R1's invega sustenna because it wasn't there, but it was not communicated to the team, that it needed to be reordered. Messages were left for LPN2, on 06/02/2026 at 8:04 AM and 06/03/2026 at 8:20 AM, to return the call to the State Survey Agency (SSA) Surveyor. Additionally, the SSA Surveyor asked the facility to reach out to LPN2. The Director of Nursing (DON) stated on 06/03/2026, she had talked with LPN2 and asked her to speak with the SSA. However, no return calls were received from LPN2. During an interview, on 06/02/2026 at 3:04 PM, the DON stated R1's April invega was marked unavailable on his MAR because pharmacy had not sent the medication, and it was not on the medication cart. She further stated R1 began having increased behaviors and was sent to the local hospital on [DATE] for evaluation. The DON explained R1 was later transferred to a state psychiatric facility who requested the date of R1's last invega injection. She stated the facility then began an investigation and found out the invega was not given in April. The DON stated she called LPN2 in and the nurse received disciplinary action. She stated staff should notify the pharmacy if a medication was unavailable to determine when it would be delivered. During an interview, on 06/03/2026 at 9:12 AM, Pharmacist1 stated the pharmacy had filled R1's invega sustenna on 04/07/2026, 05/04/2026, and 05/21/2026. He further stated the facility was supposed to reorder the medication as soon as it was administered in order for the facility to have the medication available when the next dose was due. Pharmacist1 stated he did not recall speaking with the facility regarding R1 not having the invega sustenna available. He stated the 04/07/2026 medication dose was refilled at 11 AM and shipped midday on 04/08/2026 to the facility. He stated he did not have a digital copy scanned into his system for the April invega sustenna medication to show it was delivered, although he did for the March and May medications. During an interview, on 06/03/2026 at 10:30 AM, the DON stated she had found an undated slip (believed by the facility to be 04/07/2026) of medications that were ordered, but never received from the pharmacy, including R1's invega sustenna. She stated the staff should have called the pharmacy when they realized the medication was unavailable to ensure it sent on the next shipment. During an interview, on 06/03/2026 at 11:13 AM, Advanced Practice Registered Nurse (APRN) 1 stated she was typically in the facility three (3) times per week. She further stated R1 typically had vocal behaviors but had increased behaviors and aggression since missing his April invega injection. Additionally, she stated best practice was to keep medications consistent, as missing medications could cause side effects and increased behaviors. She stated the facility's failure to administer R1's invega sustenna in April was likely a contributing factor for his increased behaviors. During an interview, on 06/03/2026 at 11:38 AM, the Pharmacy Director stated the pharmacy did not have a hard copy signed by the facility to show R1's April invega was delivered to the facility. He further stated there were no notes to indicate the facility contacted the pharmacy to notify them R1's invega was not available in April 2026. Additionally, he called the SSA Surveyor on 06/03/2026 at 1:24 PM, to state he had listened to the calls on 04/19/2026, and the facility did not call to notify the pharmacy that the invega sustenna was not available. During an interview, on 06/03/2026 at 8:05 AM, the Administrator stated medications should automatically be refilled monthly. The Administrator stated medications should arrive within a three (3) day window of the medication due date.

The facility failed to ensure staff followed infection prevention and control practices during wound care for 2 of 3 residents (Resident 8 and Resident 6) of 22 sampled residents reviewed for wound care. Based on observation, interview, record review, and review of facility policy, the facility failed to implement its infection prevention and control program by not ensuring licensed nurses performed required hand hygiene and glove changes during wound care. This deficient practice placed 2 of 21 sampled residents (Residents R6 and R8) at risk for cross-contamination, wound deterioration, and increased infection.The findings include:Review of the facility's Hand Hygiene Policy, dated 06/27/2025, revealed that staff were to perform hand hygiene before and after resident contact, before performing aseptic tasks, after removing gloves, and whenever hands were visibly soiled. The policy further revealed that proper hand hygiene was required to minimize transmission of infectious agents and reduce healthcare-associated infections.Review of the facility's Skin Integrity Policy, dated 06/09/2022 and last revised 01/31/2025, revealed that a resident with impaired skin integrity must receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent avoidable skin integrity issues from developing.1. Review of R8's admission Face Sheet revealed the facility admitted the resident on 03/13/2025, with diagnoses that included: Respiratory failure, muscle wasting and atrophy, anoxic brain damage, anxiety disorder, and complications of colostomy.Review of R8's Treatment Administration Record (08/01/2025 - 08/21/2025) directed staff to cleanse the left ischium wound with wound cleanser, pat dry, apply Santyl to the wound bed, and cover with brown foam dressing. Orders required wound care every shift,On 08/20/2025 at 11:10 AM, Licensed Practical Nurse (LPN) 4 was observed providing wound treatment to Resident R8. LPN 4 removed the resident's soiled dressing and failed to change gloves or wash hands before cleansing the wound.During the interview on 08/20/2025 at 2:40 PM, LPN 4 stated, I know better, but I was nervous that someone was watching me. I should have changed my gloves and washed my hands to prevent infections.2. Review of R6's admission Face Sheet revealed the facility admitted the resident on 03/07/2025, with diagnoses that included: Essential hypertension, osteoporosis, muscle weakness, unspecified protein-calorie malnutrition, muscle wasting and atrophy, and terminal/end-of-life skin failure.Review of R6's Treatment Administration Record dated 08/01/2025 - 08/21/2025 directed staff to cleanse the left buttock wound every shift, pat dry, apply calcium alginate with silver to the wound bed, apply triad cream to peri-wound, and cover with an appropriate dressing secured with an ABD pad. Orders required this wound care every shift.During observation on 08/20/2025 at 2:40 PM, LPN 3 removed R6's soiled dressing and failed to change gloves or wash hands before cleaning the buttock wound.During the interview on 08/20/2025 at 2:40 PM, Licensed Practical Nurse (LPN) 3 stated, I should have disposed of my dirty gloves and cleaned my hands before cleaning R6's wound to prevent germs from the old dressing spreading to her open wound. During an interview on 08/21/2025 at 12:31 PM with the Staff Development Coordinator, she stated the facility provided a skills fair in 06/2025, and all staff attended it. She confirmed the fair covered wound care and handwashing; however, the facility has failed to perform handwashing audits since the skills fair. She further explained that staff are expected to wash their hands and change gloves to prevent contamination and the spread of germs.During an interview with the Director of Nursing on 08/21/2025 at 11:20 AM, she stated that staff are expected to wash their hands and change gloves according to facility policy to prevent the spread of infection.During an interview with the Administrator on 08/21/2025 at 1:48 PM, he stated he expected staff to follow facility policy to prevent the spread of infection.

Based on observation, interviews, and a review of facility policies, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The findings include: Review of the facility's policy titled Resident Rights, last revision 01/31/2025, revealed all residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Review of the facility's policy titled Safe Environment, last revision 06/17/2025, revealed the facility will ensure in-house maintenance, housekeeping, and laundry services are provided daily to maintain a safe, comfortable, and clean environment for its residents, stakeholders, and visitors. Observations on 08/19/2025 at 12:50 PM in resident common areas revealed peeling paint on the walls, peeling paint on the ceiling, rust on ceiling vents, the door to the Reflections Unit severely scuffed and scratched, baseboards throughout the facility scuffed and scratched, handrails throughout the facility scuffed and chipped, and paint bubbling and chipping on walls. Observations on 08/19/2025 at 2:20 PM revealed all resident rooms in the Reflections Unit had scuffed walls and dressers.Observations on 08/21/2025 at 10:55 AM revealed a mold-like substance in mini-split units (heating and cooling systems that consist of an outdoor unit and one or more indoor air handlers connected by a narrow conduit containing power and refrigerant lines) on the Reflections Unit.Observations on 08/21/2025 at 1:48 PM in Resident (R) 29's room revealed rust on the doorframe to the room and to the bathroom, unpainted plaster on the walls, and scuff marks on the doors, walls, and dresser.Observations, on 08/21/2025 at 2:00 PM, in R51's room revealed chipped paint and rust on the doorframe and walls.In an interview on 08/21/2025 at 1:48 PM, Resident (R) 29 stated his room and the facility did not feel homelike to him, and there were a lot of environmental concerns that needed to be addressed. R29 stated that the facility staff had placed a sheet around the toilet in his room to absorb water that was leaking from the pipes and seeping through the tiled floor, adding that staff would clean up the water but had not attempted to fix the issue. R29 continued to state that he had been in the facility for over 5 years, in the same room, and the scuffs and rust on the doors and door frames had been there the entire time. In an interview on 08/21/2025 at 2:00 PM, R51 stated that the maintenance department had never addressed the chipped paint or scratches on the door and door frame while he has been a resident of the facility. In an interview on 08/21/2025 at 3:10 PM, Family Member (FM) 4 stated the air conditioning unit in her family member's room leaks water all the time, and when she came to visit on 08/19/2025, there were several soaking wet towels on the resident's floor to dry the leaking water from the floor. FM4 continued to state that the air conditioner's leaking has been an issue for six to eight months. In an interview on 08/21/2025 at 8:30 AM, the Environmental Services Manager stated staff would overlook certain things and address more important issues in the facility, and that it was easy to see things like missing and chipped paint and scuffs on doors and handrails and overlook them. In an interview on 08/21/2025 at 9:55 AM, the Maintenance Director stated he did not have an effective system to keep the walls in the facility painted. The Maintenance Director continued to state that paint hanging from a common area ceiling had been there for maybe two weeks, and it was not a priority for him to fix. The Maintenance Director stated that the facility had so many direct care concerns arising that he did not have time to address things like paint or scuffed areas in the facility. In an interview on 08/21/2025 at 10:10 AM, Licensed Practical Nurse (LPN) 6 stated if the facility were her home, she would not be happy with the physical environment. She stated that she would not be happy with rust on door frames or vents, chipped and missing paint, or black paint smeared on white walls. LPN 6 continued to state that she has tunnel vision and has not noticed any of these concerns until she walked through the facility, with the State Surveyor and now realized it is an issue. Additionally, LPN 6 stated she believed more environmental areas could have been addressed if the facility had more maintenance staff. In an interview on 08/21/2025 at 11:21 AM, the Director of Nursing (DON) stated it was important the mini split units were inspected for cleanliness, but she was not aware of any staff being assigned to check them. After observing the mold-like substance in the mini split units on the Reflections Unit, the DON stated that it was concerning to her for the safety of residents. In an interview on 08/21/2025 at 1:19 PM, the Administrator stated he had to prioritize tasks based on importance, and things like chipped paint and scuffed baseboards would have to wait to be addressed. In continued interview, the Administrator stated that he had additional help in the facility during the survey process, and it made it easier to attend to the areas that would normally have to wait. The Administrator stated that it was his expectation for residents to feel like they were at home in the facility, and the facility staff would maintain their homelike environment.

Based on observation, interview, record review, and facility document and policy review, it was determined the facility failed to provide adequate monitoring and supervision to prevent elopements for one (Resident (R) 2) of four sampled residents reviewed for elopement risk out of a total sample of 14 residents. On [DATE], R2 exited the facility without staff knowledge during a time period in which the facility's wander guard system (door alarm system used to alert staff of a resident's attempts to leave the facility) was not functioning. The facility's failure to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopements caused or is likely to cause serious injury, harm, impairment, or death to a resident. The findings include: Review of the facility's policy, Safety and Supervision of Residents, dated [DATE], revised [DATE], and in effect at the time of the [DATE] elopement, revealed the facility was to ensure the safety and well-being of the residents and that the environment was as free from accident hazards as possible, which was a facility-wide priority. The policy review revealed that resident safety risks and environmental hazards would be identified through employee training, monitoring, and reporting processes. In addition, the policy stated that safety risks and environmental hazards would also be identified continuously through the Quality Assurance (QA) reviews of safety and incident/accident data and a facility-wide commitment to safety at all levels of the organization. Continued review of the policy revealed individualized, resident-appropriate care was a core component of the facility's systems approach to safety, and each resident's assessed individualized needs determined the type and frequency of resident supervision. The Interdisciplinary Care Team analyzed information from assessments and observations to identify specific risks for individual residents and target interventions to reduce related environmental hazards, including adequate supervision. Further, individualized, resident-centered approach to safety included implementing interventions to reduce accident risks and hazards that included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring interventions were implemented, and documenting and monitoring the effectiveness of the interventions. A review of the facility's policy, Elopement, dated [DATE], revised [DATE], and in effect at the time of the [DATE] elopement, revealed the policy intended to ensure resident safety and protect their rights and dignity. The policy defined Elopement as any situation where a resident leaves the premises or a safe area without the facility's knowledge and supervision. Per the policy, residents would be evaluated for elopement risk upon admission, displaying exit-seeking behaviors, and preventative interventions implemented for those identified as an elopement risk and reevaluated as needed. In addition, the facility would ensure an elopement risk binder was kept at a secure location known to stakeholders and routine checks of entrance and exit doors were completed to ensure proper functioning. Review of the facility's Elopement Binder, last updated [DATE], revealed 22 current residents were at risk for elopement. Closed record review of a Resident Face Sheet revealed the facility admitted R2 on [DATE] and the resident expired on [DATE]. R2's diagnoses included vascular dementia with behavioral, psychotic, and mood disturbances, depression, anxiety disorder, loss of cognitive functions and awareness, difficulty in walking, abnormalities of gait and mobility with repeated falls, lack of coordination, muscle wasting and atrophy (gradual decline in effectiveness). Review of R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed R2 with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated severe cognitive impairment. Further review of the MDS Assessment revealed the R2 displayed wandering behaviors, required staff supervision with transfers and supervision to include contact-guard/touch assistance with mobility for the resident to walk 50 feet or greater, and was not steady with balance and during transitions. Review of R2's Elopement Risk Evaluation, dated [DATE], revealed that the facility assessed the resident to be at risk for elopement based on her cognitive impairment of poor safety awareness, self-ambulation ability, history of exit-seeking behavior, and ability to exit the facility. An Exit-Seeking/Elopement Observation, dated [DATE], also revealed the facility assessed the resident to be at risk for elopement based on ambulatory status, history of wandering into unsafe areas, statements that she was leaving or questioning the need to stay, displaying behaviors that indicate an attempt to leave the facility, and body language indicating an elopement may be forthcoming. A review of R2's Order Summary dated [DATE] revealed a written physician order for a wander guard (security bracelet) to the left ankle, check placement, and function daily. Review of current physician orders for ,d+[DATE] revealed that the order for a wander guard was still in effect. Review of an undated Elopement Investigation revealed that on [DATE], at approximately 2:59 PM, the Plant Director had the receptionist announce over the speakers to ignore the fire alarm, it is a test. Per the investigation report, the sprinkler company was in the facility for yearly testing, resulting in the door alarm system being silenced/shut down. R2, who resided in the locked unit, was last seen by Kentucky Medication Aide (KMA) 1 at approximately 3:00 PM. The facility was unaware that the resident had eloped until a person driving by the facility saw R2 trip and fall along the grassy area in front of the parking lot, called 911 at 3:33 PM, and got out of their vehicle to check on the resident, and a family member of another resident (FM1) alerted staff of the resident in front of the facility. Continued review of the investigation report revealed the Director of Nursing (DON) assessed R2 and assisted her back into the facility for transfer to the emergency room (ER) for evaluation. R2 returned from the hospital with no injuries noted and was immediately placed on additional supervision/monitoring. The investigation found that R2 exited the facility during the sprinkler system's annual inspection when the fire monitoring system was interrupted, which unlocked the exit doors on the gated community (locked unit). Staff did not realize the exit doors would not alarm/were silenced, and a resident could exit the facility. Per the investigation, R2 exited the locked unit and traveled approximately 120 feet from the exit door toward the main road when she tripped and fell in the grassy area. Observation on [DATE] at 11:05 AM revealed the main road near where the resident was found was a traffic congested, two-lane highway. During an interview on [DATE] at 9:30 AM, FM1 stated that on the day of the event, the temperature was warm outside as she had been visiting with her mother. FM1 noted that upon leaving the facility's front entrance, she looked down the hill on the main highway. FM1 recalled two vehicles stopped in the middle of the road, checking on a little lady sitting in the ditch right next to the highway. At that time, FM1 stated she knew a resident from the facility had got out without anybody knowing. Therefore, she returned to the facility and made them aware that someone had escaped, and the staff ran out the door and down the hill toward the resident. In an interview with the Plant Operations Director (POD) on [DATE] at 10:49 AM, he stated that once he and the other staff realized R2 had exited the door on the locked unit, they knew immediately that no one had been monitoring or watching that door while the door alarm system was not working. The POD stated prior to the elopement in 2023, the facility did not have a procedure in place that included monitoring responsibilities, manned stations at all exit-doors, and leadership involvement/notification to ensure resident supervision and safety when the door alarms were not functioning. He added that, at present, before any procedure is to be initiated that would affect the alarm system, all exit doors must be manned (monitored), the DON and Administrator must be notified, and a system was in place to ensure all units were covered, doors were checked/monitored, and each unit had adequate staff coverage for resident supervision and safety. In an interview with KMA7 on [DATE] at 10:29 AM, she stated she worked on the locked-down unit the day R2 eloped from the facility. KMA7 stated that R2 was mobile and assessed as a wanderer with exit-seeking behaviors, so R2 was placed in the locked unit with a wander guard alarm system to prevent elopement. KMA7 added that the resident would roam the halls and walk to the exit doors with statements of going home. KMA7 stated that during the elopement, the resident wandered out of the building unsupervised and traveled from the facility to the main roadway before staff were aware of her whereabouts. KMA7 recalled it was sometime after lunch, approximately 2:00 PM when she must have heard an announcement about a routine fire drill; however, she did not hear any information given that the facility's wander guard system was not currently functioning or that additional monitoring/supervision of wandering residents was needed. KMA 7 added that at that time, she was responsible for the safety and supervision of up to 18 residents by herself due to CNA 8 being on lunch break. KMA7 stated she had to try to gather all the mobile residents and those already up in their wheelchairs into the dayroom to monitor and supervise the residents while CNA8 was at lunch and was unaware that R2 had eloped through the unalarmed door until she was found outside the facility. KMA7 stated during the interview that she felt the elopement of R2 could have been prevented if the facility had prepared and planned to ensure adequate staff coverage to monitor all doors and units during an alarm shutdown. An attempt was made to interview CNA8 via telephone from [DATE] through [DATE]; however, it was unsuccessful, and CNA8 was no longer employed at the facility. However, a review of CNA8's Witness Statement undated, revealed she worked the locked down unit the day R2 eloped, on [DATE]. CNA8's statement noted at approximately 1:00 PM, R2 was awake and walking in the hall behind the nurse's station. At 2:35 PM, CNA8 stated she went to lunch and informed KMA7 that she would be off the unit, and there was no notation of staff coverage for CNA8 to assist KMA7 in monitoring and supervising the safety of the residents. In an interview with Registered Nurse (RN)1 on [DATE] at 3:02 PM, RN1 stated that R2 was located down an embankment in front of the facility, sitting in a ditch beside the main roadway. RN1 stated there were supposed to be two staff members monitoring and supervising in the hallways to watch and make sure the residents could not get to the doors since the alarm was not working. RN1 stated the elopement could have been prevented if R2 had been monitored closer. RN1 stated that due to the elopement incident, the facility had initiated and implemented a new system to ensure all areas of resident safety would be covered. In an interview with the former Regional Nurse Consultant (RNC) on [DATE] at 10:25 AM, she stated that during R2's elopement, the facility did not have a system in place to ensure adequate staff coverage on all units or that all exit doors were covered, assigned, and monitored when the alarm was silenced and/or shut down. The RNC stated the DON (who was in place at the time of elopement) made her aware of the incident, and she was directly involved in the plan of correction to prevent reoccurrence. Multiple attempts were made to interview the former DON and Administrator from [DATE] to [DATE]; however, all attempts were unsuccessful. In an interview on [DATE] at 12:00 PM, the current DON and Administrator stated that since taking over leadership positions beginning in ,d+[DATE], the facility has not encountered any elopements since R2's in 2023. The Administrator stated that everything now was based on policy and procedure; staff are aware and understand the policies and their responsibilities, including management and leadership roles. The facility provided an acceptable plan for the removal of the IJ on [DATE]. This plan alleged the IJ was removed, and the deficient practice was corrected on [DATE], prior to the initiation of the investigation. The plan provided by the facility alleged the following: 1.a) On [DATE], R2 was assessed for injury at the time of the incident (elopement) and assisted back into the facility via wheelchair by the DON. Immediately following the elopement event, the DON completed a head-to-toe skin assessment for injury with no new injuries noted. The Administrator initiated a Code Green, the code for a missing resident, and a head count was performed per the Unit Managers on each unit. R2's Physician and Family/Responsible Party were notified of the event per the DON and Administrator; R2 was sent to the ED for evaluation to rule out any injuries or change in condition on [DATE] and returned to the facility on [DATE] with no injuries, no change in condition, and no new orders. Following R2's return from the hospital on [DATE], R2 received 1:1 (one-to-one) supervision from facility staff for the next 72 hours. In addition, on [DATE], facility staff were assigned to monitor unlocked doors by the Administrator until the fire system and door locks resumed normal function. The care plan for R2 was also reviewed and updated by the Social Services Director (SSD) and MDS Coordinator 1 on [DATE]. An elopement risk assessment was completed for R2 on [DATE] and [DATE] and the resident was assessed to be at risk for elopement. 1.b.) Review and validation of the IJ Removal plan revealed an elopement risk assessment was performed by a licensed nurse on [DATE], [DATE], [DATE], and [DATE] and R2 remained at risk for elopement until she expired on [DATE]. Continued review of the IJ Removal Plan revealed the facility had a census of 74 on [DATE], all residents had an elopement risk assessment completed by the Unit Manager and Medical Records Nurse and 16 residents were identified to be at risk for elopement. Additionally, the profile for R2 in the elopement binder was reviewed by the SSD and R2's Activity assessment was updated by the Activities Director (AD) on [DATE]. Following the events on [DATE] the SSD completed a BIMS for R2 with a score of ,d+[DATE], and a Patient Health Questionare-9 assessment, with both scores indicating R2 suffered from severe cognitive impairment. Further validation revealed on [DATE], the [NAME] President of Operations (VPO) completed a root cause analysis, and a care plan meeting was held for R2 with the resident's family. 2. Review and validation of the facility's IJ Removal plan revealed on [DATE], the 16 residents who were identified to be at risk for elopement had orders and their care plans reviewed by the DON, Signature Care Consultant (SCC), and/or SSD. On [DATE], upon system restoration, all doors were checked to ensure locks were functioning by the Plant Operations Assistant (POA). All residents in the gated community (locked unit) had a secure unit observation and residents with a wander guard bracelet had orders reviewed, placement of wander guard checked, and care plans were reviewed by the SCC and DON on [DATE]. In addition, all exit door codes were changed by the POD on [DATE], and Activity assessments were also updated for all residents in the Reflections unit by the Activities Director on [DATE]. Following the events on [DATE], all elopement books were reviewed by the SSD on [DATE] to ensure resident profiles and pictures were updated and accurate and included all residents at risk for elopement. In addition, validation revealed that beginning [DATE] until [DATE], elopement drills and door checks were completed each shift by the POD, Unit Managers, Staff Development Coordinator (SDC), DON, Medical Records Nurse, MDS Coordinator, and Administrator. Continued validation revealed on [DATE], the POD and VPO reviewed all electronic life safety system elopement drills and door checks to validate compliance for a 90 day look back period. Additionally, starting [DATE], door checks were performed weekly ongoing, and elopement drills were performed weekly for four weeks and then monthly ongoing. 3. Education: Review and validation of the facility's IJ Removal plan revealed on [DATE], additional door alarms not tied to the fire alarm system were placed on the two (2) exterior exit doors on the Reflections unit. In addition, vinyl window frosting was also placed on the two (2) exterior exit doors on the Reflections unit to camouflage the doors and minimize exit seeking behaviors. Also, on [DATE], a Hasp lock (a flat metal plate with a hoop through which the lock goes in) and a key padlock was placed on one (1) door of the nurse's station for resident safety. In addition, on [DATE], the facility initiated that prior to the POD or POA allowing any work to be performed that could possibly affect any safety systems, the Administrator and DON must be notified to ensure staff are assigned to doors for monitoring. Beginning [DATE] and completed on [DATE], the VPO educated the Administrator, DON, POD and the POA that anytime life safety or a utility system is to be turned off, the DON and/or Administrator should be notified to allow for staff assignments to be made to ensure resident safety. Additionally, beginning [DATE] and completed on [DATE], current staff received education by the SDC on the following policies: Abuse, Neglect, Misappropriation of Property; Comprehensive Care Plans, Resident Rights: Missing Resident; Accident and Incident Investigation Reporting; Safety and Supervision. A post-test was completed by all current staff with the requirement of achieving 100% passing score to validate understanding. Validation revealed beginning [DATE], all staff that had not received education, all new hires, and agency staff were educated and received a post-test until a score of 100% was achieved prior to working their shifts. Continued review of the IJ Removal plan revealed on [DATE], the facility initiated individual resident activity boxes to be located on the Memory Care (locked unit) and a report was created for monitoring doors when the system was down. Beginning [DATE], the DON, Unit Managers (UM), SDC, Medical Records Nurse (MRN) or Manager on Duty (MoD) were required to assist the Reflections Unit (locked unit) during staff breaks to provide additional support. On [DATE] a new fence with a keypad was installed outside of the Reflections Unit (locked unit). 4.a.) Quality Assurance Performance Improvement (QAPI): On [DATE] the POD and POA, Administrator, DON, UM, SDC, MRN, SCC completed daily door checks for proper functioning of locking mechanism every shift for five (5) days, then weekly for four weeks and then monthly for two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. Starting [DATE], the POD and POA, Administrator, DON, UM, SDC, MRN, SCC completed elopement drills (code green) for every shift for five days, then weekly for four weeks, and then monthly for two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. In addition, starting on [DATE], elopement binders were reviewed by the SSD and Administrator to ensure accuracy weekly times four weeks, then monthly times two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. Starting [DATE], the Administrator or Activities Director audited documentation of activities and care plans for three random residents at risk for elopement to ensure documentation was complete and care plans were appropriate, weekly for four weeks, and then monthly for two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. 4.b.) Continued review of the QAPI and Audit validation revealed on [DATE], an Ad Hoc Quality Assurance (QA) meeting was held to review the investigation and the current plan of corrective action. Members present were the VPO, Administrator, the POD, DON, SSD, SCC, and the Medical Director attended via phone. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director validated the plan was appropriate and would be effective. In addition, starting on [DATE], a post-education test was provided by the Administrator, DON, and/or SDC to 10 random staff on different shifts weekly for four weeks, and then monthly for two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. Starting on [DATE], QA meetings were held daily for five days and weekly for four weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. Initial audits were reviewed during the meeting to ensure 100% compliance was achieved. At that time, based on evaluation, the QA committee determined what frequency ongoing audits needed to continue. The facility Administrator, Medical Director, DON, Assistant Director of Nursing (ADON), POD, SSD, Activity Director, Therapy Director, and MDS were expected to be present unless unable to attend. The QAPI Committee determined at what frequency any ongoing audits needed to continue. Additionally, the Administrator was responsible for the implementation of this plan.

Based on interview, record review, and facility document and policy review, it was determined the facility failed to ensure the comprehensive care plan for one (Resident (R) 2) of 14 sampled residents was implemented. R2 was assessed upon admission to be at risk for elopement and was care planned with the goal of not leaving the facility without staff supervision. On [DATE], R2 eloped from the facility without staff knowledge when the resident's care planned wander guard (door alarm system used to alert staff of resident's attempts to leave the facility) was not functioning and staff failed to provide additional monitoring, supervision, and/or interventions to prevent the resident from exiting the facility. The facility's failure to ensure the implementation of resident-centered care plans, with interventions to ensure adequate supervision and monitoring to prevent elopement, constituted Immediate Jeopardy (IJ), which is likely to cause serious injury, harm, impairment, or death to a resident. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, effective on [DATE], revised [DATE], and in effect at the time of the [DATE] elopement, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. Further review of the policy revealed each resident's comprehensive care plan designed to incorporate identified problem areas, risk factors associated with identified problems and the care plan to be revised as necessary with resident changes. Review of the facility's policy, Elopement, effective [DATE], revised [DATE], and in effect at the time of the ,d+[DATE] elopement, revealed the policy intended to ensure resident safety and protect their rights and dignity. Staff were required to evaluate residents on admission for elopement risk, displaying exit-seeking behaviors, and preventative interventions were required to be implemented for those residents identified as an elopement risk. These interventions were to be reevaluated as needed. The policy defined Elopement as any situation where a resident left the premises or a safe area without the facility's knowledge and supervision. Per this policy, a care plan would be developed and implemented with interventions for each resident identified as an elopement risk. Routine checks of entrance and exit doors were required to be completed to ensure proper functioning. Closed record review of R2's Resident Face Sheet revealed the facility admitted R2 on [DATE], and R2 expired on [DATE]. The resident's diagnoses included vascular dementia with behavioral, psychotic, and mood disturbances, depression, anxiety disorder, loss of cognitive functions and awareness, difficulty in walking, abnormalities of gait and mobility with repeated falls, lack of coordination, muscle wasting and atrophy. Review of an Elopement Risk Evaluation dated [DATE], as well as an Exit-Seeking/Elopement Observation, dated [DATE], revealed the resident was at risk for elopement based on factors including cognitive impairment, poor safety awareness, self-ambulation ability, history of exit-seeking behavior, ability to exit the facility, statements that she was leaving or questioning the need to stay, behaviors that indicated an attempt to leave the facility, and/or body language indicating an elopement may be forthcoming. Review of R2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed R2 with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated severe cognitive impairment. Per the MDS, R2 had wandering behaviors, and required staff supervision with transfers and mobility related to R2 not being steady with balance and during transitions. Review of R2's current physician orders for ,d+[DATE] revealed that the resident had an order, initiated [DATE], for a wander guard (security bracelet) to the left ankle, check placement, and function daily. Review of R2's Comprehensive Care Plan, initiated on [DATE], revealed the facility care planned R2 to be at risk for elopement related to wandering and exit seeking behaviors which included statements of going home at times, and poor safety awareness due to dementia. The goal of the care plan was the resident would not leave the facility and would be monitored as to her whereabouts throughout each shift. Interventions included the physician-ordered wander guard that was placed to R2's left ankle to prevent the resident from leaving the facility without staff supervision. Additional elopement risk interventions were updated on [DATE], for staff to utilize diversional activities when the resident was exhibiting exit seeking behavior to include drinking Pepsi, having snacks, playing cards or poker, and exercising. Review of an undated Elopement Investigation, revealed that on [DATE], R2, who resided on a locked unit, eloped from the facility without staff knowledge. (Refer to F689.) Although the resident's wander guard was in place per the care plan, the alarm system was shut down/not functioning while a sprinkler company was in the facility for yearly testing. Staff were unaware/not monitoring the whereabouts of R2 from approximately 3:00 PM, when she was last seen by Kentucky Medication Aide (KMA) 1, until R2 was found by a person driving by the facility, who saw the resident trip and fall along the grassy area in front of the parking lot, called 911 at 3:33 PM, and got out of their vehicle to check on the resident. At that time, another resident's family member (FM1) alerted staff that R2 was in front of the facility. After preliminary assessment R2 was transferred to the emergency room (ER) for evaluation and returned from the hospital with no injuries noted. Further review of the investigation found that when R2 exited the locked unit without supervision, she traveled approximately 120 feet from the exit door before she tripped and fell in the grassy area. The investigation determined that R2 exited the facility during an annual inspection of the sprinkler system when the fire monitoring system was interrupted and unlocked the exit doors on the gated community (locked unit). The investigation found that staff did not realize the exit doors would not alarm/were silenced when the sprinkler system was tested , and as a result, the resident could exit the facility without staff knowledge. In an interview with the Plant Operations Director (POD) on [DATE] at 10:49 AM, he stated that once he and the other staff realized R2 had exited the door on the locked unit, they knew immediately that no one had been monitoring or watching that door during the time that the wander guard system was not functioning during the inspection of the sprinkler system. Interview with KMA7 on [DATE] at 10:29 AM, revealed R2 was mobile and assessed as a wanderer with exit-seeking behaviors, so R2 was placed on the locked unit with a wander guard alarm system to prevent elopement. KMA7 stated that she worked on the locked-down unit the day R2 eloped from the facility, and that while Certified Nursing Assistant (CNA) 8 was at lunch, she was the only direct care staff on the unit. KMA7 related that she and the rest of the facility staff were unaware that R2 wandered out of the building unsupervised and got to the main roadway until after the resident was found. KMA7 stated that at the time of elopement, she was responsible for the safety and supervision of up to 18 residents and while working by herself, she had tried to gather all the mobile residents and those already up in their wheelchairs into the dayroom to monitor and supervise them. KMA7 stated she was unaware that the care plan called for diversional activities when R2 was exhibiting exit-seeking behaviors. KMA7 stated that she felt the elopement of R2 could have been prevented if the facility had prepared and planned to ensure adequate staff coverage to monitor all doors and units during the alarm shutdown. During an interview on [DATE], at 3:02 PM, Registered Nurse (RN) 1 stated there was supposed to be two staff members monitoring and supervising in the hallways to watch and make sure the residents could not get to the doors since the alarm system was not working. RN1 stated the elopement could have been prevented if staff had monitored R2 closer. Interview with MDS1 on [DATE] at 10:53 AM, revealed that R2's behaviors included walking up and down the halls of the locked-down unit, going room-to-room with signs of confusion/forgetfulness and statements of wanting to go home. MDS1 stated that it was crucial to ensure care plans were implemented for the wellbeing of the residents and their overall safety. MDS1 added that direct care staff needed to know the resident-specific interventions for each of the residents in the locked dementia unit where R2 resided, due to the challenges of their behaviors. In an interview on [DATE] at 12:00 PM, the current Director of Nursing (DON) and Administrator stated they both would expect staff to implement the care plan interventions as per policy and stated the facility has not encountered any resident elopements since R2's in 2023. The facility provided an acceptable plan for the removal of the IJ on [DATE]. This plan alleged the IJ was removed, and the deficient practice was corrected on [DATE], prior to the initiation of the investigation. The plan provided by the facility alleged the following: 1.a) On [DATE], R2 was assessed for injury at the time of the incident (elopement) and assisted back into the facility with a wheelchair by the DON. Immediately following the elopement event, the DON completed a head-to-toe skin assessment for injury and harm evaluation, with old bruises noted from a previous fall to the left flank and to the back of left thigh, but no new injuries noted. The Administrator initiated a Code Green, the code for a missing resident, and a head count was performed per the Unit Managers on each unit. Resident 2's Physician and Family/Responsible Party were notified of the event per the DON and Administrator; R2 was sent to the Emergency Department (ED) for evaluation to rule out any injuries or change in condition on [DATE] and returned on [DATE] with no injuries, no change in condition, and no new orders. Upon return from the hospital, R2 had a complete head-to-toe skin assessment per the Regional Care Consultant and the DON with no new areas of concern. Following R2's return from the hospital on [DATE], she received 1:1 (one-to-one) supervision from facility staff for the next 72 hours. In addition, on [DATE], facility staff were assigned to monitor unlocked doors by the Administrator until the fire system and door locks resumed normal function. The care plan for R2 was also reviewed and updated by the Social Services Director (SSD) and MDS1 on [DATE]. Per the IJ validation, R2 had an elopement risk assessment on [DATE] and was at risk for elopement. An elopement risk assessment was repeated for R2 by the Unit Manager on [DATE] and R2 was noted at risk for elopement. 1.b.) Continued review and validation of the IJ revealed an elopement risk assessment was performed by a licensed nurse on [DATE], [DATE], [DATE], and [DATE] and R2 remained at risk for elopement until she expired on [DATE]. Continued review of the IJ validation revealed the facility had a census of 74 on [DATE], all residents had an elopement risk assessment completed by the Unit Manager and Medical Records Nurse; 16 residents were identified to be at risk for elopement. Additionally, the profile for R2 in the elopement binder was reviewed by the Social Services Director (SSD) and R2's Activity assessment was updated by the Activities Director (AD) on [DATE]. Following the events on [DATE], continued review of the facility's corrective actions taken for the identified resident (R2), that was affected by the facility's deficient practice revealed and validated that on [DATE], the SSD completed a BIMS assessment for R2 with a score of ,d+[DATE] and a Patient Health Questionnaire-9 assessment, with both scores indicating severe cognitive impairment. Further validation revealed on [DATE], the [NAME] President of Operations (VPO) completed a root cause analysis via Fishbone Diagram, and a care plan meeting was held for R2 with the resident's family. 2. Review and validation of the facility's IJ Removal plan revealed on [DATE], all residents had an elopement risk assessment completed by the Unit Manager and Medical Records Nurse; 16 residents were identified to be at risk for elopement and those residents had orders and their care plans reviewed by the DON, Signature Care Consultant (SCC) and/or SSD. On [DATE], upon system restoration, all doors were checked to ensure locks were functioning by the Plant Operations Assistant (POA). All residents in the gated community (locked unit) had a secure unit observation and residents with a wander guard bracelet had orders reviewed, placement of wander guard checked, and care plans were reviewed by the DON on [DATE]. In addition, all exit door codes were changed by the POD on [DATE], and Activity assessments were also updated for all residents on the Reflections Unit by the Activities Director on [DATE]. Following the events on [DATE], all elopement books were reviewed by the SSD on [DATE] to ensure resident profiles and pictures were updated and accurate and included all residents at risk for elopement. In addition, validation revealed that beginning [DATE] until [DATE], elopement drills and door checks were completed each shift by the POD, Unit Managers, Staff Development Coordinator (SDC), DON, Medical Records Nurse, MDS Coordinator, and Administrator. Continued validation revealed on [DATE], the POD and VPO reviewed all electronic life safety system elopement drills and door checks to validate compliance for a 90 day look back period. Additionally, starting [DATE], door checks were performed weekly ongoing, and elopement drills were performed weekly for four weeks and then monthly ongoing. 3. Education: Review and validation of the facility's IJ Removal plan revealed on [DATE], additional door alarms not tied to the fire alarm system were placed on the two (2) exterior exit doors on the Reflections Unit. In addition, vinyl window frosting was also placed on the two (2) exterior exit doors on the Reflections Unit to camouflage the doors and minimize exit seeking behaviors. Also, on [DATE], a Hasp lock (a flat metal plate with a hoop through which the lock goes in) and a key padlock was placed on one (1) door of the nurse's station for resident safety. In addition, on [DATE], the facility initiated that prior to the POD or POA allowing any work to be performed that could possibly affect any safety systems, the Administrator and DON must be notified to ensure staff were assigned to doors for monitoring. Beginning [DATE] and completed on [DATE], the VPO educated the Administrator, DON, POD, and POA that anytime life safety or a utility system was to be turned off, the DON and/or Administrator should be notified to allow for staff assignments to be made to ensure resident safety. Additionally, beginning [DATE] and completed on [DATE], current staff received education by the SDC on the following policies: Abuse, Neglect, Misappropriation of Property; Comprehensive Care Plans, Resident Rights: Missing Resident; Accident and Incident Investigation Reporting; Safety and Supervision. A post-test was completed by all current staff with the requirement of achieving 100% passing score to validate understanding. Validation revealed beginning [DATE], all staff that had not received education, all new hires, and agency staff were educated and received a post-test until a score of 100% was achieved prior to working their shifts. Continued review of the IJ Removal plan revealed on [DATE], the facility initiated individual resident activity boxes to be located on the Memory Care (locked unit) and a report was created for monitoring doors when the system was down. Beginning [DATE], the DON, Unit Managers (UM), SDC, Medical Records Nurse (MRN) or Manager on Duty (MoD) were required to assist the Reflections Unit (locked unit) during staff breaks to provide additional support. On [DATE] a new fence with a keypad was installed outside of the Reflections Unit (locked unit). 4.a.) Quality Assurance and Performance Improvement (QAPI): Starting [DATE], the Administrator or Activities Director audited documentation of activities and care plans for three random residents at risk for elopement to ensure documentation was complete and care plans were appropriate, weekly for four weeks, and then monthly for two months. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. On [DATE], an Ad Hoc Quality Assurance (QA) meeting was held to review the investigation and the current plan of corrective action. Members present were the VPO, Administrator, the POD, DON, SSD, SCC, and the Medical Director attended via phone. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director validated the plan was appropriate and will be effective. 4.b.) In addition to QAPI, starting on [DATE], a post-education test was provided by the Administrator, DON, and/or SDC to 10 random staff on shifts weekly for four weeks, and then monthly for two weeks. Results of the audits were presented to the QAPI committee for review and recommendation. Once the committee determined the problem no longer existed the audits were conducted on a random basis. Starting on [DATE], QA meetings were held daily for five days and weekly for four weeks, then monthly for recommendations and further follow-up regarding the above-stated plan of IJ removal. Initial audits were reviewed during the meeting to ensure 100% compliance was achieved. At that time, based on evaluation, the QA committee determined what frequency ongoing audits needed to continue. The Administrator, Medical Director, DON, Assistant Director of Nursing (ADON), POD, SSD, Activity Director, Therapy Director, and MDS Coordinator were expected to be present unless unable to attend. The Quality QAPI Committee determined at what frequency any ongoing audits needed to continue. Additionally, the Administrator was responsible for the implementation of this plan.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented for two (2) of thirty-five sampled residents, Resident #67 and #175. Interview with Kentucky Medication Aide (KMA) #3 revealed that on 01/15/2022, Housekeeper #2 came to her and reported that she needed to come to the room of Resident #175. KMA #3 stated when she entered the room, Resident #67 and Resident #175 were engaged in sexual intercourse. Housekeeper #2 failed to stay with the residents to protect the residents from abuse and therefore failed to implement the abuse policy. The facility's failure to ensure that established policies and procedures were followed when allegations of abuse occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2022 and determined to exist on 12/06/2021 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600, F607, and F610) at a scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657) s/s of a J, and 42 CFR 483.70 Administration (F835) at a s/s of a J. The facility was notified of the Immediate Jeopardy on 02/12/2022. An acceptable Immediate Jeopardy removal plan was received on 02/22/2022, which alleged removal of the Immediate Jeopardy on 02/19/2022. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/19/2022, prior to exit on 02/24/2022, which lowered the scope and severity to D at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, (F600, F607 and F610) 483.21 Comprehensive Resident Centered Care Plans (F657) and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, last reviewed and revised 05/08/2019, revealed every stakeholder, contractor, and volunteer must intervene immediately, to the extent feasible and consistent with personal safety and the person's training, to prevent or interrupt an incident of abuse. Review of the Self-Reported Incident Form dated 01/15/2022, revealed on 01/15/2022, Kentucky Medication Aide (KMA) #3 reported to Licensed Practical Nurse (LPN) #10 that Resident #67 and Resident #175 were inappropriately touching one another. Further review of the facility investigation of the incident of inappropriate touching, dated 01/21/2022, revealed the Administrator unsubstantiated sexual abuse based on information obtained from investigation. Review of the medical record for Resident #67 revealed the facility admitted him/her on 04/17/2021, with diagnoses which included Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Diastolic (Congestive) Heart Failure. Review of Resident #67's Quarterly Minimum Data Set (MDS) Assessment, dated 11/13/2021, revealed the facility assessed Resident #67 as severely cognitively impaired as indicated by the Brief Interview for Mental Status (BIMS) score of two (2). Further review of the MDS revealed Resident #67 had disorganized thoughts, was independent with transfers and ambulation and the facility assessed the resident to not wander and therefore failed to assess that the resident's wandering would place the resident in dangerous situations. Review of the medical record for Resident #175 revealed the facility admitted him/her on 02/01/2021, with diagnoses which included Unspecified Dementia, Alzheimer's Disease, Unspecified Psychosis, and Parkinson's Disease. Review of Resident #175's Quarterly MDS Assessment, dated 10/29/2021, for Resident #175 revealed the facility had assessed the resident as severely cognitively impaired as indicated by the Brief Interview of Mental Status (BIMS) score of two (2). Further review of the MDS revealed the resident had disorganized thoughts and required supervision only with transfers and ambulation. Review of the facility's investigation documentation, dated 01/21/2022, revealed the facility unsubstantiated an allegation of inappropriate touching between Resident #67 and Resident #175. Review of Housekeeper #2's written statement, regarding the incident between Resident #67 and Resident #175, revealed Resident #175 had been standing between the two (2) residents' beds. Continued review of Housekeeper #2's statement revealed Resident #67 had been lying on Resident #175's bed with his/her pants down to the top of his/her pubis (bones forming the pelvis). Further review of the statement revealed Housekeeper #2 went and got Kentucky Medication Aide (KMA) #3 and the KMA took care of the problem. Interview with Housekeeper #2, on 02/09/2022 at 1:30 PM and 02/11/2022 04:25 PM, revealed after observing the residents in Resident #175's room, she left Resident #175's room to notify KMA #3 she needed to go to the resident's room because Resident #67 was in the room lying on Resident #175's bed. Housekeeper #2 denied observing the residents to be in close contact or engaging in physical touching. Therefore, Housekeeper #2 stated she did not feel it was inappropriate to leave the residents alone together in the room while she obtained the assistance of nursing staff. Further interview revealed she was aware of the facility's abuse policy which directed staff to stay with a resident when alleged and/or suspected abuse was discovered; however, she stated she did not stay with Resident #67 or Resident #175 in the room as per the policy. Interview with the Administrator, on 02/11/2022 at 11:47 AM, revealed KMA #3 had written out a statement regarding the incident and what she witnessed between Resident #67 and Resident #175 on 01/15/2022; however, the facility could not locate the witness statement, stating it was lost. Interview with Kentucky Medication Aide (KMA) #3 on 02/09/2022 at 8:30 PM and 02/10/2022 at 9:55 AM, revealed Resident #67 and #175 had been actively engaged in sexual intercourse when she entered the room after being notified by Housekeeper #2. She revealed she immediately separated Resident #67 and Resident #175, and redirected Resident #67 out of the room. KMA #3 stated she immediately notified LPN #10 of the interaction she had witnessed between Resident #67 and Resident #175. Interview on 02/11/2022 at 11:25 AM, with Licensed Practical Nurse (LPN) #10 revealed KMA #3 reported her observation of Resident #67 and Resident #175 on 01/15/2022. The LPN stated KMA #3 told her she had found Resident #175 and Resident #67 actively engaged in sexual intercourse in Resident #175's room. LPN #10 stated she notified the Administrator immediately of what KMA #3 told her regarding finding the residents actively engaged in sexual intercourse. Interview with the Administrator, on 02/11/2022 at 11:47 AM and 4:43 PM, revealed all staff was expected to protect residents and follow the facility's abuse policy if abuse was alleged or suspected. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/19/2022. 1.Incident # 1 occurred on 12/06/2021 involving Residents #174 and #10. The following steps were taken to ensure resident safety. For Resident #174, a skin assessment was completed on 12/06/2021, with no bruising, markings or concerns noted. The Care Plan was reviewed on 12/09/2021 by the Minimum Data Set (MDS) Coordinator, and interventions were updated on the resident's mood care plan. The MD (Medical Doctor) and the resident's POA (Power of Attorney) was notified on 12/06/2021. For Resident #10, the resident was placed on 1:1 supervision on 12/06/2021 and currently remains on 1:1 supervision. Resident #10's medications were reviewed on 12/07/2021 by the Psychiatric Nurse Practitioner and medication changes were made including Paxil started and Viibryd dose decreased. A Psychiatric Services Consult was completed for Resident #10 on 12/07/2021, and follow-up visits were completed on 12/14/2021 and 12/29/2021. The resident's care plan was reviewed by the Interim Director of Nursing (DON) on 12/06/2021 with new interventions added to the resident's psychosocial care plan. The MD and POA were notified of the incident on 12/06/2021. Incident #2 occurred on 12/27/2021 involving Resident #174 and Resident #175. For Resident #174, the Regional Nurse Consultant completed a skin assessment of Resident #174 on 12/27/21 with no concerns noted. Review of documentation revealed the resident's MD and POA were notified on 12/27/21. Resident #174 was discharged per a planned discharge to home on 12/28/2021. For Resident #175, a skin assessment was completed on 12/27/2021 by the Regional Nurse Consultant with no concerns identified. Resident #175 was provided 1:1 Supervision on 12/27/2021 and the elder was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. The resident's MD and Family were notified on 12/27/2021. The resident's care plan was updated on 02/18/2022 related to 1:1 status and the resident's discharge to a behavior unit on 12/27/2021 by the Regional Nurse consultant. Incident #3 occurred on 01/15/2022 involving Resident #67 and Resident #175. Resident #67 was found lying in the bed of elder #175. Both elders had pants off and were engaging in sexual activities. The following steps were taken to ensure resident safety. For Resident #67, a psychosocial follow-up was conducted for seventy-two (72) hours to provide psychosocial support and identify any concerns. The follow-ups were conducted on 01/15/2022, 01/16/2022, and 01/17/2022 by the Administrator. The Unit Manager reviewed the resident's care plan on 01/15/2022, to reflect the needs of the resident and to reflect the psychosocial follow-up. An assessment for physical trauma/injury was completed for Resident #67 via a skin assessment by the Unit Manager on 01/15/2022. The resident's MD and POA were notified of the incident on 01/15/2022. A Dementia Scale Pain Assessment and Pain Monitoring form that assesses the resident for pain by assessing the elders breathing, negative vocalization of pain, facial expressions, body language, and consolability was completed on 01/15/2022 by a Unit Manager with a score of zero (0) which indicated no pain. This assessment was noted to also indicate the resident was not in pain as did the baseline assessment completed on 12/06/2021 by Regional Nurse Consultant. For Resident #175, a skin assessment was completed on 01/15/2022 by a Unit Manager with no concerns noted. The resident was placed on 1:1 Supervision on 01/15/2022 and remained on 1:1 supervision until the resident was discharged from the facility on 02/22/2022. The resident was transferred to the hospital on 01/15/2022 and returned 01/26/2022 and remained on 1:1 supervision until transferred to the hospital on 02/01/2022 and returned on 02/10/2022. The Resident was then placed on 1:1 supervision upon return from the hospital and remained 1:1 until the resident was discharged from the facility on 02/22/2022. The resident's MD and Family were notified of the incident on 01/15/2022. The Administrator updated the resident's care plan on 01/15/2022 to reflect the resident's 1:1 status. The Housekeeper was initially educated on the abuse policy on 01/19/2022 by the facility Administrator which included protection of the resident and the Housekeeper was educated on the abuse policy on 2/16/2022 by the Staff Development Coordinator. 2. Residents residing in the facility have been assessed for any sign/ symptoms of potential abuse. Residents with a Brief Interview for Mental Status (BIMS) score of greater that eight (8) were interviewed by the Administrator and/or Unit Manager/Staff Development Coordinator for any concerns starting on 02/14/2022 and completed on 2/16/2022 with no issues identified. Residents currently residing in the facility with a BIMS of less than eight (8) were physically assessed by the Administrator, Unit Manager or Staff Development Coordinator for any signs and symptoms of potential abuse starting on 02/14/2022 with no concerns identified. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Regional Nurse Consultant or Regional [NAME] President (RVP) starting on 02/14/2022 and completed on 02/16/2022 for any indications of potential abuse concerns. No issues or concerns were identified. 3. Charts have been reviewed for all residents residing in the facility by the Independent Risk Manager for any resident status changes to include event managers and change of conditions for the past thirty (30) days starting on 02/14/2022 and completed on 02/16/2022. The charts were also reviewed for any potential abuse allegations that had not been previously reported with no concerns noted. 4. Care plans were reviewed by Regional Nurse Consultant #1, Regional Nurse Consultant #2 and the Behavioral Specialist starting on 02/16/2022 and completed on 02/18/2022 to ensure that the care plans were updated regarding behaviors, wandering and reflected the resident's current cognitive status. 5. All residents residing in the facility will had a BIMS assessment completed to ensure that all residents had an accurate assessment score by the Social Services Director starting on 02/14/2022 and completed on 02/15/2022. 6. Employees were interviewed by the Administrator, Staff Development Coordinator, and the Activities Director regarding any knowledge of unreported abuse or knowledge of any type of sexual relations that had not been previously reported starting on 02/16/2022 and completed on 2/18/2022 with no new concerns noted related to abuse reporting. 7. The Medical Director was notified of all the allegations on 12/06/2021, 12/27/2021, and 01/15/2022 by the Administrator in accordance with abuse reporting. The facility's Medical Director is the physician for Residents #10, Resident #67, Resident #174, and Resident #175. 8. The Senior [NAME] President of Regulatory Compliance educated the facility's Administrator/Regional [NAME] President and the Regional Nurse Consultant on the Center for Medicare/Medicaid Services (CMS) regulations for F610 and F835 on 02/17/2022 and the CMS regulations for F600, F607 and F657 on 02/18/2022 including: F610-responding to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his/her designated representative and to the other officials in accordance with state law, including to the state survey agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F 835, the facility must be administered in manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial wellbeing of each resident. The facility administration is not limited to the administrator and may also include the facility's governing body, management company, and/ or others identified by the facility as part of the facility administration. CMS's Abuse Critical Pathway and reporting guidelines. F600, residents have the right to be free from abuse, neglect, misappropriation, and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. F 607, The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property/ Establish policies and procedures to investigate any such allegations and include training as required and establish coordination with the QAPI program as required. F 657, to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs., and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. 9. Starting on 02/17/2022 all allegations of abuse including physical, verbal, mental, sexual, misappropriation, neglect, involuntary seclusions, corporal punishment, injuries of unknown origin, and exploitation would be reviewed by the Regional [NAME] President, Risk Manager, and/or [NAME] President of Clinical Operations to ensure that a complete, thorough, and accurate investigation has been completed for the reportable events for the next 90 days through 05/20/2022. 10. All reportable incidents were reviewed from the last six (6) months from 08/01/2021, through 02/16/2022 by the [NAME] President of Clinical Operations starting on 02/16/2021 and completed on 02/17/2022 with no concerns noted. 11. The facility Administrator, Regional [NAME] President, Regional Nurse Consultant #1 and Regional Nurse Consultant #2, Unit Manager, Business Office Manager, Assistant Business Office Manager, Activities Director, Rehab Service Manager, Scheduler, and the Staff Development Coordinator (SDC) were educated on the abuse policy to include sexual abuse on 02/14/2022 by the Director of Behavioral Health Services. The education included the following: Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with an emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. Resident Rights include that resident had the right to be free from abuse The Behavior Management policy includes supervision and interventions to redirect residents when behaviors occur. Care plan policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs. Change of Condition Policy and Procedure, to include Physician and Family notification Quality Assurance Performance Improvement (QUAPI) policy and procedure to include process improvement and monitoring. 12. Once the facility Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were educated on (a) Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. (b) the resident's right to free from abuse (c) Behavior Management policy to include supervision and interventions to redirect residents when behaviors occur. (d) Care plan policy and procedure, to include appropriately updating the residents' care plan to reflect residents' current care needs. (e) Change of Condition Policy and Procedure, to include Physician and Family notification and (f) the QAPI policy and procedure to include process improvement and monitoring. The Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were then assigned to re-educate all staff working in the facility, to include agency staff, in small groups which started on 02/15/2022 and was completed by 02/18/2022. On 02/18/2022, certified letters were sent out to the remaining PRN (as needed) staff, staff on vacation, or staff on Family Medical Leave Act (FMLA). No employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on the post-test, then the employee would be immediately re-educated, and the post-test will be re-administered. This education would be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process would continue until employee obtains a 100% score on post-test. 13. A staff post-test regarding the above education to include types of abuse, protection of the resident, and notification of abuse including MD notification would be administered daily, starting on 02/19/2022. The test will be administered by the Administrator, DON, Nursing Supervisors, SDC, Business office manager, Assistant Business Office Manager or Activities Director to six (6) different staff members on different shifts daily for two (2) weeks. After two (2) weeks, then four (4) staff member's questionnaires daily to different staff members on different shifts for two (2) weeks. Results of the staff tests will be reported to the Quality Assurance (QA) committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. 14. All grievances were reviewed on 02/18/2022 by the Regional Nurse Consultant for the last thirty (30) days to determine if any items documented were a reportable event or if concerns were not resolved. No issues were identified. The Administrator or Director of Nursing would review grievances daily for two (2) weeks starting 02/18/2022, to determine if there were any concerns related to resident abuse. The Administrator would report any allegations of abuse, neglect, or misappropriation to the State Regulatory Officials, Adult Protective Services and the Ombudsman. 15. All incident reports from 11/10/2021 through 02/10/2022 were reviewed on 01/17/2022 by the Independent Risk Manager to identify any concerns related to resident abuse, and no concerns were identified. 16. Starting on 02/19/2022 the facility Administrator, DON, Social Services Director, Assistant Director of Nursing, Staff Development Coordinator and/or Unit Manager would complete five (5) random resident observations/interviews a week to ensure residents are not exhibiting any sign or symptoms of abuse to include but not limited to being tearful, withdrawn, decreased appetite, bruising, anxiety, increased wandering, or displaying fear of staff or other elders. These audits would be ongoing for the next four (4) weeks. 17. Starting on 02/19/2022, five (5) random stakeholders would be interviewed weekly for four (4) weeks to determine if they have any knowledge of any previously unreported abuse or observed any residents exhibiting increased signs and symptoms of abuse to include but not limited to being tearful, withdrawn, decreased appetite, bruising, anxiety, increased wandering, fearful of staff or other elders. 18. Starting on 02/17/2022, all residents returning from a behavioral hospital stay would be reviewed by the Interdisciplinary Team to determine their appropriate level of supervision and/or needed modifications to their plan of care to ensure their needs were met and the needs of peers were also met. This would be ongoing to ensure resident safety. 19. Administrative oversight of the facility would be completed via telephone or in-person by the Regional Nurse Consultant, Regional [NAME] President of Operations, the Director of Clinical Operations, or a member of the regional staff daily for two (2) weeks beginning on 02/12/2022, then weekly for four (4) weeks, then monthly. This would include a review of all abuse allegations and events/incidents that occurred in the previous twenty-four (24) hours, any grievances filed, and stakeholder post-tests. 20. Starting the week of 02/12/2022, a QA meeting would be held daily for seven (7) days then weekly for four (4) weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A QA meeting was held on 02/11/2022 and an action plan was formulated and implemented at that time. On 02/12/2022, a second Quality Assurance meeting was held to review the current plan for any needed revisions, compliance and/or further education. At that time, based upon evaluation, the QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator has the oversight to ensure an effective plan was in place to ensure each resident's wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QA meetings would be completed by the Regional [NAME] President of Operations, or a member of regional staff daily until the removal of immediacy beginning 02/12/2022 and then daily for seven (7) days, then weekly for four (4) weeks, then monthly. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 02/19/2022 as alleged: 1.Observations on 02/23/2022, revealed Resident's #10 and Resident #174 were not interviewable due to cognitive impairment. Review of facility documentation and interview with the Unit Manager on 02/24/2021 at 2:14 PM, revealed she completed a skin assessment, on Resident #174 on 12/06/2021, with no concerns identified. Further review revealed the resident's POA, and MD were notified on 12/06/2021 of the incident. Review of a Psychiatric Assessment revealed the resident was assessed by Psychiatric Services on 12/07/2021, and new medications were initiated on 12/09/2021. Review of Resident #174's care plan revealed on 12/09/2021, the care plan was updated to include Mood/Anxiety interventions with a goal for the Resident to experience a reduction of relief from signs and symptoms of anxiety such as, restlessness, poor impulse control, fear/apprehension. Review of Resident #10's medical record, dated 02/23/2022, revealed Resident #10 was placed on 1:1 supervision on 12/06/2021 and remained on 1:1 supervision until 01/07/2022. Observation on 02/23/2022 revealed the facility placed the resident on every fifteen (15) minute supervision since 01/07/2022. Observation of Resident #10 on 02/23/2022, at 3:28 PM revealed the resident was in his/her room sitting at the bedside with a Personal Care Attendant (PCA) present. Further review of documentation and interview with the Unit Manager on 02/24/2021 at 2:14 PM, revealed she completed a review of Resident #10's care plan 12/06/2021 with no concerns identified. Review of a Psychiatric Assessment for Resident #10, on 12/07/2021 completed by a Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed the resident's Viibryd dosage was decreased from 20 milligrams daily to 10 milligrams daily for seven (7) days and then the medication was discontinued. On 12/14/2021, the resident was again seen by the PMHNP, and Paxil was initiated daily. The PMHNP notes revealed a collaboration with a Psychiatrist and Advanced Practice Registered Nurse (APRN) and an additional visit on 12/29/2021. Record review revealed the resident's care plan was updated on 12/06/2021 with new interventions added to the identified problem of psychosocial wellbeing section of the care plan. Review of facility documentation revealed Resident #174 was involved in a second incident with Resident #175, on 12/27/2021. Review of documentation revealed a skin assessment was completed for Resident #174 on 12/27/2021 by the Regional Nurse Consultant, with no concerns identified. Further record review revealed Resident #174 was discharged home as planned on 12/28/2021. Review of documentation revealed Resident #175 had a skin assessment completed on 12/27/2021 with no concerns identified. Further review revealed the resident was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. Review of Resident #175's medical record revealed the resident's MD and family were notified of the transfer on 12/27/2021. On 01/15/2022, another incident with Resident #175 occurred and a skin assessment was completed on 01/15/2022 by the Unit Manager with no concerns identified. Review of the Behavior monitoring log revealed Resident #175 was placed on 1:1 supervision on 1/15/2022 and transferred to the Hospital. Continued review revealed the resident returned to the facility on [DATE] and was again transferred to the hospital on 02/01/2022. Resident #175 returned to the facility on [DATE] and was discharged from the facility on 02/22/2022. Review of a facility investigation revealed Resident #67, who had a BIMS score of six (6) was involved in an incident on 01/15/2022 with Resident # 175. Resident #67, an Observation on 02/23/2022, at 3:35 PM, revealed the resident was sitting in the common area and was obviously cognitively impaired. Record review revealed the Administrator had completed a psychosocial follow-up with Resident #67 on 01/15/2022, 01/16/2022, 01/17/2022 with no concerns noted. Interview with the Unit Manager on 02/24/2022 at 2:14 PM revealed she had completed a physical trauma/injury assessment for Resident #67 on 01/15/2022, and no concerns were noted. Review of Resident #67's Care plan revealed it was reviewed by the Unit Manager on 01/15/2022 and it reflected the needs of the resident and the psychosocial follow-ups which had been completed on 01/15/2022, 01/16/2022, and 01/17/2022. Review of the Dementia Scale Pain Assessment and Pain Monitoring form for Resident #67 revealed the assessment was completed on 01/15/2022 by a Unit Manager with a score of zero(0) which indicated no pain. Resident #175, review of his/her skin assessment dated [DATE], revealed the skin assessment was completed on 01/15/2022 with no concerns identified. Review of the facility's behavior monitoring log revealed Resident #175 was placed on 1:1 supervision on 1/15/2022 and then transferred to the hospital. Continued review of Resident #175's medical record revealed the resident returned to the facility on [DATE] and went back out to the hospital on 02/01/2022 and returned to the facility on [DATE]. Resident #175 was discharged from the facility on 02/22/2022. Review of facility training records and interview with Housekeeper #1, on 02/24/2022 at 1:35 PM, revealed she was educated on the abuse policy on 01/19/2022 by the facility Administrator. The training included protection of the resident and the Housekeeper was educated again on the abuse policy on 02/16/2022 by the Staff Development Coordinator. Housekeeper #1 stated she felt confident and was able to verbalize appropriate measures to take with allegations of abuse. Further review of documentation revealed the Housekeeper had taken the post-test and scored 100 %. 2. Review of documentation revealed skin audits were completed on residents and review of Resident #10's medical record revealed the audit was present. Interview with the Unit Manager, on 02/24/2022 at 2:14 PM, revealed all residents residing in the facility were assessed for signs/symptoms of abuse starting on 02/14/2022 through 02/16/2022. Further interview with the Unit Manager revealed weekly skin sweeps continued on all residents. Interview with Administrator, on 02/24/2022 at 3:25 PM, revealed Nursing Staff from other sister facilities were brought in to assist with skin sweeps for a Fresh Eyes assessment and no concerns were noted. 3. Review of facility documentation and interview with the Independent Risk Manager on 02/18/2022, revealed all resident records were reviewed for any resident status changes, including event manager forms and change of condition forms for the past thirty (30) days starting on 02/14/2022 and completed on 02 [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure four (4) of thirty-five (35) sampled residents (Resident #10, Resident #67, Resident #174, and Resident #175), who were all cognitively impaired and lacked the capacity to consent to sexual relations, were protected from sexual abuse. In addition, it was determined the facility failed to protect two (2) of six (6) sampled residents (Resident #37 and Resident #174) from physical abuse. 1.Review of the facility's investigation documentation revealed on 12/06/2021, Resident #174 and Resident #10 were found by staff in Resident #10's room. Both residents were observed to have their pants down to mid-thigh, and Resident #10 had his/her hand on Resident #174's thigh. Resident #10 was placed on one (1) to one (1) supervision; however, the facility failed to ensure Resident #174 was provided increased supervision for his/her safety and the safety of other residents. 2. Review of the facility's investigation documentation revealed on 12/27/2021, revealed Resident #174 was involved in a second (2nd) allegation of abuse. Resident #174 was found by staff in Resident #175's room. Per the allegation, Resident #174 was found behind the door in Resident #175's room with his/her clothing disheveled and Resident #175 was lying on the bed pulling at the waist of his/her pants. Review of the residents ' medical record and interviews with staff revealed the facility failed to provide increased supervision for the residents, to ensure their safety, as well as, the safety of other residents. 3. Review of the facility's investigation documentation and interview with facility staff revealed on 01/15/2022, Resident #175 was observed in a second (2nd) sexual abuse allegation. Resident #67 was found in Resident #175's room actively engaged in sexual intercourse. Per record review, there was no documented evidence the facility provided increased monitoring and/or supervision to ensure the safety of Resident #175 and other residents. 4. In addition, on 12/21/2021, Resident #174 wandered into Resident #37's room. Staff found Resident #174 with water on his/her face and observed Resident #37 holding an empty cup. Staff also observed both residents pulling each other's hair, and immediately separated the residents. Resident #37 was placed on one (1) on one (1) monitoring following the incident and referred to psych for evaluation. However, the facility failed to provide increased supervision and monitoring for Resident #174, of whom had a history of wandering into other residents ' rooms. The facility's failure to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2022 and determined to exist on 12/06/2021 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600, F607, and F610), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 02/12/2022. An acceptable Immediate Jeopardy removal plan was received on 02/22/2022, which alleged removal of the Immediate Jeopardy on 02/19/2022. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/19/2022, prior to exit on 02/24/2022, which lowered the scope and severity (s/s) to D at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, (F600, F607 and F610) 483.21 Comprehensive Resident Centered Care Plans (F657) and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility ' s policy titled, Abuse, Neglect and Misappropriation of Property, dated 05/08/2019, revealed it was the facility's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property. Continued review revealed the facility intended to assure all alleged violations of federal and state laws which involved abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property were investigated. Review revealed all alleged violations were to be reported immediately to the facility Administrator, State Survey Agency, and other state and local agencies in accordance with federal and state law. The policy review revealed abuse included physical, mental, verbal and sexual abuse, and included deprivation by a caretaker of goods and services that were necessary to attain or maintain physical, mental and psychosocial well-being. Further review revealed sexual abuse included, but was not limited to, any physical contact with a resident's body that was not reasonably related to appropriate provision of ordered care or services. In addition, review revealed the policy presumed all abuse, as defined in the policy caused physical harm, pain or mental anguish to any resident, even if he or she did not understand the incident. 1.Review of the facility's Incident Report dated 12/06/2021, revealed Kentucky Medication Aide (KMA) #1 responded to Resident #10's call light. Review revealed upon entering the room KMA #1 observed Resident #174 lying on the bed with pants pulled down to thighs, and Resident #10 seated at the head of the bed, feet on floor with his/her pants pulled down to his/her knees. Continued review revealed Resident #10 had been observed to have his/her hand on Resident #174's thigh. Further review revealed both residents were immediately separated, and a head to toe skin assessment was conducted of both residents. The Incident Report further revealed no injuries were found on either resident, and neither resident was able to recall the incident. In addition, review revealed Resident #10 was placed on one (1) to one (1) monitoring. Review of Resident #174's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Unspecified Dementia with Behavioral disturbance; Dysphagia; and Wandering. Continued review revealed Resident #174 was discharged home with his/her spouse as a planned discharge on 12/28/2021. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/05/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), which indicated Resident #174 was severely cognitively impaired. Continued review of the Admission MDS Assessment revealed Resident #174 had been assessed to have behaviors that put the resident at risk of physical illness or injury. Further review of the MDS Assessment revealed Resident #174 had experienced behaviors that significantly interfered with the resident's care and wandering behaviors which significantly intruded on the privacy or activities of others on one (1) to three (3) occasions during the assessment period. Review of Resident #174's Comprehensive Care Plan, dated 10/29/2021, revealed the facility had noted a problem area of wandering with interventions that included to administer medications as ordered and observe for effectiveness of the medications; intervene as needed to protect the rights and safety of others; and approach in a calm manner. Further review revealed additional interventions which included for staff to divert the resident's attention, remove him/her from situations as necessary, and take to the resident to another location as needed. Review of the Care Plan further revealed a goal for the resident not to harm self or others secondary to his/her behaviors. In addition, review of the Care Plan revealed no documented revisions had been made to Resident #174's care plan following the incident which occurred on 12/06/2021, involving Resident #10. Review of Resident #174's Psychiatric Progress Note, dated 12/07/2021, revealed the resident had been referred for an acute psychiatric visit related to inappropriate sexual behaviors with other residents, aggression, and insomnia. Further review revealed Resident #174 had recently exhibited more aggressive behaviors and was wandering into other residents' rooms. Review of Resident #174's Physician Orders revealed an order for Zoloft 25 milligram (,) given by mouth every evening, initiated on 12/08/2021, for anxiety and insomnia. Behavior monitoring records for Resident #174 for after the incident on 12/06/2021 were requested; however, the facility did not provide any behavior monitoring records for the resident for after 12/06/2021. Review of Resident #10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Dementia with Behavioral Disturbance; Wandering; and COPD. Review of the Quarterly MDS Assessment, dated 11/18/2021, for Resident #10, revealed the facility assessed the resident with a BIMS score of three (3), which indicated severe cognitive impairment. Continued review of Resident #10's Minimum Data Set (MDS) Assessment revealed the facility assessed the resident as having no presence of physical, verbal or other behavioral symptoms during the assessment period. Review of Resident #10's Comprehensive Care Plan, dated 05/03/2021, revealed the facility had identified a problem area for wandering and sexually inappropriate behavior. Continued review of the wandering problem area revealed interventions which included target behavior monitoring for sexually inappropriate behaviors each shift; monitoring the resident's interaction with other residents and report inappropriate behaviors. Further review revealed the interventions also included for staff to administer Resident #10's medications as per order; perform every fifteen (15) minute checks of the resident; and obtain a psychiatric (psych) consult as needed. Review further revealed a goal for Resident #10 not to harm self or others secondary to his/her behaviors. Review of Resident #10's physician orders revealed an order, dated 12/06/2021, for Viibryd 10 mg tablet by mouth every day for seven (7) days which was to start on 12/07/2021 and end on 12/13/2021. Further review of the physician ' s orders revealed an order, dated 12/13/2021, to begin Paxil 10 mg by mouth daily for Anxiety on 12/14/2021. Review of Resident #10's Behavior Monitoring sheets revealed the resident had been placed on one (1) to one (1) monitoring beginning 12/06/2021. Continued review revealed Resident #10 remained on the one (1) to one (1) monitoring during the course of the survey with no further incidents. Review of Resident #10's Psychiatric Progress Note, dated 12/07/2021, revealed the resident had been referred related to recent sexually inappropriate behaviors, increased anxiety and for evaluation of possible pharmacological intervention to aid with the sexually inappropriate behaviors and Anxiety. Continued review revealed a recommendation for a gradual taper and dose reduction of Viibryd (antidepressant medication used to treat Major Depressive Disorder) 20 milligram (mg) daily. Further review revealed to reduce the Viibryd to 10 mg daily, and eventually discontinue the medication after seven (7) days, then initiate Paxil (antidepressant medication and also used to treat Anxiety) 10 mg by mouth daily. Observation of Resident #10 on 02/08/2022 at 12:40 PM, revealed the resident seated in the dining area interacting appropriately with other residents and a one (1) on one (1) staff member present with him/her. Observation of Resident #10, on 02/10/2022 at 10:34 AM, revealed the resident lying on the bed with eyes closed, and a one (1) on one (1) staff member present in the room. Review of the facility's investigation documentation for the 12/06/2021 incident involving Resident #10 and Resident #174, revealed the investigation concluded on 12/10/2021. Continued review revealed the facility did not substantiate sexual abuse had occurred as there had been no intent due to both residents having a diagnosis of Dementia and BIMS scores below eight (8). Further review revealed sexual abuse was not substantiated additionally because Resident #10 had his/her hand on Resident #174's thigh, with no other touching observed. Interview with Kentucky Medication Aide (KMA) #1, on 02/09/2022 at 9:35 AM, revealed she had been working when the incident occurred between Resident #174 and Resident #10 on 12/06/2021. KMA #1 stated she had been charting at the nurse's station when Resident #10's call light began going off, and she went to answer it. Per KMA #1, when she entered Resident #10's room through the closed door she observed the privacy curtain was also closed. Continued interview revealed she pulled the curtain back, and walked to the foot of the bed where she observed Resident #10 sitting at the head of the bed sitting upright with his /her feet on the floor, and his/her pants down to mid-thigh. KMA #1 stated she also observed Resident #174 with his/her pants down to mid-thigh, and Resident #10's hand had been on Resident #174's thigh. KMA #1 revealed she immediately separated the residents, and notified her charge nurse, Registered Nurse (RN) #2. Interview revealed RN #2 then notified the Administrator and Director of Nursing (DON) about the incident. She stated Resident #174 had not had wandering tendencies and had not had any incidents of sexually inappropriate behaviors prior to the incident with Resident #10 on 12/06/2021. KMA #1 revealed Resident #174 had been taken to his/her own room, and Resident #10 was placed on one (1) to one (1) monitoring immediately following the incident. Further interview revealed she was unsure of any specific interventions put in place for Resident #174 following that incident. KMA #1 further revealed, when asked if she had been trained on identifying and reporting abuse and management of residents with behaviors, she stated yes, she had been trained on abuse and management of behaviors. In addition, she revealed staff attempted to redirect residents if they were having behaviors and would attempt to engage them in an activity or conversation. She additionally revealed residents experiencing behaviors might also be placed on one (1) to (1) monitoring. Interview with State Registered Nurse Aide (SRNA) #6, on 02/10/2022 at 11:00 AM, revealed she had been working on 12/06/2021, when the incident occurred between Resident #174 and Resident #10. She stated she had not observed any inappropriate sexual behaviors or inappropriate touching with either resident during the time she provided care prior to 12/06/2021. SRNA #6 revealed she had been on break at the time the incident occurred. Continued interview revealed Resident #10 had been placed on one (1) to one (1) monitoring immediately after the incident on 12/06/2021. She stated Resident #174 frequently wandered into other residents' rooms, and staff would redirect him/her from the other resident's room. SRNA #6 revealed; however, she was unable to recall any specific interventions in place for Resident #174 following the incident involving Resident #10. Further interview revealed when asked if she had been trained on abuse, she stated yes, she had received abuse training and would report any potential abuse of a resident immediately to the charge nurse. Interview with the Unit Manager, on 02/09/2022 at 2:44 PM, revealed she was aware of the incident involving Resident #174 and Resident #10, that occurred on 12/06/2021. She stated Resident #10 had been placed on one (1) to one (1) monitoring on 12/06/2021, when the incident occurred. Continued interview revealed Resident #10 was still on the one (1) on one (1) monitoring by staff; however, she could not recall any specific interventions that were put in place for Resident #174 following the incident on 12/06/2021. The Unit Manager stated neither resident had a history of any incidents prior to 12/06/2021. Interview revealed when an incident occurred on the unit it was discussed in the morning clinical meeting, Monday through Friday, and resident care plans and interventions were reviewed. The Unit Manager revealed attendees of the morning clinical meeting were the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Administrator, Social Worker, and MDS Nurse. She stated, regarding the incident on 12/06/2021 involving Resident #174, that Resident #10 had been discussed in the morning clinical meeting. Further interview revealed Resident #174 and his/her behaviors had also been discussed in the morning clinical meeting; however, she did not recall any specific interventions having been implemented for Resident #174. She further stated the facility had identified that Resident #174 wandered into other residents' rooms and should have put interventions in place following the 12/06/2021 incident with Resident #10. In addition, the Unit Manager revealed the facility should have placed Resident #174 on increased monitoring following the incident. Interview with the facility's former Social Services Director (SSD), on 02/11/2022 at 10:00 AM, revealed she had worked at the facility for about a year and left her position at the facility on 12/29/2021. She stated she had been aware of the incident involving Resident #174 and Resident #10 on 12/06/2021, and did not recall any specific interventions which had been put into place for Resident #174 following the incident. Continued interview revealed she recalled Resident #10 had been placed on one (1) to one (1) monitoring after the incident on 12/06/2021. She stated Resident #10's behavior on 12/06/2021, had been a new behavior for the resident as he/she had no history of sexual behavior prior to the incident date. The former SSD stated they had not looked at Resident #174's behaviors after the incident, as the resident was known to wander frequently on the unit, and it was difficult to keep residents from wandering into other residents' rooms. She revealed when employed at the facility, she had been involved with residents' psych consults, referrals, and recommendations related to a resident's behaviors on the unit. Interview revealed residents' behaviors had been discussed in the facility's morning clinical meetings; however, the facility had not perceived Resident #174's behaviors as instigating the incident on 12/06/2021. The former SSD stated therefore, they had not made changes to Resident #174's care plan. Further interview revealed it might have helped to have placed Resident #174 on increased monitoring; however, they had not due to Resident #10 having been placed on one (1) to one (1) monitoring following the incident. The former SSD further stated the facility had not identified potential for abuse concern related to Resident #174's increased wandering into other residents' rooms, as the resident had already been care planned for his/her wandering behaviors. Interview with the former Administrator, on 02/11/2022 at 5:05 PM, revealed she had been the acting Administrator at the facility from June 2021 until December 20, 2021. She stated at the time of the incident on 12/06/2021 involving Resident #10 and Resident #174, she had been the facility's Abuse Coordinator. Continued interview revealed when staff was interviewed during the investigation of the 12/06/2021 incident, they stated nothing had happened as far as physical contact, except for Resident #10 having been observed with his/her hand on Resident #174's thigh. She revealed the skin assessments which had been completed of both residents, had not shown evidence of abuse. The former Administrator stated staff had not observed any other touching between the residents, and no one felt anything had happened, so she had not substantiated abuse had occurred. She stated both residents were seen by psych following the incident and Resident #10 was immediately placed on one (1) to one (1) monitoring after the incident. Further interview revealed she had received training on abuse by the company upon hire and had been trained on investigating and reporting abuse. The former Administrator further revealed the facility ensured residents were free from abuse, through screening all staff with a background check prior to hire, training the staff on abuse, and monitoring the residents for behaviors. 2. Review of the facility's Incident Report, dated 12/27/2021, revealed State Registered Nurse Aide (SRNA) #18 entered Resident #175's room for routine checks and found Resident #174 standing behind the door of the room, with his/her top disheveled and bra strap exposed. Continued review revealed SRNA #18 also observed Resident #175 lying on the bed with his/her pants and brief partially pulled down. Further review revealed the residents were immediately separated, and Resident #174 was directed back to his/her room. Review further revealed a head-to-toe assessment was completed on both residents with no injuries noted. In addition, review revealed Resident #175 had been placed on one (1) on (1) monitoring following the incident. Review of Resident #174's clinical record revealed the resident was admitted to the facility on [DATE], and was discharged home as a planned discharge with his/her spouse on 12/28/2021. Continued review revealed diagnoses which included Unspecified Dementia with Behavioral disturbance, and Wandering. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/05/2021, revealed the facility assessed Resident #174 with a Brief Interview for Mental Status (BIMS) score of one (1) which indicated he/she was severely cognitively impaired. Review of Resident #174's Comprehensive Care Plan dated 10/29/2021, revealed the facility had care planned the resident for wandering with interventions which included for staff to intervene as needed to protect the rights and safety of others, and remove Resident #174 from situations as needed, and take him/her to another location. Further review of the care plan revealed a goal for Resident #174 not to harm self or others, secondary to his/her behaviors. Additionally, review revealed no documentation of revisions made to his/her care plan following the 12/06/2021 sexually inappropriate incident, nor evidence of revisions made after the 12/27/2021 incident involving Resident #175. Review of Resident #175's medical record revealed the facility admitted the resident on 02/01/2021, with diagnoses including: Unspecified Psychosis; Parkinson's Disease; Unspecified Dementia; and Alzheimer's Disease. Review of Resident #175's Quarterly Minimum Data Set (MDS) Assessment, dated 10/29/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of two (2), indicating he/she was severely cognitively impaired. Review of Resident #175's Comprehensive Care Plan dated 11/26/2021, revealed a care plan had been developed for the resident's problem area of wandering. Continued review revealed care plan interventions which included intervening as needed to protect the rights and safety of others, and remove the resident from a situation and taking the resident to another location, as needed. Further review revealed the care plan goal was for Resident #175 not to harm self or others secondary to their behaviors. Interview with State Registered Nurse (SRNA) #7, on 02/10/2022 at 3:35 PM, revealed she had been working on 12/27/2021, when the incident occurred between Resident #174 and Resident #175. She stated she had been behind the nurse's station when SRNA #18 went into Resident #175's room during routine checks. Continued interview revealed SRNA #18 alerted her to come to assist as Resident #174 was in Resident #175's room. She stated by the time she arrived at the door to Resident #175's room, the residents had already been separated, and Resident #174 was exiting the room, with his/her shirt messed up. SRNA #7 stated Resident #175 had not had any issues of sexually inappropriate behaviors prior to the incident on 12/27/2021. Per interview with SRNA #7, Resident #174 frequently wandered into other residents' rooms and had to be redirected out of them by staff. Further interview revealed she did not recall any additional interventions which had been put in place for Resident #174; however, recalled Resident #175 had been immediately placed on one (1) on one (1) monitoring. The SRNA revealed she had been trained on abuse, and also trained on management of residents with Dementia and residents with behaviors. Interview with the Unit Manager, on 02/09/2022 at 2:44 PM, revealed she was aware of the incident with Resident #174 and Resident #175 that occurred on 12/27/2021. She stated Resident #175 had been placed on one (1) on one (1) monitoring on 12/27/2021, immediately following the incident. Continued interview revealed however, the Unit Manager could not recall any specific interventions which had been implemented for Resident #174 following the incident. She stated the facility had identified that Resident #174 wandered into other residents' rooms and should have placed the resident on increased monitoring following the incident. Further interview revealed staff had been trained on identifying and reporting abuse. Interview with the current Administrator, on 02/11/2022 at 4:23 PM, revealed she took the position of Administrator on 12/20/2021. She stated she was aware of the incident which occurred involving Resident #174 and Resident #175. Continued interview revealed she unsubstantiated the incident involving Resident #174 and Resident #175 on 12/27/2021, due to the facility having been unable to substantiate physical contact had occurred between the two (2) residents. The Administrator stated she had also been aware of the prior incident involving Resident #174; however, as the resident had already been identified as a wanderer, his/her increased behaviors had not been regarded as a concern. She revealed residents' behaviors were discussed in the facility's morning clinical meetings. Per interview, the DON, Unit Managers, SSD, Quality of Life staff person, and she all participated in the morning clinical meeting, discussed the residents ' behaviors, and reviewed and revised the residents' care plans as needed. Interview revealed facility staff was trained on managing residents with behaviors and the facility was currently working with their corporate Behavioral Health consultant on specific behavior training for staff. Further interview revealed staff was expected to provide for residents' safety, intervene as necessary, notify the Administrator, and put an immediate intervention in place after discussion with the Administrator and DON. 3. Review of the facility's Self-Reported Incident Form dated 01/15/2022, revealed on 01/15/2022, Kentucky Medication Aide (KMA) #3 reported to Licensed Practical Nurse (LPN) #10 that Resident #67 and Resident #175 were had been inappropriately touching one another (in a sexual manner). Further review of the facility's investigation documentation dated 01/21/2022, of the incident of inappropriate touching between Resident #67 and Resident #175 on 01/15/2022, revealed the Administrator had unsubstantiated sexual abuse had occurred based on information obtained from investigation. Review of Resident #67's medical record revealed the facility admitted the resident on 04/17/2021, with diagnoses including Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation and Chronic Obstructive Pulmonary Disease (COPD) and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #67, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of two (2) indicating severely impaired cognition. Further review of the MDS revealed the facility assessed Resident #67 as having no behaviors. Review of Resident #67's Comprehensive Care Plan, dated 07/01/2021, revealed the facility care planned the resident as at risk for elopement due to attempts by him/her to elope from the facility. Review of Resident #67's Progress Notes for July 2021 revealed the resident had been noted as having a behavior of wandering around unit. Further review of the Progress Notes revealed no other behaviors documented. Review of Resident #175's medical record revealed the facility admitted the resident on 02/01/2021, with diagnoses which included Alzheimer's Disease, Unspecified Dementia, and Unspecified Psychosis. Review of Resident #175's Quarterly MDS assessment dated [DATE], revealed the facility had assessed the resident as severely cognitively impaired as indicated by the BIMS score of two (2). Review of Resident #175's Comprehensive Care Plan revealed the facility had initiated a behavioral care plan on 11/26/2021, related to sexually inappropriate behaviors. Continued review of the care plan revealed no description of the sexually inappropriate behaviors the resident had displayed. Review revealed the behavior care plan interventions included: for staff to intervene as needed to protect other residents' rights and safety; approach the resident in a calm manner; and remove him/her from situations and take to another location as needed. Further review revealed additional interventions included to provide geriatric psychiatric services as needed and monitor the resident's behavioral episodes. Review of Resident #175's Progress Notes for November and December 2021 revealed Resident #175 had displayed sexually inappropriate behaviors on 11/22/2021, which were noted as the resident had groped a staff member on the buttocks and made sexual statements. Continued review revealed a Note dated 11/26/2021, which documented Resident #175 as having threatened staff and other residents, touching staff and other residents in a sexual manner, cursing, and making vulgar statements to staff and other residents. Review of a Note dated 12/01/2021, revealed Resident #175 had made a verbal sexual comment to a staff member. Review of a Note dated 12/11/2021, revealed Resident #175 made several sexual statements to staff and pinched staff on the butt. Further review of the Progress Notes revealed on 12/20/2021, Resident #175 had exhibited sexually inappropriate behavior of hitting staff on bottoms; and on 12/27/2021, the resident was noted as having increased sexual behaviors and making comments to staff. Interview with Kentucky Medication Aide (KMA) #3, on 02/09/2022 at 8:30 PM; and 02/10/2022 at 9:55 AM revealed Resident #67 and #175 had been actively engaged in sexual intercourse on 01/15/2022 when she entered Resident #175's room. She stated she separated the residents at once and immediately reported the incident to Licensed Practical Nurse (LPN) #10. KMA #3 revealed Resident #175 had previously made inappropriate sexual comments toward staff; however, she was not aware of the resident displaying any sexual behaviors toward other residents, prior to the incident involving Resident #67 on 01/15/2022. Interview on 02/11/2022 at 11:25 AM, with Licensed Practical Nurse (LPN) #10 revealed KMA #3 reported to her on 01/15/2022, she had found Resident #67 and Resident #175 actively engaged in sexual intercourse on the bed in Resident #175's room. LPN #10 stated she notified the Administrator immediately of the residents having been found actively engaged in sexual intercourse. KMA #3 stated she filled out a witness statement detailing her observations and that Resident #67 and Resident #175 were having intercourse. Interview with Resident #175's Power of Attorney (POA), on 02/10/2022 at 11:11 AM, revealed she had been aware the resident had made sexual comments towards nursing staff at the facility. Interview with Kentucky Medication Aide (KMA) #1, on 02/09/2022 at 8:46 PM, revealed Resident #175 had been sexually inappropriate towards staff and cursed at staff. Further interview revealed; however, she had not been aware of any incidents of sexual behaviors towards other residents prior to 01/15/2022. Interview with the Unit Manager, on 02/10/2022 at 3:12 PM, revealed Resident #175 had started having sexual behaviors towards staff more recently. Further interview revealed the Unit Manager had been [NAME] [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to thoroughly investigate three (3) allegations of sexual abuse involving four (4) of thirty (35) sampled residents (Resident #10, Resident #74, Resident #174 and Resident #175) to ensure appropriate action was taken to protect residents and prevent further sexual abuse/potential sexual abuse. Review of the facility's investigation, dated 12/06/2021, revealed Resident #174 and Resident #10 were found in Resident #10's room. Resident #10's pants were down to mid-thigh, as well as, Resident #174's pants down to mid-thigh. Resident #10 had his/her hand on Resident #174's thigh. Further review of the facility investigation revealed no root cause analysis was conducted following the incident and the facility failed to identify Resident #174's increased wandering as a potential factor in the incident. Review of the facility's investigation, dated 12/27/2021, revealed Resident #174 was found by staff behind the door in Resident #175's room, with his/her clothing disheveled and Resident #175 was on his/her bed pulling at his/her pants. Further review of the facility investigation revealed no root cause analysis was conducted following the incident and the facility failed to identify Resident #174's increased wandering although the resident was involved in a prior incident on 12/06/2021. Review of the Self-Reported Incident Form dated 01/15/2022, revealed on 01/15/2022, Kentucky Medication Aide (KMA) #3 reported to Licensed Practical Nurse (LPN) #10 that Resident #67 and Resident #175 were inappropriately touching one another. Further review of the facility investigation of the incident of inappropriate touching date 01/21/2022 revealed the administrator unsubstantiated sexual abuse based on information obtained from investigation. Interview with Kentucky Medication Aide (KMA) #3 revealed that Resident #67 and #175 were engaged in sexual intercourse on 01/15/2022 when she entered the room. She further stated that she separated the residents and immediately reported the incident to LPN #10. KMA #3 further stated in interview that she provided a written statement to the facility that stated Resident #67 and Resident #175 were engaged in sexual intercourse when she entered the room on 01/15/2022. Interview with LPN #10 revealed that on 01/15/2022 KMA #3 reported to her that Resident #67 and Resident #175 were engaged in sexual intercourse. LPN #10 stated she notified the administrator immediately that the residents had been engaged in sexual intercourse. Review of the facility's investigation revealed no witness statement from KMA #3 and interview with the administrator revealed even though she had an eye witness statement from KMA #3 stating Resident #67 and Resident #175 had been engaged in sexual intercourse, she did not believe sexual abuse occurred and therefore unsubstantiated sexual abuse. The facility's failure to thoroughly investigate allegations of sexual abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2022 and determined to exist on 12/06/2021 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600, F607, and F610) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657) at s/s of a J, and 42 CFR 483.70 Administration (F835) at a s/s of a J. The facility was notified of the Immediate Jeopardy on 02/12/2022. An acceptable Immediate Jeopardy removal plan was received on 02/22/2022, which alleged removal of the Immediate Jeopardy on 02/19/2022. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/19/2022, prior to exit on 02/24/2022, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, (F600, F607 and F610) 483.21 Comprehensive Resident Centered Care Plans (F657) and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 05/08/2019, revealed the facility Administrator would investigate all allegations and reports which could potentially constitute allegations of abuse. The policy stated the facility Administrator was ultimately responsible to oversee and complete the investigation and draw conclusions based on the nature of the incident. Further review revealed the facility Administrator was to make responsible efforts to determine the root cause of the violation. In addition, the policy revealed the Administrator was to implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident(s). 1. Review of the facility's investigation dated 12/06/2021, for the incident involving Resident #174 and Resident #10 which occurred on 12/06/2021, revealed the facility had unsubstantiated the allegation of sexual abuse as having occurred between Resident #174 and Resident #10. Continued review of the facility investigation revealed no witness statements were documented related to incident on 12/06/2021. Further review revealed the facility unsubstantiated abuse occurred due to both residents having BIMS below eight (8), there were no witnesses to any harm, and no injuries to either resident. No formal root cause analysis was conducted. Review of the clinical record for Resident #174 revealed the facility had admitted the resident on 10/29/2021, with diagnoses which included Wandering, and Unspecified Dementia with Behavioral disturbance. Review of the facility's Admission Minimum Data Set (MDS) Assessment for Resident #174 dated 11/05/2021, revealed the facility had assessed the resident as severely cognitively impaired, as indicated by a score of one (1) on the Brief Interview for Mental Status (BIMS) portion of the Assessment. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 04/20/2021, with diagnoses of Wandering, and Dementia with Behavioral Disturbance. Review of the facility's Quarterly MDS Assessment for Resident #10 dated 11/18/2021, revealed the facility had assessed the resident as severely cognitively impaired by the score of three (3) on the BIMS portion of the Assessment. Interview on 02/09/2022 at 9:35 AM, with Kentucky Medication Aide (KMA) #1 revealed she had been charting at the nurse's station when Resident #10's call light began going off. KMA #3 stated she went to answer the call light, and when she opened the closed door and entered the room the privacy curtain was pulled closed. Continued interview revealed she pulled the curtain back and saw Resident #10 sitting upright on the bed with his/her pants pulled down to mid-thigh. KMA #3 revealed she also saw Resident #174 with his/her pants down to mid-thigh with Resident #10's hand on Resident #174's thigh. KMA #1 stated she immediately separated the residents and notified her charge nurse Registered Nurse (RN) #2, who notified the Administrator and Director of Nursing (DON). Further interview revealed Resident #174 had always had wandering tendencies; however, had never had any incidents of inappropriate behaviors, prior to the incident with Resident #10 on 12/06/2021. KMA #1 further stated Resident #174 had been taken to his/her room and Resident #10 had been placed on one (1) to one (1) monitoring immediately following the incident. The KMA revealed however, she was unsure of any specific interventions which had been implemented for Resident #174 following the incident. Interview with the former Administrator on 02/11/2022 at 5:05 PM, revealed she had been the acting Administrator and the facility's Abuse Coordinator at the time of the incident on 12/06/2021, involving Resident #174 and Resident #10. The Administrator revealed when staff were interviewed during the investigation of the incident, it had been determined that nothing had happened as far as physical contact and no evidence of abuse (even though Resident #10's hand had been observed on Resident #174's thigh, while both residents' pants were pulled down to mid-thigh) She stated the staff interviewed had not observed any other touching, than Resident #10's hand on Resident #174's thigh, so she had not substantiated abuse as having occurred. According to the Administrator, Resident #10 had been immediately placed on one (1) to one (1) monitoring following the incident. Further interview revealed both residents were evaluated by psychiatric (psych) services after the incident occurred. The Administrator further revealed however, no increased monitoring had been initiated for Resident #174. In addition, the Administrator stated she had received training on abuse by the company when hired and trained on investigating and reporting abuse. 2. Review of the facility's Incident Report dated 12/27/2021, revealed SRNA #18 had found Resident #174 standing behind the door of Resident #175's room, with his/her top disheveled and bra strap exposed, and Resident #175 lying on the bed with his/her pants and brief pulled partially down. Review of the facility's investigation revealed no witness statements were obtained related to the incident on 12/06/2021. the facility unsubstantiated abuse occurred and the determining factors included that both residents had BIMS below eight (8), there were no witnesses to any harm, and no injuries to either resident. A root cause analysis was not performed. Review of the clinical record for Resident #174 revealed an admitted [DATE], and diagnoses of Unspecified Dementia with Behavioral disturbance, and Wandering. Review of Resident #174's Admission MDS assessment dated of 11/05/2021, revealed a BIMS score of one (1) which indicated the resident was severely impaired cognitively. Review of the clinical record for Resident #175 revealed an admitted [DATE], diagnoses which included Unspecified Dementia, Unspecified Psychosis, Parkinson's Disease, and Alzheimer's Disease. Review of the facility Quarterly MDS assessment dated [DATE], revealed a BIMS score of two (2) which indicated he/she had severely impaired cognition. Interview with State Registered Nursing Assistant (SRNA) #7 on 02/10/2022 at 3:35 PM, revealed, on the day of the incident involving Resident #174 and Resident #175, she had been at the nurse's station when SRNA #18 went into Resident #175's room during routine checks. She revealed SRNA #18 entered the room then called to her for assistance. Continued interview revealed SRNA #7 when she arrived at the doorway of Resident #175's room, Resident #174 was coming out of the room. She stated she could that Resident #174's shirt was messed up as he/she exited the room. SRNA #7 revealed she did not recall hearing of any physical contact occurring between the residents at the time of the incident. Further interview revealed Resident #174 frequently wandered into other residents' rooms and had to be redirected out of them by staff. The SRNA further revealed she did not recall additional interventions having been put into place for Resident #174 after the incident which involved Resident #174. She further stated however, Resident #175 had immediately been placed on one (1) on one (1) monitoring. Review of SRNA #18's witness statement dated 12/27/2021 revealed SRNA #18 entered Resident #175's room and opened the door to find Resident #174 standing behind the door with his/her shirt twisted and bra strap exposed through the shirt. The statement stated the SRNA immediately redirected Resident #174 out of the room. Further review revealed SRNA #18 observed Resident #175 lying on the bed attempting to pull his/her pants up. Telephone interviews were attempted with SRNA #18 on 02/11/2022, and on 02/14/2022. However, SRNA #18 was no longer employed at the facility, and the phone calls went unanswered. Interview on 02/11/22 11:47 AM and at 4:23 PM, with the Administrator revealed she was aware of the incident which occurred on 12/27/2021, between Resident #174 and Resident #175. The Administrator stated she unsubstantiated abuse regarding the incident because the facility had been unable to validate any physical contact had occurred between the two (2) residents. She stated she had been aware Resident #174 had been found in Resident #175's with his/her shirt disheveled; however, no evidence sexual abuse had occurred. Continued interview revealed when an incident occurred, as part of the investigation, the facility looked at the residents involved, and reviewed their plans of care. According to the Administrator, she had been aware of a prior incident involving Resident #174; however, the facility had not identified Resident #174's increased wandering behaviors as a concern for his/her safety. Further interview revealed staff monitored residents, and had been educated on abuse. The Administrator further stated the facility was responsible for protecting the rights of its residents. However, the facility failed to address Resident #174's behaviors of wandering into other residents rooms unsupervised which lead to Resident #174 being involved in two separate incidents of alleged sexual abuse. 3. Review of the facility's investigation document dated 01/21/2022, for the incident which occurred on 01/15/2022 involving Resident #175 and Resident #67, revealed the facility had unsubstantiated the allegation of inappropriate touching between the two (2) residents. Continued review of the investigation documentation revealed Housekeeper #2's written statement which noted Resident #175 had been standing in his/her room between the resident beds. Continued review of Housekeeper #2's written statement revealed Resident #67 had been lying on Resident #175's bed with his/her pants pulled down to top of his/her pubic area. Further review of the written statement revealed Housekeeper #2 exited the room, and went and got KMA #3 and the KMA took care of the problem after that. The investigation included no further written statements from staff. Further review of the investigation revealed no evidence of a root cause of the incident or any actions taken to prevent further incidents. Review of the facility's clinical record for Resident #67's revealed an admitted [DATE], with diagnoses which included Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Diastolic (Congestive) Heart Failure. The facility assessed Resident #67 in the Quarterly Assessment with a reference date of 11/13/2021, as having a Brief Interview for Mental Status (BIMS) score of two (2) indicating severely impaired cognition. Review of Resident #175's medical record revealed the facility admitted the resident on with diagnosis including Unspecified Psychosis, Parkinson's Disease, Unspecified Dementia and Alzheimer's Disease. Review of Resident #175's Quarterly MDS assessment dated of 10/29/2021, revealed a BIMS score of two (2) which indicated the resident was severely impaired cognitively. Interview on 02/09/2022 01:30 PM and 02/11/2022 04:25 PM, with Housekeeper #2 revealed she had left Resident #175's room after observing Resident #67 lying on Resident #175's bed with his/her pants down, and Resident #175 standing between the beds. She stated she left the room to go notify KMA #3 that she needed to go to Resident #175's room because she had seen Resident #67 in Resident #175's room lying on his/her bed. Further interview revealed Housekeeper #2 stated the facility's abuse policy directed staff to stay with a resident when alleged and/or suspected abuse incident occurred; however, she had not stayed with Resident #67 and Resident #175, as per the policy. Interview on 02/09/2022 at 8:30 PM and 02/10/2022 at 9:55 AM, with KMA #3 revealed after being notified by Housekeeper #2, she had gone to Resident #175's room. KMA #3 revealed upon entering the room, she observed Resident #67 and #175 actively engaged in sexual intercourse, and she immediately separated the residents, and reported the incident to Licensed Practical Nurse (LPN) #10. Interview on 02/11/22 at 11:47 AM and 4:43 PM, with the Administrator revealed all facility staff were expected to protect residents, and follow the facility's policy. The Administrator stated she was the facility abuse coordinator and was responsible to thoroughly investigate allegations of abuse. The Administrator further stated she was trained on investigating abuse when she was an Administrator at another facility. The Administrator stated due to the residents' cognitive impairment, there would be no willful intent to abuse, but stated she did not review their capacity to be able to consent to sexual activity. She revealed she had unsubstantiated sexual abuse occurring between Resident #67 and Resident #175. The Administrator revealed even though she had an eye witness statement from KMA #3 stating Resident #67 and Resident #175 had been engaged in sexual intercourse, she did not believe sexual abuse occurred. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/19/2022. 1.Incident # 1 occurred on 12/06/2021 involving Residents #174 and #10. The following steps were taken to ensure resident safety. For Resident #174, a skin assessment was completed on 12/06/2021, with no bruising, markings or concerns noted. The Care Plan was reviewed on 12/09/2021 by the Minimum Data Set (MDS) Coordinator, and interventions were updated on the resident's mood care plan. The MD (Medical Doctor) and the resident's POA (Power of Attorney) was notified on 12/06/2021. For Resident #10, the resident was placed on 1:1 supervision on 12/06/2021 and currently remains on 1:1 supervision. Resident #10's medications were reviewed on 12/07/2021 by the Psychiatric Nurse Practitioner and medication changes were made including Paxil started and Viibryd dose decreased. A Psychiatric Services Consult was completed for Resident #10 on 12/07/2021, and follow-up visits were completed on 12/14/2021 and 12/29/2021. The resident's care plan was reviewed by the Interim Director of Nursing (DON) on 12/06/2021 with new interventions added to the resident's psychosocial care plan. The MD and POA were notified of the incident on 12/06/2021. Incident #2 occurred on 12/27/2021 involving Resident #174 and Resident #175. For Resident #174, the Regional Nurse Consultant completed a skin assessment of Resident #174 on 12/27/21 with no concerns noted. Review of documentation revealed the resident's MD and POA were notified on 12/27/21. Resident #174 was discharged per a planned discharge to home on 12/28/2021. For Resident #175, a skin assessment was completed on 12/27/2021 by the Regional Nurse Consultant with no concerns identified. Resident #175 was provided 1:1 Supervision on 12/27/2021 and the elder was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. The resident's MD and Family were notified on 12/27/2021. The resident's care plan was updated on 02/18/2022 related to 1:1 status and the resident's discharge to a behavior unit on 12/27/2021 by the Regional Nurse consultant. Incident #3 occurred on 01/15/2022 involving Resident #67 and Resident #175. Resident #67 was found lying in the bed of elder #175. Both elders had pants off and were engaging in sexual activities. The following steps were taken to ensure resident safety. For Resident #67, a psychosocial follow-up was conducted for seventy-two (72) hours to provide psychosocial support and identify any concerns. The follow-ups were conducted on 01/15/2022, 01/16/2022, and 01/17/2022 by the Administrator. The Unit Manager reviewed the resident's care plan on 01/15/2022, to reflect the needs of the resident and to reflect the psychosocial follow-up. An assessment for physical trauma/injury was completed for Resident #67 via a skin assessment by the Unit Manager on 01/15/2022. The resident's MD and POA were notified of the incident on 01/15/2022. A Dementia Scale Pain Assessment and Pain Monitoring form that assesses the resident for pain by assessing the elders breathing, negative vocalization of pain, facial expressions, body language, and consolability was completed on 01/15/2022 by a Unit Manager with a score of zero (0) which indicated no pain. This assessment was noted to also indicate the resident was not in pain as did the baseline assessment completed on 12/06/2021 by Regional Nurse Consultant. For Resident #175, a skin assessment was completed on 01/15/2022 by a Unit Manager with no concerns noted. The resident was placed on 1:1 Supervision on 01/15/2022 and remained on 1:1 supervision until the resident was discharged from the facility on 02/22/2022. The resident was transferred to the hospital on 01/15/2022 and returned 01/26/2022 and remained on 1:1 supervision until transferred to the hospital on 02/01/2022 and returned on 02/10/2022. The Resident was then placed on 1:1 supervision upon return from the hospital and remained 1:1 until the resident was discharged from the facility on 02/22/2022. The resident's MD and Family were notified of the incident on 01/15/2022. The Administrator updated the resident's care plan on 01/15/2022 to reflect the resident's 1:1 status. The Housekeeper was initially educated on the abuse policy on 01/19/2022 by the facility Administrator which included protection of the resident and the Housekeeper was educated on the abuse policy on 2/16/2022 by the Staff Development Coordinator. 2. Residents residing in the facility have been assessed for any sign/ symptoms of potential abuse. Residents with a Brief Interview for Mental Status (BIMS) score of greater that eight (8) were interviewed by the Administrator and/or Unit Manager/Staff Development Coordinator for any concerns starting on 02/14/2022 and completed on 2/16/2022 with no issues identified. Residents currently residing in the facility with a BIMS of less than eight (8) were physically assessed by the Administrator, Unit Manager or Staff Development Coordinator for any signs and symptoms of potential abuse starting on 02/14/2022 with no concerns identified. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Regional Nurse Consultant or Regional [NAME] President (RVP) starting on 02/14/2022 and completed on 02/16/2022 for any indications of potential abuse concerns. No issues or concerns were identified. 3. Charts have been reviewed for all residents residing in the facility by the Independent Risk Manager for any resident status changes to include event managers and change of conditions for the past thirty (30) days starting on 02/14/2022 and completed on 02/16/2022. The charts were also reviewed for any potential abuse allegations that had not been previously reported with no concerns noted. 4. Care plans were reviewed by Regional Nurse Consultant #1, Regional Nurse Consultant #2 and the Behavioral Specialist starting on 02/16/2022 and completed on 02/18/2022 to ensure that the care plans were updated regarding behaviors, wandering and reflected the resident's current cognitive status. 5. All residents residing in the facility will had a BIMS assessment completed to ensure that all residents had an accurate assessment score by the Social Services Director starting on 02/14/2022 and completed on 02/15/2022. 6. Employees were interviewed by the Administrator, Staff Development Coordinator, and the Activities Director regarding any knowledge of unreported abuse or knowledge of any type of sexual relations that had not been previously reported starting on 02/16/2022 and completed on 2/18/2022 with no new concerns noted related to abuse reporting. 7. The Medical Director was notified of all the allegations on 12/06/2021, 12/27/2021, and 01/15/2022 by the Administrator in accordance with abuse reporting. The facility's Medical Director is the physician for Residents #10, Resident #67, Resident #174, and Resident #175. 8. The Senior [NAME] President of Regulatory Compliance educated the facility's Administrator/Regional [NAME] President and the Regional Nurse Consultant on the Center for Medicare/Medicaid Services (CMS) regulations for F610 and F835 on 02/17/2022 and the CMS regulations for F600, F607 and F657 on 02/18/2022 including: F610-responding to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his/her designated representative and to the other officials in accordance with state law, including to the state survey agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F 835, the facility must be administered in manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial wellbeing of each resident. The facility administration is not limited to the administrator and may also include the facility's governing body, management company, and/ or others identified by the facility as part of the facility administration. CMS's Abuse Critical Pathway and reporting guidelines. F600, residents have the right to be free from abuse, neglect, misappropriation, and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. F 607, The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property/ Establish policies and procedures to investigate any such allegations and include training as required and establish coordination with the QAPI program as required. F 657, to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs., and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. 9. Starting on 02/17/2022 all allegations of abuse including physical, verbal, mental, sexual, misappropriation, neglect, involuntary seclusions, corporal punishment, injuries of unknown origin, and exploitation would be reviewed by the Regional [NAME] President, Risk Manager, and/or [NAME] President of Clinical Operations to ensure that a complete, thorough, and accurate investigation has been completed for the reportable events for the next 90 days through 05/20/2022. 10. All reportable incidents were reviewed from the last six (6) months from 08/01/2021, through 02/16/2022 by the [NAME] President of Clinical Operations starting on 02/16/2021 and completed on 02/17/2022 with no concerns noted. 11. The facility Administrator, Regional [NAME] President, Regional Nurse Consultant #1 and Regional Nurse Consultant #2, Unit Manager, Business Office Manager, Assistant Business Office Manager, Activities Director, Rehab Service Manager, Scheduler, and the Staff Development Coordinator (SDC) were educated on the abuse policy to include sexual abuse on 02/14/2022 by the Director of Behavioral Health Services. The education included the following: Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with an emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. Resident Rights include that resident had the right to be free from abuse The Behavior Management policy includes supervision and interventions to redirect residents when behaviors occur. Care plan policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs. Change of Condition Policy and Procedure, to include Physician and Family notification Quality Assurance Performance Improvement (QUAPI) policy and procedure to include process improvement and monitoring. 12. Once the facility Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were educated on (a) Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. (b) the resident's right to free from abuse (c) Behavior Management policy to include supervision and interventions to redirect residents when behaviors occur. (d) Care plan policy and procedure, to include appropriately updating the residents' care plan to reflect residents' current care needs. (e) Change of Condition Policy and Procedure, to include Physician and Family notification and (f) the QAPI policy and procedure to include process improvement and monitoring. The Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were then assigned to re-educate all staff working in the facility, to include agency staff, in small groups which started on 02/15/2022 and was completed by 02/18/2022. On 02/18/2022, certified letters were sent out to the remaining PRN (as needed) staff, staff on vacation, or staff on Family Medical Leave Act (FMLA). No employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on the post-test, then the employee would be immediately re-educated, and the post-test will be re-administered. This education would be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process would continue until employee obtains a 100% score on post-test. 13. A staff post-test regarding the above education to include types of abuse, protection of the resident, and notification of abuse including MD notification would be administered daily, starting on 02/19/2022. The test will be administered by the Administrator, DON, Nursing Supervisors, SDC, Business office manager, Assistant Business Office Manager or Activities Director to six (6) different staff members on different shifts daily for two (2) weeks. After two (2) weeks, then four (4) staff member's questionnaires daily to different staff members on different shifts for two (2) weeks. Results of the staff tests will be reported to the Quality Assurance (QA) committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. 14. All grievances were reviewed on 02/18/2022 by the Regional Nurse Consultant for the last thirty (30) days to determine if any items documented were a reportable event or if concerns were not resolved. No issues were identified. The Administrator or Director of Nursing would review grievances daily for two (2) weeks starting 02/18/2022, to determine if there were any concerns related to resident abuse. The Administrator would repor [TRUNCATED]

Based on interview, record review, and review of facility policy it was determined the facility failed to review and revise the person-centered comprehensive care plan for four (4) of thirty-five (35) sampled residents (Resident #10, Resident #37, Resident #67, Resident #174 and Resident #175). Record review and interview revealed Resident #37, Resident #67, Resident #174, and Resident #175 had displayed behaviors that put them at risk for abuse and had care plans in place for behavioral problems. Review of the facility's investigation revealed, on 12/06/2021, Resident #174 and Resident #10 were found in Resident #10's room with Resident #10's pants down to mid-thigh. Resident #174's pants were down to mid-thigh and Resident #10 had his/her hand on Resident #174's thigh. Further review of the care plans for Resident #10 and Resident #174 revealed no evidence the care plan was revised after the incident to prevent further incidents. Review of the facility's Incident Report dated 12/21/2021, revealed Kentucky Medication Aide (KMA) #1 had entered Resident #37's room after hearing a noise in the room. Further review revealed upon entering the resident's room, KMA #1 observed Resident #37 holding an empty cup, and Resident #174 with water on his/her face and both residents were pulling each other's hair. Further review revealed the residents were immediately separated. Review of the care plan for Resident #37 and Resident #174 revealed the care plan was not revised after the incident to prevent further incidents. Review of a facility investigation revealed on 12/27/2021, Resident #174 was found in Resident #175's room. Resident #174 was found by staff behind the door in Resident #175's room with his/her clothing disheveled and Resident #175 was on the bed pulling at his/her pants. Review of the care plans for Resident #174 and Resident #175 revealed the care plans were not revised after the incident to prevent further incidents. Review of a facility investigation and interview with facility staff revealed on 01/15/2022, Resident #67 was found in Resident #175's room engaged in sexual intercourse. Review of the care plans for the residents revealed the care plans were not revised for Resident #67 and Resident #175 with individualized interventions to prevent further incidents. In addition, on 12/21/2021, Resident #174 wandered into Resident #37's room and upon entering the room staff found Resident #174 had water on his/her face with Resident #37 holding an empty cup and both residents were pulling each other's hair. The residents were immediately separated, and Resident #37 was placed on one (1) on one (1) monitoring following the incident and referred to psych for evaluation. There was no evidence that the care plans were reviewed and revised to prevent further incidents. The facility's failure to ensure resident person-centered care plans were reviewed and revised has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2022 and determined to exist on 12/06/2021 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600, F607, and F610) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657) at s/s of a J, and 42 CFR 483.70 Administration (F835), at s/s of a J. The facility was notified of the Immediate Jeopardy on 02/12/2022. An acceptable Immediate Jeopardy removal plan was received on 02/22/2022, which alleged removal of the Immediate Jeopardy on 02/19/2022. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/19/2022, prior to exit on 02/24/2022, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, (F600, F607 and F610) 483.21 Comprehensive Resident Centered Care Plans (F657) and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 07/19/2018 revealed the facility developed person-centered comprehensive care plans that included measurable objectives and timetables for each resident's medical, nursing, mental and psychosocial needs. Continued review revealed care plans were ongoing and revised as information about the resident and the resident's condition changed. Review revealed care plan interventions were implemented after consideration of the resident's problem areas and causes. Further review revealed the interventions were to address the underlying source(s) of the resident's problem area(s), rather than addressing only symptoms or triggers. Review further revealed the interventions were to reflect action, treatment, or procedure to meet the objectives toward achieving the resident's goals. 1. Review of Resident #174's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Unspecified Dementia with Behavioral Disturbance, and Wandering. Review of the facility's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #174 to have a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident had severe cognitive impairment. Continued review of the Admission MDS Assessment revealed the facility had assessed Resident #174 as having behaviors placed him/her at risk of physical illness or injury, which significantly interfered with the resident's care, and wandering behaviors that significantly intruded on the privacy or activities of others during the assessment period. Review of the facility's Comprehensive Care Plan for Resident #174 dated 10/29/2021, revealed a problem area noted regarding the resident's wandering behavior. Continued review revealed the care plan interventions included for staff to remove the resident from a situation and take him/her to another location as needed, and to intervene as needed to protect the rights and safety of others. Review of the facility's Incident Report dated 12/06/2021 revealed Kentucky Medication Aide (KMA) #1 responded to Resident #10's call light. Review revealed upon entering the resident's room KMA #1 observed Resident #174 lying on the bed with his/her pants pulled down to the thigh area, and Resident #10 seated at the head of the bed, feet on floor with his/her pants pulled down to knees. Continued review revealed Resident #10 had his/her hand on Resident #174's thigh area. Further review revealed the residents were immediately separated and a head to toe skin assessment was conducted of both. In addition, review further revealed no injuries were found on either resident, both residents were unable to recall the incident, and Resident #10 was placed on one (1) to one (1) monitoring. Continued review of Resident #174's care plan dated 10/29/2021, revealed no documented evidence of revisions made to the resident's care plan following the incident on 12/06/2021, involving Resident #10. Interview on 02/09/2022 at 9:35 AM, with KMA #1 revealed she had been charting at the nurse's station when Resident #10's call light started going off. Per KMA #1, she went to answer the call light, and the room door was closed. She stated she entered the room and the privacy curtain was pulled closed. Continued interview revealed she pulled the curtain open and observed Resident #10 sitting upright on the bed with his/her feet on the floor, and his/her pants down to mid-thigh. KMA #1 stated she also observed Resident #174 and his/her pants were also down to mid-thigh, and Resident #10's hand was lying on Resident #174's thigh. Further interview revealed Resident #10 had been placed on one (1) to one (1) monitoring immediately following the incident; however, she was not aware of any specific interventions having been put in place for Resident #174 after the incident. In addition, she stated Resident #174 was known to wander, but had not had any incidents of inappropriate behavior prior to the incident with Resident #10. Interview with the Unit Manager on 02/09/2022 at 2:44 PM revealed neither of the two (2) residents involved in the 12/06/2021 incident, Resident #10 and Resident #174, had a history of any incidents prior to that date. The Unit Manager revealed after the incident on 12/06/2021, Resident #10 had been placed on one (1) on one (1) monitoring and remained on one (1) on one (1) at the time of interview. Continued interview revealed the Unit Manager could not recall any specific interventions which had been implemented for Resident #174 following the incident. Additionally, the UM stated the facility had identified Resident #174's behavior of wandering into other residents' rooms and the resident's care plan should have been reviewed and revised with interventions implemented following the 12/06/2021 incident involving Resident #10. Interview with the former Social Services Director (SSD), on 02/11/2022 at 10:00 AM, revealed she was unable to recall any specific interventions which were put into place for Resident #174 following the incident with Resident #10 on 12/06/2021. Continued interview revealed; however, she did recall Resident #10 had been placed on one (1) to one (1) monitoring. She stated the facility had not looked at Resident #174's behaviors as the resident was known to wander frequently on the unit and it was difficult to keep the residents on that unit from wandering into other residents' rooms. She stated residents' behaviors had been discussed in the morning clinical meetings, which included Resident #174's behaviors; however, the facility had not perceived Resident #174's behaviors as instigating the incident with Resident #10. Further interview revealed it might have helped to place Resident #174 on increased monitoring; however, had not done that due to Resident #10 having been placed on one (1) to one (1) monitoring following the incident. The former SSD further stated the facility had not identified a potential for abuse concern regarding Resident #174's increased wandering into other residents' rooms, as the resident had already been care planned for his/her wandering behaviors. Interview with the former Administrator on 02/11/2022 at 5:05 PM, revealed she been the acting Administrator and facility's Abuse Coordinator when the incident involving Resident #174 and Resident #10 occurred on 12/06/2021. The former Administrator stated following the incident both the residents were evaluated by psych services, and Resident #10 had been placed on one (1) on one (1) monitoring immediately following the incident. Further interview revealed the former Administrator had been unable to recall any specific care plan revisions or interventions implemented for Resident #174. The former Administrator further stated however, Resident #174's and Resident #10's care plans should have been reviewed and revised following the incident which occurred on 12/06/2021. 2. Review of the clinical record for Resident #37 revealed the resident had been admitted to the facility on [DATE], with diagnoses which included Delirium due to psychological condition, and Dementia with Behavioral Disturbance. Review of the facility's Quarterly MDS assessment dated [DATE] for Resident #37 revealed the facility assessed the resident with a BIMS score of three (3), which indicated severe cognitive impairment. Continued review of the MDS Assessment revealed the facility had assessed Resident #37 as having verbal behaviors of screaming, cursing or threatening others during the observation period. Further review of the MDS Assessment revealed the facility had assessed Resident #37 as having no occurrences of physical behaviors during the observation period. Review of Resident #37's care plan dated 04/12/2021 revealed a problem area of behaviors with interventions to Administer and observe effectiveness and side effects of medications as ordered, intervene as needed to protect rights and safety of others, approach in calm manner, divert attention, remove from situation and take to another location as needed, with goal that resident will not harm themselves or others secondary to behaviors. Review of the clinical record for Resident #174's revealed an admitted [DATE], and diagnoses which included Wandering and Unspecified Dementia with Behavioral Disturbance. Review of Resident #174's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as severely cognitively impaired as indicated by a BIMS score of one (1). Continued review of the Admission MDS Assessment revealed Resident #174 had been assessed to have wandering behaviors which markedly intruded on other people's privacy or activities. Further review of the Assessment revealed Resident #174 had also been assessed with behaviors which placed the resident at risk of injury. Review of Resident #174's Comprehensive Care Plan dated 10/29/2021, revealed the facility had care planned the resident for his/her wandering behaviors. Review revealed the care plan interventions included for staff to intervene as needed to protect the rights and safety of others, and remove Resident #174 from a situation and move the resident to another location as needed. Further review revealed the goal was for Resident #174 not to harm self or others resultant to his/her behaviors. Review of the facility's Incident Report dated 12/21/2021, revealed KMA #1 had entered Resident #37's room after hearing a noise there. Review revealed upon entering the resident's room KMA #1 observed Resident #37 holding an empty cup, and Resident #174 with water on his/her face, both residents pulling each other's hair. Further review revealed the residents were immediately separated, and Resident #37 was placed on one (1) on one (1) monitoring and referred for a psychiatric evaluation due to his/her increased behaviors. However, further review of Resident #37's Comprehensive Care Plan dated 04/12/2021, revealed no documented evidence of revisions made to the resident's care plan following the incident with Resident #174 on 12/21/2021. (Even though the Incident Report noted the resident had been placed on the one [1] to one [1] monitoring and had been referred for a psych evaluation due to his/her increase behaviors) Further review of Resident #174's Comprehensive Care Plan dated 10/29/2021, revealed no documented evidence of revisions made to the resident's care plan following the incident with Resident #37 on 12/21/2021. Interview on 02/10/2021 at 10:38 AM with KMA #1 revealed she had been working on documentation behind the nursing station on 12/21/2021, when she heard a ruckus going on in Resident #37's room. KMA #1 stated upon entering the resident's room she observed Resident #37 to have an empty cup in his/her hand, and Resident #174 with water on his/her face, and the two (2) residents pulling each other's hair. Continued interview revealed she immediately separated the residents and notified the Unit Manager and the Administrator. Further interview revealed Resident #37 had been placed on one (1) to one (1) monitoring immediately after the incident; however, she could not recall Resident #174 having been placed on any specific interventions after the incident. Interview on 02/10/2022 at 11:00 AM with SRNA #6 revealed she had not been working when the 12/21/2021 incident between Resident #37 and Resident #174 occurred. She stated however, she was aware Resident #37 had been placed on one (1) to one (1) monitoring after the incident. Further interview revealed she could not recall any specific behavior interventions put into place for Resident #174 after the incident though. Interview with Unit Manager on 02/09/22 at 2:44 PM revealed Resident #37 was immediately placed on one (1) on one (1) monitoring after the incident on 12/21/2021. She stated she recalled discussion of Resident #174's behaviors after the incident; however, did not recall any specific behavior interventions implemented for the resident after the incident though. Continued interview revealed Resident #174's wandering into other residents' rooms behavior should have had interventions put in place following the first incident on 12/06/2021 which involved Resident #10. Further interview revealed an intervention to increase Resident #174's monitoring should have also been implemented after the first incident. In addition, she revealed Resident #37's and Resident #174's care plans should have been reviewed and revised following the incident on 12/21/2021. Interview with former Social Services Director (SSD) on 02/11/2022 at 10:00 AM, revealed additional interventions for Resident #174 and Resident #37 had not really been discussed after the incident on 12/21/2021, because both residents had already been care planned for their Dementia diagnoses and wandering behaviors. Further interview revealed the facility had determined the incident occurred due to Resident #37 becoming upset that Resident #174 had wandered into his/her room, therefore, the residents care plans were not reviewed and revised following the incident. Interview with the Administrator on 02/11/22 at 4:23 PM, revealed Resident #174 had wandered into Resident #37's room and Resident #37 had thrown water in Resident #174's face. The Administrator stated when staff entered Resident #37's room, the two (2) residents were also observed pulling each other's hair. Continued interview revealed Resident #37 was known to be territorial of his/her space and did not like others in his/her space. She stated the facility felt Resident #37 had been the aggressor in the incident due to being territorial and had thrown water on Resident #174. Per interview, Resident #37 was immediately placed on one (1) to one (1) monitoring following the incident. She stated Resident #174's care plan was reviewed following the incident with Resident #37; however, the resident's care plan was not revised with new interventions due to Resident #37 having been placed on one (1) to one (1) monitoring. Further interview revealed the facility should have put new interventions in place for Resident #174's wandering behaviors though, and his/her behaviors should have been thoroughly addressed on the resident's care plan. The Administrator further stated both residents' care plans should have been reviewed and revised following the incident on 12/21/2021. 3. Review of the facility's Self-Reported Incident Form dated 01/15/2022, revealed KMA #3 reported to a nurse (Licensed Practical Nurse #10) on 01/15/2022, that Resident #67 and Resident #175 had been inappropriately touching one another. Review of the facility's investigation documentation of the incident of inappropriate touching date 01/21/2022, revealed the Administrator unsubstantiated sexual abuse based on information obtained from investigation. Review of Resident #175's clinical record revealed the facility admitted him/her on 02/01/2021, with diagnoses including Unspecified Psychosis, Parkinson's Disease, Unspecified Dementia and Alzheimer's Disease. Review of Resident #175's Quarterly MDS assessment dated [DATE], revealed the resident had been assessed to have a BIMS score of two (2), indicating severely impaired cognition. Review of the Comprehensive Care Plan for Resident #175 revealed on 11/26/2021 a behavioral care plan for sexually inappropriate behaviors had been initiated. Continued review of the care plan revealed no description of the sexually inappropriate behavior Resident #175 had displayed. Review of the care plan revealed the interventions included: intervene as needed to protect the rights and safety of others, approach in a calm manner, divert attention, and remove from the situation and take to another location as needed. Further review of the care plan revealed additional interventions which included geriatric psychiatric services as needed and to monitor behavioral episodes. Review of the Progress Notes for Resident #175 for the months of November and December 2021 revealed the resident had displayed sexually inappropriate behaviors on 11/22/2021, where he/she groped a staff member's buttocks and made sexual statements. Continued review revealed a Note dated 11/26/2021 which noted Resident #175 was threatening other staff and residents, cursing and making vulgar comments, and was touching staff and other residents. Further review revealed a Note dated 12/01/2021 which documented Resident #175 had made a verbal sexual comment to a staff member, and a Note dated 12/11/2021, which noted the resident made several sexual statements towards staff and pinched staff on the butt. Additional review of the Progress Notes revealed a Note dated 12/20/2021, documenting Resident #175 had exhibited sexually inappropriate behavior by hitting staff on bottoms; and a Note dated 12/27/2021, which recorded the resident as having increased sexual behaviors of making comments to staff. Further review of Resident #175's Comprehensive Care Plan revealed the care plan had not been updated to reflect the sexual behaviors toward resident(s) and staff documented in the Progress Notes. Interview with KMA #3 on 02/09/2022 at 8:30 PM and 02/10/2022 at 9:55 AM, revealed Resident #67 and #175 had been actively engaged in sexual intercourse on 01/15/2022, when she entered the room. She further stated she separated the residents and immediately reported the incident to LPN #10. 4. Review of Resident #67's clinical record revealed the facility admitted the resident on 04/17/2021, with diagnosis including Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly MDS assessment dated [DATE], revealed a BIMS score of two (2) which indicated severely impaired cognition. Further review of the MDS revealed the resident had been assessed to have no behaviors. Review of the Comprehensive Care Plan for Resident #175 dated 07/01/2021, revealed the resident had been care planned as at risk for elopement due to attempts to elope from the facility. Review of Progress Notes for July 2021 for Resident #67 revealed the resident had been care planned for wandering around [the] unit, with no other behaviors documented. Further review of Resident #67's care plan revealed no documented evidence of any revisions/updates to address sexual behaviors toward other resident(s). Interview with the facility's Minimum Data Set (MDS) Coordinator on 02/12/22 at 5:32 PM, revealed the facility's Interdisciplinary Team (IDT) had the responsibility to ensure residents' care plans were updated/revised. She stated Resident #67's and Resident #175's care plan should have been updated and revised to reflect any new and/or worsening behaviors. Further interview revealed she was unaware why the resident's care plans were not accurately revised/updated. Interview with the Director of Nursing (DON) on 02/11/2022 at 4:22 PM revealed she expected the MDS staff to update and revise each resident's plan of care and make necessary changes as needed. The DON stated she routinely reviewed resident care plans to ensure their appropriateness. Interview with the Administrator on 02/11/2022 at 04:15 PM revealed she expected revisions be made to each resident's care plan timely and appropriately. The Administrator stated she had not identified any concerns with care plans not being revised when a change occurred. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/19/2022. 1.Incident # 1 occurred on 12/06/2021 involving Residents #174 and #10. The following steps were taken to ensure resident safety. For Resident #174, a skin assessment was completed on 12/06/2021, with no bruising, markings or concerns noted. The Care Plan was reviewed on 12/09/2021 by the Minimum Data Set (MDS) Coordinator, and interventions were updated on the resident's mood care plan. The MD (Medical Doctor) and the resident's POA (Power of Attorney) was notified on 12/06/2021. For Resident #10, the resident was placed on 1:1 supervision on 12/06/2021 and currently remains on 1:1 supervision. Resident #10's medications were reviewed on 12/07/2021 by the Psychiatric Nurse Practitioner and medication changes were made including Paxil started and Viibryd dose decreased. A Psychiatric Services Consult was completed for Resident #10 on 12/07/2021, and follow-up visits were completed on 12/14/2021 and 12/29/2021. The resident's care plan was reviewed by the Interim Director of Nursing (DON) on 12/06/2021 with new interventions added to the resident's psychosocial care plan. The MD and POA were notified of the incident on 12/06/2021. Incident #2 occurred on 12/27/2021 involving Resident #174 and Resident #175. For Resident #174, the Regional Nurse Consultant completed a skin assessment of Resident #174 on 12/27/21 with no concerns noted. Review of documentation revealed the resident's MD and POA were notified on 12/27/21. Resident #174 was discharged per a planned discharge to home on 12/28/2021. For Resident #175, a skin assessment was completed on 12/27/2021 by the Regional Nurse Consultant with no concerns identified. Resident #175 was provided 1:1 Supervision on 12/27/2021 and the elder was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. The resident's MD and Family were notified on 12/27/2021. The resident's care plan was updated on 02/18/2022 related to 1:1 status and the resident's discharge to a behavior unit on 12/27/2021 by the Regional Nurse consultant. Incident #3 occurred on 01/15/2022 involving Resident #67 and Resident #175. Resident #67 was found lying in the bed of elder #175. Both elders had pants off and were engaging in sexual activities. The following steps were taken to ensure resident safety. For Resident #67, a psychosocial follow-up was conducted for seventy-two (72) hours to provide psychosocial support and identify any concerns. The follow-ups were conducted on 01/15/2022, 01/16/2022, and 01/17/2022 by the Administrator. The Unit Manager reviewed the resident's care plan on 01/15/2022, to reflect the needs of the resident and to reflect the psychosocial follow-up. An assessment for physical trauma/injury was completed for Resident #67 via a skin assessment by the Unit Manager on 01/15/2022. The resident's MD and POA were notified of the incident on 01/15/2022. A Dementia Scale Pain Assessment and Pain Monitoring form that assesses the resident for pain by assessing the elders breathing, negative vocalization of pain, facial expressions, body language, and consolability was completed on 01/15/2022 by a Unit Manager with a score of zero (0) which indicated no pain. This assessment was noted to also indicate the resident was not in pain as did the baseline assessment completed on 12/06/2021 by Regional Nurse Consultant. For Resident #175, a skin assessment was completed on 01/15/2022 by a Unit Manager with no concerns noted. The resident was placed on 1:1 Supervision on 01/15/2022 and remained on 1:1 supervision until the resident was discharged from the facility on 02/22/2022. The resident was transferred to the hospital on 01/15/2022 and returned 01/26/2022 and remained on 1:1 supervision until transferred to the hospital on 02/01/2022 and returned on 02/10/2022. The Resident was then placed on 1:1 supervision upon return from the hospital and remained 1:1 until the resident was discharged from the facility on 02/22/2022. The resident's MD and Family were notified of the incident on 01/15/2022. The Administrator updated the resident's care plan on 01/15/2022 to reflect the resident's 1:1 status. The Housekeeper was initially educated on the abuse policy on 01/19/2022 by the facility Administrator which included protection of the resident and the Housekeeper was educated on the abuse policy on 2/16/2022 by the Staff Development Coordinator. 2. Residents residing in the facility have been assessed for any sign/ symptoms of potential abuse. Residents with a Brief Interview for Mental Status (BIMS) score of greater that eight (8) were interviewed by the Administrator and/or Unit Manager/Staff Development Coordinator for any concerns starting on 02/14/2022 and completed on 2/16/2022 with no issues identified. Residents currently residing in the facility with a BIMS of less than eight (8) were physically assessed by the Administrator, Unit Manager or Staff Development Coordinator for any signs and symptoms of potential abuse starting on 02/14/2022 with no concerns identified. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Regional Nurse Consultant or Regional [NAME] President (RVP) starting on 02/14/2022 and completed on 02/16/2022 for any indications of potential abuse concerns. No issues or concerns were identified. 3. Charts have been reviewed for all residents residing in the facility by the Independent Risk Manager for any resident status changes to include event managers and change of conditions for the past thirty (30) days starting on 02/14/2022 and completed on 02/16/2022. The charts were also reviewed for any potential abuse allegations that had not been previously reported with no concerns noted. 4. Care plans were reviewed by Regional Nurse Consultant #1, Regional Nurse Consultant #2 and the Behavioral Specialist starting on 02/16/2022 and completed on 02/18/2022 to ensure that the care plans were updated regarding behaviors, wandering and reflected the resident's current cognitive status. 5. All residents residing in the facility will had a BIMS assessment completed to ensure that all residents had an accurate assessment score by the Social Services Director starting on 02/14/2022 and completed on 02/15/2022. 6. Employees were interviewed by the Administrator, Staff Development Coordinator, and the Activities Director regarding any knowledge of unreported abuse or knowledge of any type of sexual relations that had not been previously reported starting on 02/16/2022 and completed on 2/18/2022 with no new concerns noted related to abuse reporting. 7. The Medical Director was notified of all the allegations on 12/06/2021, 12/27/2021, and 01/15/2022 by the Administrator in accordance with abuse reporting. The facility's Medical Director is the physician for Residents #10, Resident #67, Resident #174, and Resident #175. 8. The Senior [NAME] President of Regulatory Compliance educated the facility's Administrator/Regional [NAME] President and the Regional Nurse Consultant on the Center for Medicare/Medicaid Services (CMS) regulations for F610 and F835 on 02/17/2022 and the CMS regulations for F600, F607 and F657 on 02/18/2022 including: F610-responding to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his/her designated representative and to the other officials in accordance with state law, including to the state survey agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F 835, the facility must be administered in manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial wellbeing of each resident. The facility administration is not limited to the administrator and may also include the facility's governing body, management company, and/ or others identified by the facility as part of the facility administration. CMS's Abuse Critical Pathway and reporting guidelines. F600, residents have the right to be free from abuse, neglect, misappropriation, and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical re [TRUNCATED]

Based on interview, record review, review of the Administrator's Job Description, and review of the facility's policies and procedures, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being and protect its residents from abuse/potential abuse. The facility's Administration failed to ensure residents were free from abuse; failed to ensure its abuse policies were implemented; failed to ensure thorough investigations of abuse allegation incidents were conducted; and, failed to implement residents' Comprehensive Care Plans (CPs) for four (4) of four (4) allegations of resident abuse. (Refer to F600, F607, F610, and F656) The facility's failure to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to protect its residents from abuse/potential abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2022 and determined to exist on 12/06/2021 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600, F607, and F610), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 02/12/2022. An acceptable Immediate Jeopardy removal plan was received on 02/22/2022, which alleged removal of the Immediate Jeopardy on 02/19/2022. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/19/2022, prior to exit on 02/24/2022, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect and Explotation, (F600, F607 and F610) 483.21 Comprehensive Resident Centered Care Plans (F657) and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Job Description for the Administrator with a revision date of December 2018, revealed the Administrator was to lead and direct the overall operations of the facility in accordance with government regulations. Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property with a revision date of 05/08/2019, revealed the Administrator was to investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of crime. Review further revealed the facility's Administrator retained the ultimate responsibility for overseeing and completing the investigations, and to draw conclusions regarding the nature of the incident. 1. Review of the Self-Reported Incident Form dated 01/15/2022, revealed on 01/15/2022, a Kentucky Medication Aide (KMA) reported to the nurse her observation of Resident #67 and Resident #175 inappropriately touching one another. Review of the facility's investigation of the incident dated 01/15/2022, revealed no documented evidence of written statements from KMA #3 or LPN #10 regarding the incident. Interview with KMA #3, on 02/09/2022 at 8:30 PM and 02/10/2022 at 9:55 AM, revealed she had observed Resident #67 and #175 actively engaged in sexual intercourse on 01/15/2022. Review of Resident #67's and Resident #175's clinical record revealed both residents had been assessed as severely cognitively impaired making them unable to consent to sexual activity with another person. Interview with the Administrator, on 02/11/2022 at 11:47 AM, revealed she unsubstantiated sexual abuse for the 01/15/2022 investigation. Interview revealed the Administrator stated the investigation for the 01/15/2022 incident had been unsubstantiated due to Resident #67 and #175 had no willful intent for sexual abuse. Further interview revealed the witnesses had given conflicting statements. 2. Review of the Self-Reported Incident Form dated 12/27/2021, revealed a State Registered Nurse Aide (SRNA) reported to a charge nurse her observation of Resident #175 lying on the bed pulling at the waist of his/her pants, and Resident #174 with his/her blouse disheveled. Review of the Witness Statement completed by the SRNA revealed Resident #174 had been standing behind the door of Resident #175's room with his/her shirt twisted and his/her bra showing through the crisscross of his/her shirt. Continued review revealed the SRNA noted observing Resident #175 on his/her bed with his/her pants down. Review of Resident #174's and Resident #175's clinical records revealed the residents had been assessed as severely cognitively impaired making them unable to consent to sexual activity with another person. Interview with the Administrator, on 02/11/2022 at 11:47 AM, revealed she unsubstantiated sexual abuse for the investigation of the incident on 12/27/2021. Per the Administrator, the investigation for 12/27/2021 incident had been unsubstantiated due to lack of evidence that sexual abuse had occurred. 3. Review of the Self-Reported Incident Form dated 12/06/2021, revealed KMA #1 entered Resident #10's room, and observed Resident #174 lying on the bed with Resident #10 sitting on the bed with his/her hand on Resident #10's thigh. Review of the Summary of Incident documentation revealed KMA #1 observed Resident #174 lying on Resident #10's bed with his/her pants down to the mid-thigh area, with Resident #10 seated at the head of the bed with his/her pants down to the knees and his/her hand on Resident #174's thigh. Review of Resident #10's and Resident #174's clinical records revealed the facility had assessed both residents as severely cognitively impaired, and unable to consent to sexual activity with another person. Interview with the facility's former Administrator, on 02/11/2022 at 5:05 PM, revealed she unsubstantiated sexual abuse for the investigation of the 12/06/2021 incident involving Resident #174 and Resident #10. Per the Administrator, she unsubstantiated sexual abuse as when she interviewed staff regarding the incident they stated nothing had happened as far as physical contact aside from Resident #10's hand on Resident #174's thigh. Further interview revealed skin assessments had been completed for both residents and there was no evidence of sexual abuse. 4. Review of the facility's Incident Report dated 12/21/2021, revealed KMA #1 found Resident #174 in Resident #37's room with water on his/her face, and Resident #37 holding an empty cup. Continued review revealed the KMA also observed both residents pulling each other's hair. Further review revealed Resident #37 had been placed on one (1) on one (1) monitoring and referred for a psychiatric (psych) evaluation due to increased behaviors. However, review further revealed no documented evidence that the facility had identified Resident #174's increased wandering into other resident rooms, or identified that Resident #174 was involved in one (1) prior incident of alleged abuse on 12/06/2021 after wandering into another resident room. Interview with the Unit Manager, on 02/09/22 at 2:44 PM, revealed she was aware of the altercation between Resident #174 and Resident #37 on 12/21/2021. However, the Unit Manager stated no interventions were initiated related to Resident #174's wandering behavior, but Resident #37 was placed on 1:1 monitoring and referred for a psychiatric evaluation. Interview with the Administrator on 02/11/2022 at 4:23 PM, revealed she stated Resident #174 wandered into Resident #37's room on 12/21/2021, and Resident #37 threw water on Resident #174's face, and then the two (2) began pulling each other's hair. Further interview with the Administrator revealed revealed the facility concluded that Resident #37 had been the aggressor because the resident threw water on Resident #174's face, and immediately placed Resident #37 on one (1) to one (1) monitoring. Continued interview with the Administrator revealed Resident #37 was territorial of his/her space and did not like others in his/her space. However, the Administrator stated she did nor consider that Resident #174's wandering into Resident #37's room was the precipitating event that led to the altercation, and therefore failed to implement any action to prevent Resident #174 from being assaulted again if the resident continued to wander into dangerous situations. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/19/2022. 1.Incident # 1 occurred on 12/06/2021 involving Residents #174 and #10. The following steps were taken to ensure resident safety. For Resident #174, a skin assessment was completed on 12/06/2021, with no bruising, markings or concerns noted. The Care Plan was reviewed on 12/09/2021 by the Minimum Data Set (MDS) Coordinator, and interventions were updated on the resident's mood care plan. The MD (Medical Doctor) and the resident's POA (Power of Attorney) was notified on 12/06/2021. For Resident #10, the resident was placed on 1:1 supervision on 12/06/2021 and currently remains on 1:1 supervision. Resident #10's medications were reviewed on 12/07/2021 by the Psychiatric Nurse Practitioner and medication changes were made including Paxil started and Viibryd dose decreased. A Psychiatric Services Consult was completed for Resident #10 on 12/07/2021, and follow-up visits were completed on 12/14/2021 and 12/29/2021. The resident's care plan was reviewed by the Interim Director of Nursing (DON) on 12/06/2021 with new interventions added to the resident's psychosocial care plan. The MD and POA were notified of the incident on 12/06/2021. Incident #2 occurred on 12/27/2021 involving Resident #174 and Resident #175. For Resident #174, the Regional Nurse Consultant completed a skin assessment of Resident #174 on 12/27/21 with no concerns noted. Review of documentation revealed the resident's MD and POA were notified on 12/27/21. Resident #174 was discharged per a planned discharge to home on 12/28/2021. For Resident #175, a skin assessment was completed on 12/27/2021 by the Regional Nurse Consultant with no concerns identified. Resident #175 was provided 1:1 Supervision on 12/27/2021 and the elder was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. The resident's MD and Family were notified on 12/27/2021. The resident's care plan was updated on 02/18/2022 related to 1:1 status and the resident's discharge to a behavior unit on 12/27/2021 by the Regional Nurse consultant. Incident #3 occurred on 01/15/2022 involving Resident #67 and Resident #175. Resident #67 was found lying in the bed of elder #175. Both elders had pants off and were engaging in sexual activities. The following steps were taken to ensure resident safety. For Resident #67, a psychosocial follow-up was conducted for seventy-two (72) hours to provide psychosocial support and identify any concerns. The follow-ups were conducted on 01/15/2022, 01/16/2022, and 01/17/2022 by the Administrator. The Unit Manager reviewed the resident's care plan on 01/15/2022, to reflect the needs of the resident and to reflect the psychosocial follow-up. An assessment for physical trauma/injury was completed for Resident #67 via a skin assessment by the Unit Manager on 01/15/2022. The resident's MD and POA were notified of the incident on 01/15/2022. A Dementia Scale Pain Assessment and Pain Monitoring form that assesses the resident for pain by assessing the elders breathing, negative vocalization of pain, facial expressions, body language, and consolability was completed on 01/15/2022 by a Unit Manager with a score of zero (0) which indicated no pain. This assessment was noted to also indicate the resident was not in pain as did the baseline assessment completed on 12/06/2021 by Regional Nurse Consultant. For Resident #175, a skin assessment was completed on 01/15/2022 by a Unit Manager with no concerns noted. The resident was placed on 1:1 Supervision on 01/15/2022 and remained on 1:1 supervision until the resident was discharged from the facility on 02/22/2022. The resident was transferred to the hospital on 01/15/2022 and returned 01/26/2022 and remained on 1:1 supervision until transferred to the hospital on 02/01/2022 and returned on 02/10/2022. The Resident was then placed on 1:1 supervision upon return from the hospital and remained 1:1 until the resident was discharged from the facility on 02/22/2022. The resident's MD and Family were notified of the incident on 01/15/2022. The Administrator updated the resident's care plan on 01/15/2022 to reflect the resident's 1:1 status. The Housekeeper was initially educated on the abuse policy on 01/19/2022 by the facility Administrator which included protection of the resident and the Housekeeper was educated on the abuse policy on 2/16/2022 by the Staff Development Coordinator. 2. Residents residing in the facility have been assessed for any sign/ symptoms of potential abuse. Residents with a Brief Interview for Mental Status (BIMS) score of greater that eight (8) were interviewed by the Administrator and/or Unit Manager/Staff Development Coordinator for any concerns starting on 02/14/2022 and completed on 2/16/2022 with no issues identified. Residents currently residing in the facility with a BIMS of less than eight (8) were physically assessed by the Administrator, Unit Manager or Staff Development Coordinator for any signs and symptoms of potential abuse starting on 02/14/2022 with no concerns identified. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Regional Nurse Consultant or Regional [NAME] President (RVP) starting on 02/14/2022 and completed on 02/16/2022 for any indications of potential abuse concerns. No issues or concerns were identified. 3. Charts have been reviewed for all residents residing in the facility by the Independent Risk Manager for any resident status changes to include event managers and change of conditions for the past thirty (30) days starting on 02/14/2022 and completed on 02/16/2022. The charts were also reviewed for any potential abuse allegations that had not been previously reported with no concerns noted. 4. Care plans were reviewed by Regional Nurse Consultant #1, Regional Nurse Consultant #2 and the Behavioral Specialist starting on 02/16/2022 and completed on 02/18/2022 to ensure that the care plans were updated regarding behaviors, wandering and reflected the resident's current cognitive status. 5. All residents residing in the facility will had a BIMS assessment completed to ensure that all residents had an accurate assessment score by the Social Services Director starting on 02/14/2022 and completed on 02/15/2022. 6. Employees were interviewed by the Administrator, Staff Development Coordinator, and the Activities Director regarding any knowledge of unreported abuse or knowledge of any type of sexual relations that had not been previously reported starting on 02/16/2022 and completed on 2/18/2022 with no new concerns noted related to abuse reporting. 7. The Medical Director was notified of all the allegations on 12/06/2021, 12/27/2021, and 01/15/2022 by the Administrator in accordance with abuse reporting. The facility's Medical Director is the physician for Residents #10, Resident #67, Resident #174, and Resident #175. 8. The Senior [NAME] President of Regulatory Compliance educated the facility's Administrator/Regional [NAME] President and the Regional Nurse Consultant on the Center for Medicare/Medicaid Services (CMS) regulations for F610 and F835 on 02/17/2022 and the CMS regulations for F600, F607 and F657 on 02/18/2022 including: F610-responding to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his/her designated representative and to the other officials in accordance with state law, including to the state survey agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F 835, the facility must be administered in manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychosocial wellbeing of each resident. The facility administration is not limited to the administrator and may also include the facility's governing body, management company, and/ or others identified by the facility as part of the facility administration. CMS's Abuse Critical Pathway and reporting guidelines. F600, residents have the right to be free from abuse, neglect, misappropriation, and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. F 607, The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property/ Establish policies and procedures to investigate any such allegations and include training as required and establish coordination with the QAPI program as required. F 657, to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs., and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. 9. Starting on 02/17/2022 all allegations of abuse including physical, verbal, mental, sexual, misappropriation, neglect, involuntary seclusions, corporal punishment, injuries of unknown origin, and exploitation would be reviewed by the Regional [NAME] President, Risk Manager, and/or [NAME] President of Clinical Operations to ensure that a complete, thorough, and accurate investigation has been completed for the reportable events for the next 90 days through 05/20/2022. 10. All reportable incidents were reviewed from the last six (6) months from 08/01/2021, through 02/16/2022 by the [NAME] President of Clinical Operations starting on 02/16/2021 and completed on 02/17/2022 with no concerns noted. 11. The facility Administrator, Regional [NAME] President, Regional Nurse Consultant #1 and Regional Nurse Consultant #2, Unit Manager, Business Office Manager, Assistant Business Office Manager, Activities Director, Rehab Service Manager, Scheduler, and the Staff Development Coordinator (SDC) were educated on the abuse policy to include sexual abuse on 02/14/2022 by the Director of Behavioral Health Services. The education included the following: Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with an emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. Resident Rights include that resident had the right to be free from abuse The Behavior Management policy includes supervision and interventions to redirect residents when behaviors occur. Care plan policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs. Change of Condition Policy and Procedure, to include Physician and Family notification Quality Assurance Performance Improvement (QUAPI) policy and procedure to include process improvement and monitoring. 12. Once the facility Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were educated on (a) Abuse policy and procedure to include types of abuse, recognizing abuse and reporting abuse with emphasis on sexual abuse, the federal regulations pertaining to abuse, and the stakeholder's role in prevention, protection, recognition and reporting of abuse. (b) the resident's right to free from abuse (c) Behavior Management policy to include supervision and interventions to redirect residents when behaviors occur. (d) Care plan policy and procedure, to include appropriately updating the residents' care plan to reflect residents' current care needs. (e) Change of Condition Policy and Procedure, to include Physician and Family notification and (f) the QAPI policy and procedure to include process improvement and monitoring. The Administrator, Nursing Supervisors, SDC, Business Office Manager, Social Services Director and Activities Director were then assigned to re-educate all staff working in the facility, to include agency staff, in small groups which started on 02/15/2022 and was completed by 02/18/2022. On 02/18/2022, certified letters were sent out to the remaining PRN (as needed) staff, staff on vacation, or staff on Family Medical Leave Act (FMLA). No employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on the post-test, then the employee would be immediately re-educated, and the post-test will be re-administered. This education would be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered, and a score of 100% obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process would continue until employee obtains a 100% score on post-test. 13. A staff post-test regarding the above education to include types of abuse, protection of the resident, and notification of abuse including MD notification would be administered daily, starting on 02/19/2022. The test will be administered by the Administrator, DON, Nursing Supervisors, SDC, Business office manager, Assistant Business Office Manager or Activities Director to six (6) different staff members on different shifts daily for two (2) weeks. After two (2) weeks, then four (4) staff member's questionnaires daily to different staff members on different shifts for two (2) weeks. Results of the staff tests will be reported to the Quality Assurance (QA) committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. 14. All grievances were reviewed on 02/18/2022 by the Regional Nurse Consultant for the last thirty (30) days to determine if any items documented were a reportable event or if concerns were not resolved. No issues were identified. The Administrator or Director of Nursing would review grievances daily for two (2) weeks starting 02/18/2022, to determine if there were any concerns related to resident abuse. The Administrator would report any allegations of abuse, neglect, or misappropriation to the State Regulatory Officials, Adult Protective Services and the Ombudsman. 15. All incident reports from 11/10/2021 through 02/10/2022 were reviewed on 01/17/2022 by the Independent Risk Manager to identify any concerns related to resident abuse, and no concerns were identified. 16. Starting on 02/19/2022 the facility Administrator, DON, Social Services Director, Assistant Director of Nursing, Staff Development Coordinator and/or Unit Manager would complete five (5) random resident observations/interviews a week to ensure residents are not exhibiting any sign or symptoms of abuse to include but not limited to being tearful, withdrawn, decreased appetite, bruising, anxiety, increased wandering, or displaying fear of staff or other elders. These audits would be ongoing for the next four (4) weeks. 17. Starting on 02/19/2022, five (5) random stakeholders would be interviewed weekly for four (4) weeks to determine if they have any knowledge of any previously unreported abuse or observed any residents exhibiting increased signs and symptoms of abuse to include but not limited to being tearful, withdrawn, decreased appetite, bruising, anxiety, increased wandering, fearful of staff or other elders. 18. Starting on 02/17/2022, all residents returning from a behavioral hospital stay would be reviewed by the Interdisciplinary Team to determine their appropriate level of supervision and/or needed modifications to their plan of care to ensure their needs were met and the needs of peers were also met. This would be ongoing to ensure resident safety. 19. Administrative oversight of the facility would be completed via telephone or in-person by the Regional Nurse Consultant, Regional [NAME] President of Operations, the Director of Clinical Operations, or a member of the regional staff daily for two (2) weeks beginning on 02/12/2022, then weekly for four (4) weeks, then monthly. This would include a review of all abuse allegations and events/incidents that occurred in the previous twenty-four (24) hours, any grievances filed, and stakeholder post-tests. 20. Starting the week of 02/12/2022, a QA meeting would be held daily for seven (7) days then weekly for four (4) weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A QA meeting was held on 02/11/2022 and an action plan was formulated and implemented at that time. On 02/12/2022, a second Quality Assurance meeting was held to review the current plan for any needed revisions, compliance and/or further education. At that time, based upon evaluation, the QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator has the oversight to ensure an effective plan was in place to ensure each resident's wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QA meetings would be completed by the Regional [NAME] President of Operations, or a member of regional staff daily until the removal of immediacy beginning 02/12/2022 and then daily for seven (7) days, then weekly for four (4) weeks, then monthly. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 02/19/2022 as alleged: 1.Observations on 02/23/2022, revealed Resident's #10 and Resident #174 were not interviewable due to cognitive impairment. Review of facility documentation and interview with the Unit Manager on 02/24/2021 at 2:14 PM, revealed she completed a skin assessment, on Resident #174 on 12/06/2021, with no concerns identified. Further review revealed the resident's POA, and MD were notified on 12/06/2021 of the incident. Review of a Psychiatric Assessment revealed the resident was assessed by Psychiatric Services on 12/07/2021, and new medications were initiated on 12/09/2021. Review of Resident #174's care plan revealed on 12/09/2021, the care plan was updated to include Mood/Anxiety interventions with a goal for the Resident to experience a reduction of relief from signs and symptoms of anxiety such as, restlessness, poor impulse control, fear/apprehension. Review of Resident #10's medical record, dated 02/23/2022, revealed Resident #10 was placed on 1:1 supervision on 12/06/2021 and remained on 1:1 supervision until 01/07/2022. Observation on 02/23/2022 revealed the facility placed the resident on every fifteen (15) minute supervision since 01/07/2022. Observation of Resident #10 on 02/23/2022, at 3:28 PM revealed the resident was in his/her room sitting at the bedside with a Personal Care Attendant (PCA) present. Further review of documentation and interview with the Unit Manager on 02/24/2021 at 2:14 PM, revealed she completed a review of Resident #10's care plan 12/06/2021 with no concerns identified. Review of a Psychiatric Assessment for Resident #10, on 12/07/2021 completed by a Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed the resident's Viibryd dosage was decreased from 20 milligrams daily to 10 milligrams daily for seven (7) days and then the medication was discontinued. On 12/14/2021, the resident was again seen by the PMHNP, and Paxil was initiated daily. The PMHNP notes revealed a collaboration with a Psychiatrist and Advanced Practice Registered Nurse (APRN) and an additional visit on 12/29/2021. Record review revealed the resident's care plan was updated on 12/06/2021 with new interventions added to the identified problem of psychosocial wellbeing section of the care plan. Review of facility documentation revealed Resident #174 was involved in a second incident with Resident #175, on 12/27/2021. Review of documentation revealed a skin assessment was completed for Resident #174 on 12/27/2021 by the Regional Nurse Consultant, with no concerns identified. Further record review revealed Resident #174 was discharged home as planned on 12/28/2021. Review of documentation revealed Resident #175 had a skin assessment completed on 12/27/2021 with no concerns identified. Further review revealed the resident was transferred to the hospital on 12/27/2021, then returned to the facility on [DATE]. Review of Resident #175's medical record revealed the resident's MD and family were notified of the transfer on 12/27/2021. On 01/15/2022, another incident with Resident #175 occurred and a skin assessment was completed on 01/15/2022 by the Unit Manager with no concerns identified. Review of the Behavior monitoring log revealed Resident #175 was placed on 1:1 supervision on 1/15/2022 and transferred to the Hospital. Continued review revealed the resident returned to the facility on [DATE] and was again transferred to the hospital on 02/01/2022. Resident #175 returned to the facility on [DATE] and was discharged from the facility on 02/22/2022. Review of a facility investigation revealed Resident #67, who had a BIMS score of six (6) was involved in an incident on 01/15/2022 with Resident # 175. Resident #67, an Observation on 02/23/2022, at 3:35 PM, revealed the resident was sitting in the common area and was obviously cognitively impaired. Record review revealed the Administrator had completed a psychosocial follow-up with Resident #67 on 01/15/2022, 01/16/2022, 01/17/2022 with no concerns noted. Interview with the Unit Manager on 02/24/2022 at 2:14 PM revealed she had completed a physical trauma/injury assessment for Resident #67 on 01/15/2022, and no concerns were noted. Review of Resident #67's Care plan revealed it was reviewed by the Unit Manager on 01/15/2022 and it reflected the needs of the resident and the psychosocial follow-ups which had been completed on 01/15/2022, 01/16/2022, and 01/17/2022. Review of the Dementia Scale Pain Assessment and Pain Monitoring form for Resident #67 revealed the assessment was completed on 01/15/2022 by a Unit Manager with a score of zero(0) which indicated no pain. Resident #175, review of his/her skin assessment dated [DATE], revealed the skin assessment was completed on 01/15/2022 with no concerns identified. Review of the facility's behavior monitoring log revealed Resident #175 was placed on 1:1 supervision on 1/15/2022 and then transferred to the hospital. Continued review of Resident #175's medical record revealed the resident returned to the facility on [DATE] and went back out to the hospital on 02/01/2022 and returned to the facility on [DATE]. Resident #175 was discharged from the facility on 02/22/2022. Review of facility training records and interview with Housekeeper #1, on 02 [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of thirty-five (35) sampled residents (Resident #18). The facility had developed a plan of care for Resident #18 related to Diabetes Mellitus. Interventions to be followed by staff included notifying the resident's physician when his/her blood glucose level was above 401 milligrams per deciliter (mg/dl). However, on five (5) occasions from 11/17/2021 through 02/08/2022, the resident's blood glucose was above 401 mg/dl, but staff failed to follow the resident's plan of care and did not notify the resident's physician. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 07/19/2018, revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes. The interventions will be actions, treatments, or procedures to meet the objectives toward achieving resident goals. Review of Resident #18's medical record revealed the facility readmitted the resident on 01/18/2021 with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, Hyperlipidemia and Hypertension. 0 Review of physician orders for Resident #18, dated 09/08/2021, revealed staff were to contact Resident #18's physician the resident's blood glucose level was above 401 mg/dl. Review of Resident #18's Comprehensive Care Plan 07/20/2020, revealed the resident had Diabetes and health related complications. Further review of the Care Plan revealed the resident was at risk for unstable blood glucose levels, which would be evident by increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss and elevated blood glucose levels greater than 180 mg/dl. (Greater than 125 mg/dl normal). Continued review of the Care Plan revealed staff was to notify Resident #18's physician anytime the resident's blood glucose level was greater than 401 mg/dl. Continued review of Resident #18's medical record revealed on 11/17/2021, 12/18/2021, 01/01/2022, 01/04/2022, and 02/08/2022, Resident #18's blood glucose levels were documented as greater than 401 mg/dl, however, the staff did not notify the resident's physician. Observations of Resident #18 on daily during the survey on 02/08/2022, 02/09/2022, 02/10/2022 and 02/11/2022 revealed no signs and symptoms of hyperglycemia. Interview with Resident #18 on 02/11/2022 at 10:02 am revealed the Resident acknowledged being non-compliant with diabetic nutritional guidelines and stated he/she liked to drink Mountain Dew. Interview with Licensed Practical Nurse (LPN) #7 on 02/11/2022 at 11:44 AM, revealed she obtained Resident #18's blood glucose level on 02/11/2021 at 11:44 AM, when the resident's blood glucose was 401 mg/dl. Although LPN #7 stated she was aware of the interventions listed on the resident's diabetic care plan, including notifying the physician, she stated she failed to follow the care plan and did not notify the physician. Interview with LPN #8 on 02/11/2022 at 11:51 AM revealed, she obtained Resident #18's blood glucose level on 11/17/2021, when the glucometer (machine which measures blood glucose levels) would only read high. Although LPN #8 stated she was knowledgeable of the resident's diabetic care plan and that she was to notify the resident's physician when his/her blood glucose level was greater than 401 mg/dl, she acknowledged there was no evidence that she had notified the physician on 11/17/2021. Interview with the Director of Nursing (DON) on 02/11/2022 at 4:22 PM revealed she expected the nurses to follow each resident's plan of care and make necessary documentations regarding the interventions listed on the resident's plan of care. The DON stated she routinely reviewed resident care plans to ensure their appropriateness and stated care plan interventions should be followed by all staff. The DON stated she had not identified any concerns with resident care plans not being followed. Interview with the Administrator on 02/11/2022 at 04:15 PM revealed she expected staff to implement all interventions on resident care plans, unless there was a specific reason not to do so. The Administrator stated she had not identified any concerns with care plans not being followed for residents.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure residents received care and treatment in accordance with accepted standards of practice to treat and prevent adverse events related to Hyperglycemia (high blood sugar) for one (1) of thirty-five (35) sampled residents (Resident #18). Resident #18's Blood glucose levels were elevated above 400 mg/dl (normal range below 125) on 11/17/2021, 12/18/2021, 01/04/2022 and on 02/08/2022. However, there was no evidence found to indicate that the resident's condition was monitored after the levels were obtained, that staff rechecked the resident's glucose levels, or called the resident's physician to obtain further orders for evaluation and treatment of the resident's condition. The findings include: Review of the facility's policy titled, Aspects of Care, undated, revealed medical services would be provided for all residents in a manner to achieve and maintain optimal standards of quality of care and professional services. The policy further revealed clinical services would be provided for resident care twenty-four (24)hours per day. Review of the clinical record for Resident #18 revealed the facility readmitted the resident on 01/18/2021, with diagnoses which included Hypertension, Diabetes Mellitus, Hyperlipidemia, and Peripheral Vascular Disease. Review of Resident #18's Comprehensive Care Plan revealed the resident had been care planned for a health related complication of Diabetes and was at risk for unstable blood glucose as evidenced by Hyperglycemia with signs and symptoms of increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss and elevated blood glucose levels greater than 180 mg/dl. Further review revealed the facility had care planned Resident #18 with interventions which included to notify the medical doctor for increased blood glucose readings above 400 mg/dl, and to observe for and report signs and symptoms of Hyperglycemia to the physician. Review of the Physician's orders for Resident #18 revealed an order beginning 09/08/2021 for Novolog Flexpen U-100 Insulin (insulin aspart u-100) insulin pen 100 unit/ml (3 ml); amount. Continued review of the Novolog Flexpen order for Resident #18 revealed a Sliding Scale for the insulin which was documented as follows: if Blood Sugar was less than 60 mg/dl, call Medical Doctor; if Blood Sugar was 150 mg/dl to 200 mg/dl, give 2 units; if Blood Sugar was 201 mg/dl to 250 mg/dl, give 4 units; if Blood Sugar was 251 mg/dl to 300 mg/dl, give 6 units; if Blood Sugar was 301 mg/dl to 350 mg/dl, give 8 units; if Blood Sugar was 351 mg/dl to 400 mg/dl, give 10 units; if Blood Sugar was greater than 400 mg/dl, give 12 units; if Blood Sugar was greater than 401 mg/dl, call the Medical Doctor. Further review of the insulin order revealed Special Instructions which stated: Obtain blood glucose levels and follow Sliding Scale Insulin schedule before meals and at bedtime; at 7:00 AM, 11:15 AM, 5:00 PM, 9:00 PM. Continued review of the clinical record revealed Resident #18's blood glucose levels were documented in the medication administration history. Review of the medication administration history revealed nursing staff had documented Resident #18's blood glucose on 11/17/2021 was High, which indicated the resident's blood glucose was higher than the machine's range to read (typically greater than 600 mg/dl); 12/18/2021 High; 01/01/2022 401 mg/dl; 01/04/2022 411 mg/dl; and on 02/08/2022 455 mg/dl. However, there was no evidence found to indicate that the resident's condition was monitored after the levels were obtained, that the resident's blood glucose levels were rechecked, or that the levels were documented in the resident's nursing progress notes, to ensure other clinical staff were aware of the increased levels so monitoring the resident for complications occurred. In addition, there was no evidence the resident's physician was notified of the resident's increased blood glucose levels. Interview with Resident #18 on 02/11/2022 at 10:02 AM, revealed staff obtained his/her blood glucose levels as ordered. Continued interview revealed his/her blood glucose readings were usually 200 mg/dl to 300 mg/dl; however, stated he/she did have episodes of his/her blood glucose readings being over 400 mg/dl. Resident #18 revealed she was non-compliant with his/her diabetic nutritional recommendations and liked to drink Mountain Dew. Further interview revealed when the resident drank Mountain Dew, his/her blood glucose levels would increase at times to over 400 mg/dl. Resident #18 further revealed he/she was unaware if staff notified the medical doctor or if they assessed him/her for signs and symptoms of Hyperglycemia. Interview with Licensed Practical Nurse (LPN) #8, on 02/11/2022 at 11:51 AM, revealed she could not remember if she monitored Resident #18 for complications related to high glucose levels on 11/17/2021, or if she had rechecked the resident's levels to ensure they were declining and not increasing. The LPN stated Resident #18 often had increased blood glucose levels due to his/her non-compliance with dietary recommendations. LPN #8 stated she did not know why she did not document the blood glucose reading in the progress notes and only documented the blood glucose reading in the medication administration record. LPN #8 further revealed she should have notified the resident's physician of the elevated blood glucose reading per the order. Interviews were attempted, on 02/11/2022 and 02/12/2022, by phone with LPN #11, who documented on 12/18/2021 at 11:15 AM, that Resident #18's blood glucose reading wasHigh. However, the telephone calls were not answered. Interview with LPN #7, on 02/11/2022 at 11:44 AM, revealed she had not preformed any special monitoring of Resident #18, on 01/01/2022 at 09:00 PM, when the resident's blood glucose level was 401 mg/dl. The LPN stated she could not recall if she rechecked the resident's levels again that night. LPN #7 stated it was an oversight and she should have followed-up on the resident's condition, called the physician and documented the resident's increased blood glucose level in the resident's nursing notes. Interview was attempted by phone, on 02/11/2022 with LPN #9, however there was no answer and there was no mechanism to leave a message. The medication administration record revealed LPN #9 had obtained a blood glucose reading of 411 mg/dl on 01/04/2022 at 11:15 AM and a blood glucose reading of 455 mg/dl, on 02/08/2022 at 09:00 PM. However, there was no evidence found that LPN #9 monitored Resident #18's condition for complications from the increased blood glucose level, called the physician, rechecked the levels or documented the levels in the resident's nursing notes. Interview with the Director of Nursing (DON), on 02/11/2022 at 04:22 PM, revealed she expected the nurses to conduct monitoring of a resident's condition when the resident had an increased blood glucose level. Continued interview revealed she also expected the nurses to follow residents' care plans and to document any abnormalities in a resident's nursing notes. The DON revealed she monitored residents' care provision by reviewing their Progress Notes, change of condition events and speaking with the staff. However, she stated if the resident's condition was not accurately documented, she could miss concerns with the resident. Interview with the Administrator, on 02/11/2022 at 04:15 PM, revealed she expected nurses to conduct appropriate nursing assessments and monitor a resident's condition when warranted, including when blood glucose levels were elevated. The Administrator stated she monitored for quality of care by reviewing new orders, reviewing staffs' documentation and making rounds of the facility.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the Physician when a change occurred in a resident, and there was a need to alter the resident's treatment for one of thirty-five (35) sampled residents (Resident #18). Resident #18 had orders to notify the physician when the resident's blood glucose level was greater than 400 milligrams per deciliter (mg/dl). However, the facility failed to notify the resident's physician on 11/17/2021, 12/18/2021, 01/01/2022, 01/04/2022, and on 02/08/2022, when Resident #18's blood glucose level was elevated above 400 mg/dl. The findings include: Review of the facility's policy titled, Change of Condition, revised 11/06/2019, revealed the facility was to evaluate and document changes in a resident's physical and/or mental health, or psychosocial status. Further review revealed staff were to effectively relay information to the Physician when there was a need to alter treatment. Review of Resident #18's medical record revealed the facility readmitted the resident on 01/18/2021, with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, Hyperlipidemia and Hypertension. Review of Resident #18's Annual Minimum Data Set Assessment, dated 12/02/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) revealing the resident was cognitively intact. Review of Resident #18's Comprehensive Care Plan dated 07/20/2020, revealed an intervention to notify the medical doctor for blood glucose levels above 400 mg/dl. Review of physician orders for Resident #18 dated 09/08/2021, revealed an order beginning for staff to administer the resident Novolog U-100 Insulin per sliding scale (the amount of insulin administered was dependent on blood glucose level) before meals and at bedtime. Further review of the sliding scale order revealed if the resident's blood glucose level was greater than 400 mg/dl, staff was to notify the resident's physician. Review of Resident #18's medical record revealed staff documented the resident's blood glucose level, on 11/17/2021 at 11:15 AM and 12/18/2021 at 11:15 AM, was high, on 01/01/2022 at 09:00 PM, it was documented as 401 mg/dl, on 01/04/2022 at 11:15 AM, it was documented as 411 mg/dl, and on 02/08/2022 at 09:00 PM staff documented the resident's blood glucose level as 455 mg/dl. However, there was no evidence found to indicate the facility notified the resident's physician of the increased blood glucose levels. Interview with Licensed Practical Nurse (LPN) #8, on 02/11/2022 at 11:51 AM, revealed she could not remember if she notified Resident #18's physician on 11/17/2021 at 11:15 AM that the resident's glucose level was reading high. However, the LPN stated she should have notified the resident's physician. Interview could not be conducted with LPN #11, who documented Resident #18's blood glucose as high on 12/18/2021 at 11:15 AM, due to the LPN being employed through an agency and the facility did not have a working phone number for the LPN or the agency who had employed her. Interview with LPN #7, on 02/11/2022 at 11:44 AM, revealed it was an oversight and she should have called Resident #18's physician on 01/01/2022 at 09:00 PM when the resident's blood glucose was 401 mg/dl. A telephone interview was attempted, on 02/11/2022 at 11:40 AM and 2:20 PM with LPN #9, who had documented Resident #18's blood glucose level as 455 mg/dl, on 02/08/2022 at 09:00 PM and 411 mg/dl on 01/04/2022 at 11:15 AM. However, there was no answer and no option to leave a message. Interview with Resident #18, on 02/11/2022 at 10:02 AM, revealed staff obtained his/her blood glucose levels as ordered, and that his/her level was usually 200 mg/dl to 300 mg/dl. However, Resident #18 stated there were times when his/her levels were over 400 mg/dl. Continued interview revealed Resident #18 liked to drink Mountain Dew, which was usually when his/her blood glucose levels were elevated above 400 mg/dl. The resident stated the facility provided him/her with nutritional counseling. Resident #18 was unaware if staff notified the physician when his/her glucose level was elevated above 400 mg/dl. Interview with Resident #18's physician, on 02/11/2022 at 11:19 AM, revealed he could not ever recall being notified of Resident #18's glucose levels being above 400 mg/dl or greater. The physician stated he expected facility staff to follow his orders and notify him accordingly. Interview with the Director of Nursing (DON), on 02/11/2022 at 4:22 PM, revealed she expected staff to follow physician's orders and notify the physician as ordered or when the resident's condition warranted. The DON stated she had not identified any concerns with residents' blood glucose levels being elevated and of staff not notifying the residents' physicians. Interview with the Administrator, on 02/11/2022 at 4:15 PM, revealed she expected nurses to notify the resident's physician when the resident had a change in condition or there was an order to do so.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of three (3) sampled residents (Resident #1). The facility identified Resident #1 to be at risk for elopement due to the resident's cognitive impairment, poor decision-making skills, and exit seeking behavior. On 07/04/2021, at approximately 1:30 PM, Licensed Practical Nurse (LPN) #1 heard an exit door alarm sounding in the front lobby of the facility. LPN #1 responded to the alarm and disabled it, however, failed to follow the facility's policy and procedure to determine if a resident had eloped from the facility. Approximately ten (10) minutes later, visitors came to the facility and notified staff that a resident was outside in the road. Staff found Resident #1 approximately 287 feet from the facility on the main road. Review of a police report revealed police were dispatched at 1:40 PM due to reports of a person in a wheelchair being in the road just past the facility. The facility's investigation stated the police reported the resident had fallen out of the wheelchair and was in the roadway when they arrived on scene. Emergency Medical Services (EMS) transferred Resident #1 to the local hospital who diagnosed the resident with an abrasion to the left knee. Skin assessments performed by facility staff after Resident #1's return to the facility revealed the resident had abrasions to the left knee, left elbow, left hand/fingers and bruising to the right forearm and right hand. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/15/2021, and determined to exist on 07/04/2021 at 42 CFR 483.21 Comprehensive Resident Centered Care plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 07/15/2021. An acceptable Allegation of Compliance was received on 07/19/2021, which alleged removal of the Immediate Jeopardy on 07/08/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/08/2021, prior to exit on 07/28/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Elopement/Wandering, reviewed on 05/30/2018, revealed staff would complete an elopement/wandering assessment for each resident upon admission and quarterly thereafter. In addition, the policy stated resident care plans would address wandering as a specific problem. Approaches would be formulated, patterns identified, and the causes determined. Further, the policy stated if staff determined a resident was missing, they were to follow the missing resident procedure. Review of the Missing Resident policy, revised 01/24/2020, revealed staff notified the charge nurse and nursing staff when a resident was missing. The nursing staff would then notify the Supervisor, the Director of Nursing (DON), Administrator, Regional Vice President (RVP) and the Corporate Consultant. Staff would identify the missing resident to stakeholders (facility staff) and immediately check all exit doors. Interview with the Administrator, on 07/15/2021 at 4:13 PM, and the DON on 07/15/2021 at 3:33 PM, revealed when an exit door alarm sounded staff were required to respond to the alarm, check the door and look for any resident who may have activated the alarm. In addition, staff was required to look outside for any potential resident and initiate a head count of residents in the facility. The Administrator and DON went on to say if staff identified a missing resident, they were to follow the Missing Resident policy. Review of Resident #1's medical record revealed the facility readmitted the resident on 01/13/2019, with diagnoses including Alzheimer's [NAME] Body Dementia, Essential Hypertension, Difficulty Walking, Generalized Anxiety Disorder, [CONDITION(S)] and [CONDITION(S)]. Review Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitively impaired. The facility assessed the resident to display no wandering behaviors during the seven (7) day look back period. The assessment also stated Resident #1 was non-ambulatory, but utilized a wheelchair for locomotion with supervision. Review of Resident #1's Elopement Assessment, dated 06/08/2021, revealed the facility identified Resident #1 was cognitively impaired, independently mobile (ambulatory or wheelchair), had poor decision making skills, demonstrated exit-seeking behavior, wandered obliviously to safety needs and had the ability to exit the facility. The facility assessed the resident to be at risk for elopement. Review of a facility investigation initiated on 07/04/2021, revealed on 07/04/2021, at approximately 1:45 PM, LPN #1 heard the facility's front lobby door alarming. LPN #1 reset the alarm and did not see anyone outside of the facility. On 07/04/2021 at approximately 1:50 PM, a visitor came to the door and reported a resident was outside by the road. LPN #1 found Resident #1 on the side of the road approximately three (3) houses down from the facility. Further review of the report revealed police officers were with the resident when LPN #1 approached. According to the report, police officers told LPN #1 that the resident had fallen out of the wheelchair and they had transferred the resident back into the wheelchair. Continued review of the investigation revealed LPN #1 assessed the resident and found no harm. The facility transferred Resident #1 to the local emergency room for further evaluation and treatment. Continued review of the report revealed Resident #1 returned to the facility on [DATE], with no identified fractures or dislocations. Interview with LPN #1, on 07/13/2021 at 12:13 PM, 2:46 PM and 3:10 PM revealed she was providing care to Resident #1, on 07/04/2021. The LPN stated Resident #1 had a history of exit seeking and would frequently go to exit doors and shake on them, trying to get them open. LPN #1 stated she last observed Resident #1 at approximately at 10:30 AM, moving about the facility in his/her wheelchair. Continued interview with LPN #1, revealed at approximately 1:30, PM she heard a door alarm in the front lobby area. However, LPN #1 stated when she got to the front door she did not see anyone in the lobby area and did not observe anyone outside the facility when she looked through the glass doors. However, LPN #1 stated she did not open the doors and look any further than the immediate outside area visible through the doors. LPN #1 stated she then shut the alarm off and went back to the nursing station, but failed to conduct a resident head count or take any action to ensure a resident was not missing from the facility. Further interview with LPN #1 revealed approximately five (5) to ten (10) minutes later, a visitor came to the facility and notified her that an individual in a wheelchair was in the road. LPN #1 stated she immediately went outside to the road in front of the facility and found Resident #1 on the edge of the roadway approximately three houses down (approximately 287 feet) from the facility. LPN #1 stated police and fire personnel were with Resident #1 and notified her that an individual passing by witnessed the resident fall out of the wheelchair onto the roadway. However, the emergency personnel had placed the resident back into the wheelchair and moved him/her out of the road for the resident's safety. LPN #1 stated two (2) police cars and a fire truck were present at the scene blocking the road and directing traffic around the resident. LPN #1 at that time assessed Resident #1 to have an abrasions to the right elbow and knuckles of the right hand. LPN #1 stated she notified the weekend supervisor of the incident and asked for guidance on what to do, and the supervisor advised her to send Resident #1 to the Emergency Department for evaluation. Further interview with LPN #1 revealed a police officer assisted staff with pushing Resident #1 back to the facility's parking lot in the wheelchair, while awaiting Emergency Medical Services (EMS) for transport. LPN #1 stated the resident was wearing a long sleeve shirt, khaki pants, tennis shoes and a hat. In addition, LPN #1 described the weather that day as sunny and hot, and stated Resident #1 told her he/she was going to the Christmas Parade. Continued interview with LPN #1 revealed she stated she was unaware that she should have conducted a resident head count after a door alarm sounded to ensure a resident had not left the facility, but did say she should have initiated a search of the premises when the alarm sounded. Interview with Patient Care Assistant (PCA) #1, on 07/14/2021 at 1:20 PM, revealed she was working on 07/04/2021. PCA #1 stated at approximately 10:00 AM, she observed Resident #1 in the front lobby area around the front doors causing them to alarm. The PCA stated she re-directed Resident #1 away from the door, turned the alarm off and went back to the floor. However, PCA #1 stated she did not notify the nurse or other staff that Resident #1 was at the door and exhibiting exit-seeking behavior. Interview with State Registered Nurse Aide (SRNA) #1, on 07/13/2021 at 3:23 PM, revealed she worked on the unit Resident #1 resided, the day he/she eloped. RNA #1 stated she last observed Resident #1 at approximately 1:30 PM to 1:45 PM, prior to leaving the unit for lunch. Interview with SRNA #2, on 07/14/2021 at 8:18 AM, revealed she was working on 07/04/2021 on the unit where Resident #1 resided, and last observed the resident at 12:42 PM prior to going to lunch. SRNA #2 stated she was at the nursing station with LPN #1 at approximately 1:30 PM when they heard an alarm sound. SRNA #2 stated LPN #1 left the nurses station to respond to the alarm. SRNA #2 stated she heard the alarm stop sounding, and LPN #1 returned to the nurse's station. SRNA #2 stated LPN #1 told her she had reset the alarm. SRNA #2 stated LPN #1 did not instruct staff to complete a head count or take any action related to a possible missing resident. SRNA #2 stated she left the nurse's station and the next thing she knew, a police officer was in the facility and told her that LPN #1 was outside with Resident #1. SRNA #2 stated she proceeded to go outside to provide LPN #1 assistance and observed Resident #1 on the edge of the road at the turning lane (approximately 287 feet from the facility). SRNA #1 stated the alarm had to be going off awhile for (Resident #1) to get where (he/she) was in the road. Interview with Weekend Supervisor #1, on 07/14/2021 at 1:40 PM, revealed at approximately 1:50 PM on 07/04/2021, a police officer approached her and told her LPN #1 had sent him into the facility to notify staff that she (LPN #1) was outside the facility with Resident #1. Review of a police report, dated 07/04/2021, revealed 911 dispatch received a call on 07/04/2021 at 1:40 PM. The report stated a person in a wheelchair was in the roadway in the northbound lane just past the facility. Continued review of the report revealed at 1:43 PM, 911 dispatch received an additional call reporting the person had fallen out of the wheelchair onto the road. The report revealed police arrived on the scene at 1:45 PM. Interview with Witness #1, on 07/15/2021 at 6:10 PM, revealed on 07/04/2021, sometime after lunch, she was traveling on the road that passed in front of the facility when she observed an individual in a wheelchair in the opposite lane. Witness #1 stated she was traveling toward the facility, but the individual was traveling away from the facility. Witness #1 stated traffic was trying to go around the individual, and one vehicle was completely in my lane trying to avoid hitting the individual, causing witness #1 to have to come to a complete stop. Witness #1 stated the road in front of the facility was a dangerous area and people fly on that road. Review of an EMS run sheet, dated 07/04/2021, revealed EMS arrived on scene at 2:01 PM, and at 2:08 PM, assessed Resident #1 to have bilateral abrasions to the knees. EMS transported Resident #1 to the hospital for further evaluation. Review of Resident #1's Hospital record, dated 07/04/21, revealed the hospital diagnosed the resident with an abrasion to the left knee and discharged the resident back to the facility. Review of weather archives from AccuWeather for 07/04/2021, revealed the high temperature in the facility's city was 86 degrees Fahrenheit and the low temperature was 57 degrees Fahrenheit. Observation of the road on 07/14/2021, at 5:00 PM, in front of the facility was narrow and heavily traveled with a speed limit of 35 miles per hour (mph). Interview with LPN #4, on 07/14/2021, at 1:10 PM, revealed she was the Nurse on Call for the weekend of 07/04/2021. LPN #4 stated Weekend Supervisor #1 notified her sometime between 1:00 PM and 3:00 PM, that Resident #1 had exited the facility without staff knowledge. LPN #4 stated the supervisor was asking her what to do, and she instructed her to call the Director of Nursing (DON) and the Administrator immediately. The LPN stated she came to the facility at approximately 3:00 PM and took over responsibility for LPN #1's residents. LPN #4 stated Resident #1 returned from the hospital to the facility at approximately 7:20 PM on 07/04/2021. LPN #4 conducted a skin assessment on Resident #1, and identified abrasions to the resident's left knee. LPN #4 denied Resident #1 had further injury. Review of skin an assessment for Resident #1, dated 07/04/2021 at approximately 7:00 PM, revealed after returning to the facility from the hospital the resident staff assessed the resident to have two (2) scraped areas to the left knee. However, a skin assessment on 07/05/2021 at 5:44 PM, revealed the resident had abrasions to the left knee, left elbow and left hand/fingers. In addition, the skin assessment from 07/05/2021, revealed the resident had bruising to the right forearm and right hand. Interview with the DON, on 07/14/2021 at 3:33 PM, revealed Weekend Supervisor #1 notified her on 07/04/2021 that Resident #1 had eloped from the facility without staff knowledge. The DON stated she suspended LPN #1 on 07/04/2021, for failure to follow the facility's protocols and procedures when a door alarm sounded. The DON stated LPN #1 should have completed a search of the premise while another employee completed a head count when the alarm door sounded. Interview with the Administrator, on 07/14/2021 at 4:13 PM, revealed staff notified her on 07/04/2021 at approximately 2:00 PM, that Resident #1 had exited the facility without staff knowledge. The Administrator stated she immediately initiated an investigation and notified all appropriate agencies. The Administrator stated it was determined LPN #1 failed to follow the facility's protocol and procedure regarding elopement and alarms. The Administrator stated the facility placed Resident #1 on one (1) to one (1) supervision upon arrival back to the facility on [DATE], and the resident was transferred to the facility's locked unit on 07/05/2021. Interview with Resident #1's Physician, on 07/14/2021 at 1:28 PM, revealed the resident was cognitively impaired, required staff supervision, and was not safe to be out of the facility alone. Observation of Resident #1, on 7/13/2021 at 10:48 AM, revealed the resident was up in a wheelchair and residing in the facility's locked unit. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/08/2021: 1. Resident #1 was transferred to the emergency room at the local hospital for evaluation on 07/04/2021, and returned to the facility same day with no significant injuries. 2. Upon return to the facility from the emergency roiagnom on [DATE], Charge Nurse #2 performed a head to toe skin assessment on Resident #1. The facility found the resident had scrapes to knees bilaterally with no complaints of pain. On 07/05/2021, Charge Nurse #3 completed a follow up skin assessment on Resident #1, and found scrapes to knees bilaterally and a bruise to the right arm. 3. When Resident #1 returned to the facility from the emergency roiagnom on [DATE], the facility placed the resident on one to one supervision and the facility notified the physician and power of attorney of the new supervision intervention. 4. On 07/05/2021, the Nurse Consultant re-evaluated Resident #1 for elopement and completed a new elopement assessment. The Nurse Consultant on 07/04/2021 also reviewed and updated the resident's elopement care plan and the nurse aide's care plan, to reflect the resident's current needs including the one to one supervision. 5. The facility placed Resident #1 on one to one supervision on 07/04/2021, and remained on one to one supervision until staff transferred the resident to the serenity locked unit. 6. The facility conducted a head count of facility residents was performed by the unit nurses on 07/04/2021 and all the residents residing in the facility were accounted for and present. 7. Charge Nurse #1 was educated on the elopement process by the Nurse Consultant on 07/04/2021 and received further education regarding elopement processes by the House Supervisor on 07/04/2021. 8. On 07/04/2021, the Plant Operations staff checked all the facility doors to ensure they locked, and the delayed egress was functioning properly. The Plant Operations staff found all the doors working properly. 9. The DON, Unit Manager and Medical Records staff re-assessed all residents for elopement potential beginning on 07/05/2021 and completed on 07/06/2021. 10. The Nurse Consultant reviewed and updated all comprehensive care plans for residents identified as at risk for elopement on 07/05/2021. 11. The Social Services Director updated the elopement binders for accuracy on 07/05/2021 to reflect current elopement assessments. 12. On 07/05/2021, the Social Services Director reviewed all behavioral management care plans for the nineteen (19) residents assessed to be at risk for elopement to ensure interventions for wandering or exit-seeking behaviors were included. 13. The Regional Vice President and Maintenance Director completed environmental rounds on 07/07/2021, to identify any safety issues. This included observation for hazards such as loose floor tiles, damage to windows or doors, and faulty equipment such as beds/lifts/shower beds/chairs and doors. 14. On 07/04/2021, the Regional Maintenance Director completed an audit of all facility exit doors to ensure all the doors locked and the delayed egress was functioning. The Regional Maintenance Director identified no concerns. 15. The Regional Vice President and Plant Operations Director checked the TELS system (an electronic system to manage the physical plant) on 07/04/2021 to ensure systems were functioning appropriately. 16. The Nurse Consultant started on 07/04/2021 and completed on 07/05/2021 a thirty (30) day look back in the Electronic Medical Record (EMR) and twenty-four (24) hour report all events that had occurred in the facility for exit seeking behaviors. 17. The Nurse Consultant reviewed nurse notes from 07/04/2021 thru 07/05/2021 for the nineteen (19) residents assessed as at risk for elopement for exit seeking behaviors/and or elopements with wandering behavior for thirty days prior to 07/04/2021. 18. The facility Administrator, DON, Unit Managers, ADON, Social Services Director, Admissions Director, Dietary Manager, Minimum Data Set (MDS) Coordinators, Plant Operations staff and the Quality of Life Director were trained on 07/05/2021 by the Nurse Consultant. The education consisted of detailed and specific training on the facility's elopement policy and procedures. Including the missing resident policy and procedures. The door codes and alarms process. The accident and incident policy and procedures. The safety and supervision processes. The abuse policy and procedures. The resident rights policy and procedures. The care plan policy and procedures. The facility administration policy and procedures. The resident change of condition procedures. The behavior management policy and procedures. The quality assurance process/improvement policy and procedures. The facility conducted these trainings face to face to facilitate discussion and questions. The Department Administrative Managers could not return to work until receiving the education and they scored one-hundred percent on a post-test. If the Department Administrative Manager did not score one hundred percent on the post-test education continued until, they scored one-hundred percent. The Nurse Consultant reviewed all post-test for compliance. 19. Beginning on 07/05/2021, the facility's Administrator, DON, ADON, Staff Development Coordinator, Business Office Manager, Social Services Director, Dietary Manager and Rehab Service Manager re-educate the facility staff to include nursing, dietary, therapy, housekeeping and administrative staff on policies and procedures. The training included elopement, missing resident, safety and supervision, accident and incident procedures, abuse policy and procedures, resident rights procedures, care plan procedures, facility administration, resident change of condition procedures, behavior management procedures and quality assurance process improvement procedures. The staff completed the training on 07/07/2021. The IDT team members consisting of the Administrator, DON, ADON, Staff Development Coordinator, Business Office Manager, Social Services Director, Dietary Manager and Rehab Service Manager, were responsible for helping to establish interventions such as increased or decreased supervision (which would be determined based on individual resident need and behaviors exhibited). The facility does utilize agency staff and any agency staff's working have or will receive education prior to working beginning on 07/05/2021. Education will be ongoing after 07/05/2021 to ensure all facility staff not educated on by 07/07/2021 will be educated prior to working on the floor. The information included education regarding the elopement books and the care plan information. Staff included nursing, therapy, dietary, housekeeping, and administrative. The DON, ADON and/or Staff Development Coordinator educated staff to redirect wandering or exit seeking residents back to their assigned unit and/or room. Staff should then consult the residents behavioral management care plan for a list of personalized interventions. This education is ongoing and all employees will be educated prior to working on the floor. 20. Starting on 07/04/2021 all doors will be checked daily for proper function to ensure door locks are secure and that the delayed egress was functioning appropriately by members of the IDT team to include but not limited to the Administrator, DON, ADON, Maintenance Director, Maintenance Assistant, Dietary Director, Social Services Director and/or Business Office Manager. The staff will report any concern immediately to the Administrator and Plant Operations Director. Staff has identified no concerns. 21. An elopement drill was completed on 07/05/2021 by the Administrator and an elopement drill will be conducted daily on random shifts, for one week and then weekly for four (4) weeks to follow by the Administrator, DON or Department Head Managers. The staff will conducted drills quarterly thereafter. Staff will perform the drills on different shifts including weekends. Elopement drills will be conducted to ensure staff are following the missing resident policy and procedure, specifically, actions to take when door alarms sound, including responding to active door alarms, walking the outside perimeter by the alarming door to ensure no resident is observed outside of resident care areas unattended, and to report to the nurse and do a headcount. 22. Beginning 07/06/2021, The DON, ADON or Unit Manager monitored all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decreased to Monday through Friday for three (3) months to determine if there are any new exit seeking behaviors. The Administrator, DON and/or members of the IDT team have been onsite in the facility including weekends since 07/05/2021 to provide oversight and monitoring of the residents at risk for elopement with visual rounding through the facility since 07/05/2021. Staff completed the monitoring daily and it included reviews of events in event manager, the elopement risk assessments, and the twenty-four (24) hour report. 23. Beginning on 07/05/2021 the facility would conduct an elopement paper test including questions regarding policies on elopement, quality improvement, abuse reporting, and change of condition procedures, care plans, accidents and incidents procedures, and safety and supervision procedures. The staff tested must make one hundred (100) percent, and if not they must be re-educated and re-tested until a score of one hundred (100) percent was obtained. Random selection of employees across various shifts. The schedule for testing would be five (5) employees per shift for two (2) weeks for a total of ten (10) per day. Then the schedule decreases to three (3) employees per shift for one week for a total of six (6) per day. Then the schedule decreases to two (2) employees per shift for one week for a total of four (4) per day. Then the schedule decreases to one employee per shift for one week for a total of two (2) per day. Then the schedule decreases to one employee per week for four weeks and then decrease to one employee every other week for four weeks. 24. A Quality Assurance Performance Improvement (QAPI) meeting was conducted following the incident on 07/05/2021 and would be conducted weekly for four weeks to include but not limited to the Facility Medical Director, Administrator, DON, SCC, ADON, Unit Manager, Social Services, MDS, Plant Operations staff, Dietary Manager, Restorative Nurse in attendance. Discussion included an immediate action plan as well as the facility's plan to ensure compliance. 25. A nurse from the regional team or corporate office and or the vice president of operations has been available on site or by phone since 07/04/2021. The Administrator and or DON have been on site daily since 07/05/2021 to ensure continued compliance with audits established by the Quality Assurance and Performance Improvement Committee. The SCC and/or Regional Vice President provided oversight beginning on 07/04/2021. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 07/08/2021 as alleged: 1. Review of Resident #1's medical record on 7/27/2021, revealed an emergency room Record dated 07/04/2021. The record revealed the hospital examined the resident in the emergency room and found to have superficial abrasion on the knees. The record also stated the hospital discharged the resident back to the facility. 2. Review of Resident #1's medical record on 07/27/2021 revealed documentation of a skin assessment completed on 07/04/2021 by Charge Nurse #2 revealed the resident had scraped knees. The resident had a follow up skin assessment completed on 07/05/2021, by Charge Nurse #3, which revealed the resident had scraped knees and a bruise to the right forearm due to a venipuncture in the emergency roiagnom on [DATE]. Observation of Resident #1, on 07/27/2021 at 5:00 PM, revealed no bruises or scrapes visible. 3. Review of the medical record for Resident #1, revealed Resident #1 received one to one supervision until the facility transferred the resident to the secured locked unit. Review of completed safety check logs dated 07/04/2021 and 07/05/2021 revealed no concerns. Review of the medical record revealed staff notified the physician and the resident's power of attorney of the increased supervision provided for the resident. Interview with LPN #2 on 07/27/2021 at 4:50 PM, LPN #7 on 07/28/2021 at 10:16 AM, and SRNA #7 on 07/28/2021 at 10:10 AM, revealed the facility had conducted elopement drills daily. 4. Review of the medical record for Resident #1 revealed the Nurse Consultant completed an Elopement Risk Evaluation, on 07/05/2021 at 10:30 AM, and Resident #1 was determined to be at risk for elopement. Review of the Comprehensive Care Plan, revealed the Nurse Consultant updated it on 07/04/2021 and 07/05/2021, to reflect Resident #1's current needs of one to one supervision and diversional activities for exit seeking behaviors. The Nurse Consultant updated the Resident Profile form (Nurse Aide Care Plan) for Resident #1, on 07/04/2021 and 07/05/2021, to reveal the resident was on one to one supervision and diversional activities as needed for exit seeking behaviors. Interview with the Nurse Consultant on 04/28/21 at 2:10 PM revealed she had updated the care plan and Resident Profile. 5. Review of Resident #1's medical record revealed safety check logs indicated one to one supervision, beginning, 07/04/2021 at 7:50 PM, and ending on 07/05/2021 at 4:00 PM when the resident was placed in the secured locked unit on fifteen (15) minutes checks continuing through 07/27/2021. Interview with Licensed Practical Nurse #3, on 07/28/2021 at 9:22 AM, the Unit Manager, on 07/28/2021 at 9:05 AM, the Social Services Director, on 07/28/2021 at 9:28 AM, revealed Resident #1 was one to one until moved to the locked unit. 6. The facility provided a Midnight Census Worksheet, dated 07/04/2021, revealed an accountability check by the weekend supervisor of every resident presently admitted to the facility. Interview with Charge Nurse #1, on 07/27/2021 at 3:45 PM, revealed no other residents were missing from the facility on 07/04/2021. 7. The facility provided a statement signed by the Nurse Consultant, revealed Charge Nurse #1 was educated on elopement procedures on 07/04/2021. The facility provided a sign in sheet dated 07/04/2021, that indicated Charge Nurse #1 was educated on door alarms and elopement procedures. Interview with Charge Nurse #1 on 07/27/2021 at 3:45 PM revealed the Nurse Consultant and Weekend Supervisor had both educated her on elopement procedures. 8. The facility provided documentation that indicated the Plant Operations employee conducted a door and window audit on 07/04/2021. The Plant Operations Employee revealed on the documentation all the facility doors and windows were functioning properly. Interview with the Administrator, on 07/28/2021 at 1:55 PM, revealed the doors had been functioning properly. Observation of the facility doors, on 07/27/2021 from 8:30 AM thru 8:45 AM, revealed the doors functioned properly. 9. Review of a checklist revealed DON, Unit Manager and Medical Records staff documented from 07/05/2021 and finishing on 07/06/2021 all resident assessments for elopement potential. The staff identified no new residents assessed for elopement risk. Interview with the DON on 07/28/2021 at 01:40 and the Unit Manager on 07/28/2021 at 9:05 AM revealed they had reassessed all residents. 10. Review of the comprehensive care plans and the resident profiles, on 07/27/2021, for the nineteen (19) residents identified as at risk for elopement revealed the Nurse Consultant reviewed and updated the care plans on 07/05/2021. Interview with the Nurse Consultant on 04/28/21 at 2:10 PM revealed she updated the comprehensive care plans. 11. A signed statement by the Social Services Director dated 07/05/2021, revealed she had reviewed all the elopement binders for all the residents identified for elopement risk and made updates as necessary. Interview with the Social Services Director, on 07/28/2021 at 9:28 AM, revealed the facility did have elopeme [TRUNCATED]

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to develop and implement a person-centered comprehensive care plan with specific interventions to meet the needs of one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's care plan, dated 01/08/2020, revealed the facility established a goal for the resident to remain safe in the facility with no elopement attempts or events. The care plan revealed interventions developed by the facility to meet the goal included using diversional activities and allowing the resident to call close family/friends for reassurance when exit-seeking behaviors occurred. On 07/04/2021 at approximately 10:00 AM, Resident #1 triggered the front door alarm located in the facility's lobby. Although Patient Care Assistant (PCA) #1 responded and redirected the resident away from the door, she failed to notify staff caring for the resident that the resident was displaying exit-seeking behavior. Therefore, staff failed to implement the resident's elopement care plan in order to divert the resident's exit seeking behavior. Subsequently, on 07/04/2021 at approximately 1:30 PM to 1:45 PM, Resident #1 exited the facility without staff knowledge and was found approximately 287 feet from the facility on the edge of the main road in his/her wheelchair being attended to by fire and police personnel. Resident #1 was transported to the hospital and diagnosed with only abrasions and bruises as a result of the elopement. The facility's failure to ensure residents received adequate supervision to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/15/2021, and determined to exist on 07/04/2021 at 42 CFR 483.21 Comprehensive Resident Centered Care plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 07/15/2021. An acceptable Allegation of Compliance was received on 07/19/2021, which alleged removal of the Immediate Jeopardy on 07/08/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/08/2021, prior to exit on 07/28/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Comprehensive Care Plans, revised 07/19/2018, revealed the Nurse/Interdisciplinary Team was responsible for the review and updating of care plans. The policy stated the care plan should reflect the status of the resident and be updated with changes in the resident's status. Further review revealed, the comprehensive care plan would be person-centered to meet the resident's preferences and goals to address the resident's medical, physical, mental and psychosocial needs. Care plan interventions should address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions would reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Review of Resident #1's medical record revealed the facility readmitted the resident on 01/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/12/2021, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitively impaired. Continued review of the MDS assessment revealed the resident was non-ambulatory, but utilized a wheelchair for locomotion. Review of an Elopement Assessment for Resident #1 dated 06/08/2021, revealed the facility identified Resident #1 had poor decision-making skills and demonstrated exit-seeking behavior. The facility assessed the resident to be at risk for elopement. Review of Resident #1's elopement care plan dated 01/08/2020, revealed the facility determined the resident was at risk for elopement and had made previous attempts to elope from the facility. The care plan stated Resident #1 wandered through the hallways in a wheelchair and would attempt to push exit doors open. The established goal for Resident #1 was to remain safe within the environment and have no elopement or events. Interventions listed on the care plan included diversional activities and allowing the resident to call close family/friends for reassurance when the resident displayed exit-seeking behavior. Review of a facility investigation initiated on 07/04/2021, and interview with LPN #1 on 07/13/2021 at 12:13 PM, 2:46 PM and 3:10 PM, revealed on 07/04/2021 She was providing care to Resident #1. LPN #1 stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated she last observed Resident #1 on 07/04/2021, up in a wheelchair in the hallway at approximately at 12:30 PM. At approximately 1:30 PM, LPN #1 stated she heard a door alarm in the front lobby area. Although LPN #1 responded to the door alarm, she stated she did not see a resident in the lobby or close to the door. LPN #1 reset the alarm without conducting a thorough search of the area to ensure a resident had not exited the facility. Approximately, five (5) to ten (10) minutes later a visitor came to the facility and notified staff that an elderly individual in a wheelchair was in the roadway on the main road in front of the facility. LPN #1 left the facility and found Resident #1 approximately 287 feet from the facility on the side of the road. Fire and police personnel were with the resident and told LPN #1 that the resident had fallen from the wheelchair onto the road, but they had assisted the resident back into the wheelchair. The investigation revealed Resident #1 went to the hospital, but only suffered bruises and abrasions as a result of the elopement and subsequent fall. Observation of Resident #1 on 07/13/2021 at 10:48 AM, revealed the resident was up in a wheelchair and able to move about independently. Further observation, revealed the resident was residing in the facility's locked unit and had a Wanderguard bracelet to the right ankle. Interview with Patient Care Assistant (PCA) #1 on 07/14/2021 at 1:20 PM and 07/15/2021 at 10:58 AM revealed she was working on 07/04/2021, but not caring for Resident #1. PCA #1 stated at approximately 10:00 AM, Resident #1 was in the front lobby area and had caused the door alarm to sound. PCA #1 stated she re-directed the resident from the door, turned the alarm off and went back to the floor. The PCA stated she did not notify anyone caring for Resident #1, that the resident had set the door alarm off and/or that the resident was exhibiting exit-seeking behavior. The PCA stated since she was not caring for the resident she did not know the resident was at risk for eloping and had interventions listed on the care plan to follow when exhibiting exit seeking behavior. Interview with State Registered Nursing Assistant (SRNA) #2 on 07/14/2021 at 8:18 AM revealed she was working on 07/04/2021, and was caring for Resident #1. However, the SRNA stated she was unaware that Resident #1 was at risk for elopement, stating she must have overlooked it on the resident's plan of care. However, SRNA #2 denied ever observing Resident #1 exhibiting exit seeking behavior including on 07/04/2021. Interviews on 07/14/2021, with SRNA #3 at 2:10 PM and SRNA #4 at 2:20 PM, revealed both staff stated they knew to follow resident care plans. However, neither of the staff was able to state what diversional activities would be appropriate for Resident #1, and where unable to state where they could find that information at. Interview with State Medication Aide (SMA) #1, on 07/14/2021 at 2:37 PM, revealed she interpreted implementing diversional activities on Resident #1's care plan to mean staff should get the activities department involved in the resident's care if the resident exhibited exit-seeking behaviors. Interview with Minimum Data Set (MDS) Nurse #2, on 07/14/2021 at 3:10 PM, revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Nurse #2 stated the intervention of diversional activity was a general intervention, and the goal was to get the resident engaged in something besides exit seeking behavior. However, the MDS nurse stated the care plan was not very individualized for Resident #1 and failed to list activities that the facility had assessed the resident to be interested in or that staff could implement for the resident. MDS Nurse # 2 stated individualized interventions specific to a resident's interests would be important to ensure the goal of holding the resident's interest and successfully redirecting the resident from a problematic behavior such as exit seeking occurred. The MDS nurse stated calling family was an individualized intervention for Resident #1, however stated if staff did not know about the intervention or failed to implement it, the intervention could not be successful. Interview with the Director of Nursing (DON), on 07/14/2021 at 3:33 PM, revealed she expected staff to utilize resident care plans to ensure residents received individualized care to better meet their needs. The DON stated she expected each care plan to be resident specific, and Resident #1's care plan should have included what diversional activities the resident enjoyed to deter any exit seeking behavior. The DON stated that all direct care staff should be familiar with interventions for each resident's care. The DON stated that although PCA #1 may not have been familiar with Resident #1's needs or behaviors, she should have immediately notified the staff caring for the resident that the resident was displaying exit-seeking behavior. Subsequently, familiar staff could have intervened and provided the resident with the approaches listed on his/her care plan and possibly prevented the resident from exiting the facility. Interview with the Administrator, on 07/14/2021 at 4:13 PM, revealed she expected care plans to be resident specific. She further revealed she felt the staff could utilize the activities care plan to help identify what specific diversional activities were appropriate for Resident #1. However, was unable to determine why the elopement care plan did not include these specific activities. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/08/2021: 1. Resident #1 was transferred to the emergency room at the local hospital for evaluation on 07/04/2021, and returned to the facility same day with no significant injuries. 2. Upon return to the facility from the emergency roiagnom on [DATE], Charge Nurse #2 performed a head to toe skin assessment on Resident #1. The facility found the resident had scrapes to knees bilaterally with no complaints of pain. On 07/05/2021, Charge Nurse #3 completed a follow up skin assessment on Resident #1, and found scrapes to knees bilaterally and a bruise to the right arm. 3. When Resident #1 returned to the facility from the emergency roiagnom on [DATE], the facility placed the resident on one to one supervision and the facility notified the physician and power of attorney of the new supervision intervention. 4. On 07/05/2021, the Nurse Consultant re-evaluated Resident #1 for elopement and completed a new elopement assessment. The Nurse Consultant on 07/04/2021 also reviewed and updated the resident's elopement care plan and the nurse aide's care plan, to reflect the resident's current needs including the one to one supervision. 5. The facility placed Resident #1 on one to one supervision on 07/04/2021, and remained on one to one supervision until staff transferred the resident to the serenity locked unit. 6. The facility conducted a head count of facility residents was performed by the unit nurses on 07/04/2021 and all the residents residing in the facility were accounted for and present. 7. Charge Nurse #1 was educated on the elopement process by the Nurse Consultant on 07/04/2021 and received further education regarding elopement processes by the House Supervisor on 07/04/2021. 8. On 07/04/2021, the Plant Operations staff checked all the facility doors to ensure they locked, and the delayed egress was functioning properly. The Plant Operations staff found all the doors working properly. 9. The DON, Unit Manager and Medical Records staff re-assessed all residents for elopement potential beginning on 07/05/2021 and completed on 07/06/2021. 10. The Nurse Consultant reviewed and updated all comprehensive care plans for residents identified as at risk for elopement on 07/05/2021. 11. The Social Services Director updated the elopement binders for accuracy on 07/05/2021 to reflect current elopement assessments. 12. On 07/05/2021, the Social Services Director reviewed all behavioral management care plans for the nineteen (19) residents assessed to be at risk for elopement to ensure interventions for wandering or exit-seeking behaviors were included. 13. The Regional Vice President and Maintenance Director completed environmental rounds on 07/07/2021, to identify any safety issues. This included observation for hazards such as loose floor tiles, damage to windows or doors, and faulty equipment such as beds/lifts/shower beds/chairs and doors. 14. On 07/04/2021, the Regional Maintenance Director completed an audit of all facility exit doors to ensure all the doors locked and the delayed egress was functioning. The Regional Maintenance Director identified no concerns. 15. The Regional Vice President and Plant Operations Director checked the TELS system (an electronic system to manage the physical plant) on 07/04/2021 to ensure systems were functioning appropriately. 16. The Nurse Consultant started on 07/04/2021 and completed on 07/05/2021 a thirty (30) day look back in the Electronic Medical Record (EMR) and twenty-four (24) hour report all events that had occurred in the facility for exit seeking behaviors. 17. The Nurse Consultant reviewed nurse notes from 07/04/2021 thru 07/05/2021 for the nineteen (19) residents assessed as at risk for elopement for exit seeking behaviors/and or elopements with wandering behavior for thirty days prior to 07/04/2021. 18. The facility Administrator, DON, Unit Managers, ADON, Social Services Director, Admissions Director, Dietary Manager, Minimum Data Set (MDS) Coordinators, Plant Operations staff and the Quality of Life Director were trained on 07/05/2021 by the Nurse Consultant. The education consisted of detailed and specific training on the facility's elopement policy and procedures. Including the missing resident policy and procedures. The door codes and alarms process. The accident and incident policy and procedures. The safety and supervision processes. The abuse policy and procedures. The resident rights policy and procedures. The care plan policy and procedures. The facility administration policy and procedures. The resident change of condition procedures. The behavior management policy and procedures. The quality assurance process/improvement policy and procedures. The facility conducted these trainings face to face to facilitate discussion and questions. The Department Administrative Managers could not return to work until receiving the education and they scored one-hundred percent on a post-test. If the Department Administrative Manager did not score one hundred percent on the post-test education continued until, they scored one-hundred percent. The Nurse Consultant reviewed all post-test for compliance. 19. Beginning on 07/05/2021, the facility's Administrator, DON, ADON, Staff Development Coordinator, Business Office Manager, Social Services Director, Dietary Manager and Rehab Service Manager re-educate the facility staff to include nursing, dietary, therapy, housekeeping and administrative staff on policies and procedures. The training included elopement, missing resident, safety and supervision, accident and incident procedures, abuse policy and procedures, resident rights procedures, care plan procedures, facility administration, resident change of condition procedures, behavior management procedures and quality assurance process improvement procedures. The staff completed the training on 07/07/2021. The IDT team members consisting of the Administrator, DON, ADON, Staff Development Coordinator, Business Office Manager, Social Services Director, Dietary Manager and Rehab Service Manager, were responsible for helping to establish interventions such as increased or decreased supervision (which would be determined based on individual resident need and behaviors exhibited). The facility does utilize agency staff and any agency staff's working have or will receive education prior to working beginning on 07/05/2021. Education will be ongoing after 07/05/2021 to ensure all facility staff not educated on by 07/07/2021 will be educated prior to working on the floor. The information included education regarding the elopement books and the care plan information. Staff included nursing, therapy, dietary, housekeeping, and administrative. The DON, ADON and/or Staff Development Coordinator educated staff to redirect wandering or exit seeking residents back to their assigned unit and/or room. Staff should then consult the residents behavioral management care plan for a list of personalized interventions. This education is ongoing and all employees will be educated prior to working on the floor. 20. Starting on 07/04/2021 all doors will be checked daily for proper function to ensure door locks are secure and that the delayed egress was functioning appropriately by members of the IDT team to include but not limited to the Administrator, DON, ADON, Maintenance Director, Maintenance Assistant, Dietary Director, Social Services Director and/or Business Office Manager. The staff will report any concern immediately to the Administrator and Plant Operations Director. Staff has identified no concerns. 21. An elopement drill was completed on 07/05/2021 by the Administrator and an elopement drill will be conducted daily on random shifts, for one week and then weekly for four (4) weeks to follow by the Administrator, DON or Department Head Managers. The staff will conducted drills quarterly thereafter. Staff will perform the drills on different shifts including weekends. Elopement drills will be conducted to ensure staff are following the missing resident policy and procedure, specifically, actions to take when door alarms sound, including responding to active door alarms, walking the outside perimeter by the alarming door to ensure no resident is observed outside of resident care areas unattended, and to report to the nurse and do a headcount. 22. Beginning 07/06/2021, The DON, ADON or Unit Manager monitored all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decreased to Monday through Friday for three (3) months to determine if there are any new exit seeking behaviors. The Administrator, DON and/or members of the IDT team have been onsite in the facility including weekends since 07/05/2021 to provide oversight and monitoring of the residents at risk for elopement with visual rounding through the facility since 07/05/2021. Staff completed the monitoring daily and it included reviews of events in event manager, the elopement risk assessments, and the twenty-four (24) hour report. 23. Beginning on 07/05/2021 the facility would conduct an elopement paper test including questions regarding policies on elopement, quality improvement, abuse reporting, and change of condition procedures, care plans, accidents and incidents procedures, and safety and supervision procedures. The staff tested must make one hundred (100) percent, and if not they must be re-educated and re-tested until a score of one hundred (100) percent was obtained. Random selection of employees across various shifts. The schedule for testing would be five (5) employees per shift for two (2) weeks for a total of ten (10) per day. Then the schedule decreases to three (3) employees per shift for one week for a total of six (6) per day. Then the schedule decreases to two (2) employees per shift for one week for a total of four (4) per day. Then the schedule decreases to one employee per shift for one week for a total of two (2) per day. Then the schedule decreases to one employee per week for four weeks and then decrease to one employee every other week for four weeks. 24. A Quality Assurance Performance Improvement (QAPI) meeting was conducted following the incident on 07/05/2021 and would be conducted weekly for four weeks to include but not limited to the Facility Medical Director, Administrator, DON, SCC, ADON, Unit Manager, Social Services, MDS, Plant Operations staff, Dietary Manager, Restorative Nurse in attendance. Discussion included an immediate action plan as well as the facility's plan to ensure compliance. 25. A nurse from the regional team or corporate office and or the vice president of operations has been available on site or by phone since 07/04/2021. The Administrator and or DON have been on site daily since 07/05/2021 to ensure continued compliance with audits established by the Quality Assurance and Performance Improvement Committee. The SCC and/or Regional Vice President provided oversight beginning on 07/04/2021. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 07/08/2021 as alleged: 1. Review of Resident #1's medical record on 7/27/2021, revealed an emergency room Record dated 07/04/2021. The record revealed the hospital examined the resident in the emergency room and found to have superficial abrasion on the knees. The record also stated the hospital discharged the resident back to the facility. 2. Review of Resident #1's medical record on 07/27/2021 revealed documentation of a skin assessment completed on 07/04/2021 by Charge Nurse #2 revealed the resident had scraped knees. The resident had a follow up skin assessment completed on 07/05/2021, by Charge Nurse #3, which revealed the resident had scraped knees and a bruise to the right forearm due to a venipuncture in the emergency roiagnom on [DATE]. Observation of Resident #1, on 07/27/2021 at 5:00 PM, revealed no bruises or scrapes visible. 3. Review of the medical record for Resident #1, revealed Resident #1 received one to one supervision until the facility transferred the resident to the secured locked unit. Review of completed safety check logs dated 07/04/2021 and 07/05/2021 revealed no concerns. Review of the medical record revealed staff notified the physician and the resident's power of attorney of the increased supervision provided for the resident. Interview with LPN #2 on 07/27/2021 at 4:50 PM, LPN #7 on 07/28/2021 at 10:16 AM, and SRNA #7 on 07/28/2021 at 10:10 AM, revealed the facility had conducted elopement drills daily. 4. Review of the medical record for Resident #1 revealed the Nurse Consultant completed an Elopement Risk Evaluation, on 07/05/2021 at 10:30 AM, and Resident #1 was determined to be at risk for elopement. Review of the Comprehensive Care Plan, revealed the Nurse Consultant updated it on 07/04/2021 and 07/05/2021, to reflect Resident #1's current needs of one to one supervision and diversional activities for exit seeking behaviors. The Nurse Consultant updated the Resident Profile form (Nurse Aide Care Plan) for Resident #1, on 07/04/2021 and 07/05/2021, to reveal the resident was on one to one supervision and diversional activities as needed for exit seeking behaviors. Interview with the Nurse Consultant on 04/28/21 at 2:10 PM revealed she had updated the care plan and Resident Profile. 5. Review of Resident #1's medical record revealed safety check logs indicated one to one supervision, beginning, 07/04/2021 at 7:50 PM, and ending on 07/05/2021 at 4:00 PM when the resident was placed in the secured locked unit on fifteen (15) minutes checks continuing through 07/27/2021. Interview with Licensed Practical Nurse #3, on 07/28/2021 at 9:22 AM, the Unit Manager, on 07/28/2021 at 9:05 AM, the Social Services Director, on 07/28/2021 at 9:28 AM, revealed Resident #1 was one to one until moved to the locked unit. 6. The facility provided a Midnight Census Worksheet, dated 07/04/2021, revealed an accountability check by the weekend supervisor of every resident presently admitted to the facility. Interview with Charge Nurse #1, on 07/27/2021 at 3:45 PM, revealed no other residents were missing from the facility on 07/04/2021. 7. The facility provided a statement signed by the Nurse Consultant, revealed Charge Nurse #1 was educated on elopement procedures on 07/04/2021. The facility provided a sign in sheet dated 07/04/2021, that indicated Charge Nurse #1 was educated on door alarms and elopement procedures. Interview with Charge Nurse #1 on 07/27/2021 at 3:45 PM revealed the Nurse Consultant and Weekend Supervisor had both educated her on elopement procedures. 8. The facility provided documentation that indicated the Plant Operations employee conducted a door and window audit on 07/04/2021. The Plant Operations Employee revealed on the documentation all the facility doors and windows were functioning properly. Interview with the Administrator, on 07/28/2021 at 1:55 PM, revealed the doors had been functioning properly. Observation of the facility doors, on 07/27/2021 from 8:30 AM thru 8:45 AM, revealed the doors functioned properly. 9. Review of a checklist revealed DON, Unit Manager and Medical Records staff documented from 07/05/2021 and finishing on 07/06/2021 all resident assessments for elopement potential. The staff identified no new residents assessed for elopement risk. Interview with the DON on 07/28/2021 at 01:40 and the Unit Manager on 07/28/2021 at 9:05 AM revealed they had reassessed all residents. 10. Review of the comprehensive care plans and the resident profiles, on 07/27/2021, for the nineteen (19) residents identified as at risk for elopement revealed the Nurse Consultant reviewed and updated the care plans on 07/05/2021. Interview with the Nurse Consultant on 04/28/21 at 2:10 PM revealed she updated the comprehensive care plans. 11. A signed statement by the Social Services Director dated 07/05/2021, revealed she had reviewed all the elopement binders for all the residents identified for elopement risk and made updates as necessary. Interview with the Social Services Director, on 07/28/2021 at 9:28 AM, revealed the facility did have elopement books prior to the elopement on 07/04/2021; however, after the incident she went through every elopement book and updated the books. The Social Services Director revealed Elopement Books were at every nurse's station, therapy room, the front business office and the social services office. 12. A signed statement by the Social Services Director, dated 07/05/2021, revealed she reviewed/updated behavior management care plans for all residents residing in the facility to include interventions wandering or exit seeking behavior. Interview with the Social Services Director, on 07/27/2021 at 2:45 PM, revealed that the elopement binders contain policy and procedures for missing residents, each residents picture and description of the resident along with a face sheet for the resident and the behavior management care plan for the resident revealing personalized interventions for the resident when exit seeking. 13. The facility provided a signed statement, revealing the Regional Vice President completed environmental rounding with the Maintenance Assistant on 07/07/2021 to identify any safety concerns to include but not limited to assessing environmental hazards such as loose floor tiles, damaged windows or doors, faulty equipment such as beds, lifts, shower beds and chairs. Interview with the Regional Vice President on 07/28/2021 at 1:00 PM, revealed he did come in and do environmental rounding was done and no concerns were found. 14. The facility provided a documentation checklist dated 07/04/2021 indication staff verified all doors and windows locked and delayed egress functioned. Interview with the Regional Vice President on 07/27/2021 at 1:00 PM revealed he phoned the Regional Maintenance Director to go to the facility and check all doors and windows. The Regional Vice President revealed the Regional Maintenance Director phoned him after the inspection was completed and stated he found no mechanical failure. 15. The facility provided a signed statement from the Regional Vice President revealing he reviewed the TELS system for daily door checks for the thirty days prior to 07/04/2021 and he found no mechanical failures. The statement also revealed the Regional Vice President discussed with the Regional Plant Operations Staff and the Plant Operations Staff for the facility the requirements for daily door checks in the TELS system. The facility also provided print out of the daily checklist of the TELS system for thirty days prior to 07/04/2021 and review of the print out revealed no concerns with the doors. Interview with the Regional Vice President on 07/28/2021 at 1:00 PM revealed he reviewed the TELS system for the thirty days prior to 07/04/2021 for any concerns, none found. 16. Review of a Midnight Census Worksheet and the twenty-four (24) hour report dated 07/04/2021, listing all the residents admitted to the facility, was signed by the Nurse Consultant revealing she had reviewed the Electronic Medical Record Event Manager for each resident for the past thirty (30) days and found no concerns of exit seeking behavior. This review began on 07/04/2021 and ended on 07/05/2021. Interview with the Nurse Consultant on 04/28/21 at 2:10 PM, revealed she did a thirty (30) day look back and reviewed all events and the twenty-four (24) hour reports for residents having exit seeking behaviors and had no concerns. 17. Review of a Midnight Census Worksheet dated 07/04/2021 listed all the residents admitted to the facility. The Nurse Consultant documented a review of the nurses' notes for the thirty days prior to 07/04/2021 for documentation of residents exit seeking or having wandering behaviors. The Nurse Consultant began the review on 07/04/2021, ended on 07/05/2021, and found no concerns. Interview with the Nurse Consultant on 07/28/21 at 2:10 PM, revealed she did a complete look back of the nurse's notes for the past thirty days from 07/04/2021 and found no documentation of residents having exit seeking behaviors. 18. The facility provided a list of all the attendees for the training conducted on 07/05/2021 by the Nurse Consultant. The facility also provided the training materials. The facility provided a copy of the post-test compliance completed by the employees. Interviews on 07/28/2021, at 2:10 PM with the Nurse Consultant, 1:55 PM with the Administrator, 1:40 PM with the DON, 9:22 AM with LPN #3 and 9:05 AM with the Unit Manager, revealed they were educated on the policies. 19. The facility provided training sheets for the remainder of the staff including any new staff hired since 07/05/2021. The training sheets revealed all staff trained on the same policies as the managers including elopement, Quality Assurance and Performance Improvement, Behavioral Care Plans, Abuse, Missing Residents, Safety and Supervision, Accident and Incident, Behavior Management, Resident Rights, Facility Administration and Change of Condition. Interview with Housekeeper #1 on 07/28/2021 at 9:41 AM, SRNA #7 on 07/28/2021 at 10:10 AM, and SMA on 07/28/2021 at 9:56 AM, revealed they all received the training. 20. Since 07/04/2021, s [TRUNCATED]

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure that pain management was provided for one (1) of five (5) sampled residents (Resident #1). On 07/28/2020 at 11:10 AM, Resident #1 reported a fall and was assessed to have a bruise with limited/painful range of motion to the right shoulder. Resident #1 was noted to be in pain and the pain was documented as being five (5) out of ten (10) on the pain scale; however, documentation on the Medication Administration Record [REDACTED]. Additional pain medication ([MEDICATION NAME]) was ordered for the resident after the injury but the order for this pain medication was not filled/administered until 07/30/2020. The findings include: Review of the facility policy titled, Pain Management, dated 11/06/2019, revealed, The purpose of this policy is to outline guidelines that will promote effective pain management, including initial and ongoing pain assessments, timely response to complaints of pain . Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #1's Care Plan dated August 2020, revealed the resident had history of chronic pain (Back) with an intervention to administer medications as ordered. Review of Resident #1's Physician Orders revealed in August 2020 the resident had orders for [MEDICATION NAME] 500 mg two (2) capsules twice daily as needed for pain. Review of Resident #1's fall event, dated 07/28/2020 at 11:10 AM, revealed the resident's pain was documented as being five (5) out of (10) on the pain scale. The resident was noted to have a bruise to the right shoulder. The resident was documented as having painful/limited range of motion. According to the fall event documentation, the physician and the family were notified. Review of the Physician's Orders for Resident #1 revealed an order dated 07/28/2020, for an x-ray of the right shoulder. Review of an x-ray of the right shoulder for Resident #1, dated 07/28/2020 at 8:11 PM, revealed the resident had sustained a [MEDICAL CONDITION] distal clavicle (collarbone). Further review of Resident #1's Physician Orders revealed an order dated 07/30/2020, for [MEDICATION NAME] 50 mg every six (6) hours PRN (as needed), for [DIAGNOSES REDACTED]. Interview with Licensed Practice Nurse #2 on 09/11/2020 at 4:30 PM, revealed the [MEDICATION NAME] was originally ordered on [DATE] but since the provider did not send a written prescription to the pharmacy, the order was discontinued by the pharmacy. Review of Resident #1's Medication Administration Record [REDACTED]. The resident received [MEDICATION NAME] HCL 50 mg on 07/30/2020 at 3:00 PM. Observation and interview with Resident #1 on 09/10/2020 at 1:00 PM, revealed the resident was sitting on the side of the bed. When asked if the resident was in pain, he/she shook his/her head no. When asked if the resident's shoulder hurt, the resident pulled back his/her shoulder in a protective gesture and said, Sometimes. When asked what happened to hurt his/her shoulder, the resident did not answer. Interview on 09/11/2020 at 1:00 PM, with State Registered Nursing Assistant (SRNA) #1 revealed on 07/28/2020, when she took breakfast to Resident #1, the resident was lying in bed and was unable to raise up in bed. The SRNA stated she reported this to the nurse. The SRNA stated the resident was able to tell staff when he/she was in pain and on 07/28/2020, the resident complained of shoulder pain. Interview on 09/11/2020 at 4:30 PM, with Licensed Practice Nurse #2 revealed an SRNA reported to her on the morning of 07/28/2020, that Resident #1 had a difficult time getting up from bed. The LPN stated she assessed the resident and found a raised bruised area to the right clavicle. Per the LPN, the resident told her he/she had fallen into the sink the previous night and hurt himself/herself. LPN #2 stated she gave Resident #1 1,000 mg of Tylenol and notified the physician and the family. The LPN stated on 07/28/2020, the Advanced Practice Registered Nurse (APRN) ordered [MEDICATION NAME] 50 mg for Resident #1 for pain. The LPN stated that on 07/28/2020, she sent the order for [MEDICATION NAME] to the pharmacy; however, the LPN stated she did not follow up to ensure the pain medication order was received and would be delivered. The LPN stated she did not work on 07/29/2020, and on 7/30/2020, when she returned to work, she noticed the resident had not received the [MEDICATION NAME]. Per the LPN, she investigated to see why the resident had not received the [MEDICATION NAME] and found out the APRN had not sent the prescription for the [MEDICATION NAME] to the pharmacy. The resident did not receive [MEDICATION NAME] until 07/30/2020 (two days after the initial order). The LPN was asked about the MAR indicated [REDACTED]? I was aggravated that the resident had fallen the night before and nothing got done about it. I did give the Tylenol but I probably forgot to chart it. Interview on 09/11/2020 at 10:48 AM, with the Director of Nursing (DON) revealed she felt that the resident's pain had been addressed with the 1,000 mg of Tylenol due to the resident having no further complaints of pain that day. She stated the LPN had assessed the resident for pain and the APRN had ordered [MEDICATION NAME] in anticipation of the resident needing something stronger than Tylenol. The DON agreed that the Tylenol had not been charted on the Medication Administration Record [REDACTED]. Per the DON, it was the practice of the pharmacy to require a written prescription for any narcotic. The DON further stated that the order for [MEDICATION NAME] should have been followed up on before 07/30/2020.

Based on observation, interview, record review, facility investigation, and facility policy review, it was determined the facility failed to immediately notify the resident's physician and responsible party when there was an accident involving the resident for one (1) of five (5) sampled residents (Resident #1). Resident #1 sustained a fall on the evening of 07/27/2020, and reported the fall to State Registered Nurse Aide (SRNA) #1, around 10:00 PM on 07/27/2020. However, the physician and responsible party were not notified of the resident's fall, until 07/28/2020 at 11:15 AM and 11:33 AM, after the resident reported the fall to a nurse (Licensed Practical Nurse #4). The resident was assessed to have a bruise to the right shoulder and the physician ordered an x-ray, which revealed a right distal clavicle (collarbone) fracture. The findings include: Review of the facility policy titled, Falls, with a revision date of 11/06/2019, revealed the facility would provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. The policy revealed if a fall occurred the resident would be evaluated, the physician and family would be notified, and an investigation would begin. The policy also revealed the Interdisciplinary Team (IDT), of which the Director of Nursing (DON) was a member, reviewed all falls to identify additional referrals, consultations, and interventions needed. Review of the medical record for Resident #1 revealed the facility admitted the resident on 05/17/2019, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/09/2020, revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was severely cognitively impaired. The MDS revealed Resident #1 had been assessed to require supervision for ambulation and extensive assistance of one (1) person for toileting. Review of the comprehensive plan of care for Resident #1, with a revision date of 06/25/2020, revealed the resident was at risk for falls. The comprehensive plan of care revealed interventions had been developed for fall prevention such as an intervention dated 05/19/2020, to keep the environment safe and to cue the resident for safety awareness. Review of a facility Safety Event for Falls completed by Licensed Practical Nurse (LPN) #4, dated 07/28/2020 at 11:03 AM, revealed the resident had sustained an unwitnessed fall, which the resident stated occurred the previous night in the resident's bathroom. The investigation revealed the resident stated he/she had hit his/her right shoulder on the sink. Per the investigation, the resident had a bruise observed that measured three (3) centimeters (cm) by four (4) cm to the right shoulder. The fall investigation revealed Resident #1 had told LPN #4 he/she was experiencing moderate pain (distressing) in his/her right shoulder. Review of the fall investigation revealed the resident's physician had been notified, on 07/28/2020 at 11:15 AM, and the resident's family had been notified, on 07/28/2020 at 11:33 AM. Review of the Physician's Orders for Resident #1, revealed an order, dated 07/28/2020, for an X-ray of the right shoulder. Review of Resident #1's X-ray Report of the right shoulder, dated 07/28/2020 at 8:11 PM, revealed the resident had sustained a [MEDICAL CONDITION] distal clavicle (collarbone). Review of a Falls Investigation Report, for Resident #1 completed by the Director of Nursing (DON), dated 07/28/2020, revealed on 07/28/2020 at 11:10 AM, Resident #1 reported he/she had fallen the night before on 07/27/2020. The investigation revealed LPN #2 and LPN #3, who worked the 6:45 PM to 7:00 AM shift, were interviewed and stated the resident had not reported a fall during their shift. However, there was no evidence that SRNA #1 and SRNA #7, who had also worked during that timeframe, had been interviewed. The investigation revealed Resident #1's physician had been notified, with new orders for an X-ray to be obtained for the right shoulder. Review of the X-ray report for Resident #1 revealed the resident had a fractured right distal clavicle (collarbone). Observation of Resident #1, on 08/04/2020 at 12:45 PM, revealed the resident was observed to be under droplet precautions as evidenced by the signage on the resident's door and the personal protective equipment (PPE) in a container by the door. The resident was observed to be lying in bed on his/her back and a sling was observed on the resident's right arm. Interview conducted with Resident #1, on 08/04/2020 at 12:45 PM, revealed the resident stated he/she had fallen last week in his/her bathroom and hit the sink, hurting his/her right shoulder. The resident stated that it hurts a lot sometimes. The resident stated he/she had told a girl that night but could not remember who it was. Interview with State Registered Nursing Assistant (SRNA) #1, on 08/03/2020 at 4:50 PM, revealed Resident #1 had reported to her, on 07/27/2020 at approximately 10:00 PM, that he/she had fallen and hit the sink in the bathroom. The SRNA stated SRNA #7 was with her and heard the resident. The SRNA stated she and SRNA #7 went to LPN #2 and LPN #3 and she reported the resident's fall. SRNA #1 stated SRNA #7 had witnessed her reporting the incident to LPN #2 and LPN #3. The SRNA stated she was required to immediately report any fall to the nurse. Interview with LPN #2, on 08/04/2020 at 7:20 AM, and LPN #3, on 08/04/2020 at 7:25 AM, revealed SRNA #1 had not reported the fall Resident #1 sustained, on 07/27/2020. The LPNs both stated they would have immediately assessed the resident and notified the resident's physician and responsible party. Interview with SRNA #7, on 08/04/2020 at 11:30 AM, revealed she had worked on 07/27/2020. The SRNA stated she had not heard Resident #1 report the fall nor had she witnessed SRNA #1 report the fall to LPN #2 and LPN #3. The SRNA stated SRNA #1 had told her what the resident reported and told her that she had reported the incident to the LPNs but she had not witnessed either event. The SRNA stated she was required to immediately report any fall to the nurse. Interview with LPN #4, on 08/04/2020 at 12:05 PM, revealed on 07/28/2020, Resident #1 had reported to her that he/she had sustained a fall on the evening of 07/27/2020. The LPN stated the resident told her he/she had hit the sink in the bathroom. LPN #4 stated she had been concerned about the resident because he/she was usually up and ambulating and the resident would not get up or eat. The LPN stated she observed a bruise on the resident's right shoulder. The LPN stated she asked the resident if he/she had told anybody and the resident stated yeah, but was unable to tell her who he/she had told. The LPN stated the resident could tell you simple things but could not carry on a long conversation. The LPN stated she immediately notified the resident's physician and obtained x-ray orders for the resident's right shoulder. The LPN stated she also notified the resident's responsible party. The LPN stated she began the Safety Event for Falls for Resident #1. Interview with the Director of Nursing (DON), on 08/05/2020 at 10:00 AM, revealed she had completed the fall investigation for Resident #1, dated 07/28/2020. The DON stated she had interviewed LPN #2 and LPN #3 and should have interviewed SRNA #1 and SRNA #7. The DON stated after LPN #2 and LPN #3 had told her they were not aware of any fall experienced by Resident #1 she had not taken it any further and should have. The DON stated SRNA #1 was required to notify LPN #2 and LPN #3 immediately after the resident reported the fall on 07/27/2020, so the resident's physician and responsible party could be notified immediately. The DON further stated she had not identified any concerns with residents' physicians and responsible parties not being notified immediately with any change in their conditions or after an accident.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #1) received necessary care and treatment in accordance with professional standards. Resident #1 reported to State Registered Nurse Aide (SRNA) #1 on 07/27/2020 at approximately 10:00 PM, that he/she had fallen, and indicated that his/her shoulder was hurting. However, staff failed to assess the resident or provide treatment to the resident until 07/28/2020 at approximately 11:00 AM, approximately thirteen (13) hours later when Resident #1 reported the fall and injury to Licensed Practical Nurse (LPN) #4. The nurse assessed Resident #1 at that time to have a bruise to the right shoulder, and a subsequent x-ray revealed the resident had a right distal clavicle (collarbone) fracture. The findings include: Review of the facility policy, Falls, revised 11/06/2019, revealed if a fall occurred the resident would be evaluated, the physician and family would be notified, and an investigation would be initiated. Review of Resident #1's medical record revealed the facility admitted the resident on 05/17/2019, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have severe cognitive impairment and require supervision for ambulation. Review of Resident #1's comprehensive plan of care, revised 06/25/2020, revealed the resident was at risk for falls. Review of a facility Safety Event for Falls report completed by LPN #4, dated 07/28/2020 at 11:03 AM, revealed Resident #1 had reported falling the previous night in the bathroom. Continued review of the report indicated the resident also stated that his/her right shoulder had struck the sink during the fall. LPN #4 assessed the resident to have a bruise to the right shoulder measuring three (3) centimeters (cm) by four (4) cm, and the resident was experiencing pain to the right shoulder. Further review of the fall report revealed the resident's physician was not notified of the resident's fall with injury until 07/28/2020 at 11:15 AM. Review of the Physician's Orders for Resident #1, dated 07/28/2020, revealed an order was received to obtain an x-ray of the resident's right shoulder. Review of the x-ray report for Resident #1, dated 07/28/2020 at 8:11 PM, revealed the resident had a [MEDICAL CONDITION] distal clavicle (collarbone). Review of a Falls Investigation for Resident #1 completed by the Director of Nursing (DON), dated 07/28/2020, revealed Resident #1 reported falling the previous night. The investigation revealed LPN #2 and LPN #3, who were working on the night of 07/27/2020, had no knowledge of Resident #1 sustaining a fall on 07/27/2020. However, there was no evidence the facility interviewed SRNA #1 or SRNA #7, who cared for Resident #1 on 07/27/2020, or that Resident #1 was interviewed. Observation and interview of Resident #1 on 08/04/2020 at 12:45 PM, revealed the resident was lying in bed with a sling applied to the right arm. Resident #1 recalled falling in the bathroom, striking the sink, and injuring his/her shoulder. The resident stated his/her shoulder hurts a lot sometimes. The resident also recalled telling a girl about the fall on the night it occurred. Interview with SRNA #1 on 08/03/2020 at 4:50 PM revealed on 07/27/2020, Resident #1 reported falling and hitting the sink to her at approximately 10:00 PM. SRNA #1 stated she reported the resident's fall to LPN #2 and LPN #3. Interview with LPN #2 on 08/04/2020 at 7:20 AM, and LPN #3 on 08/04/2020 at 7:25 AM, revealed both staff members denied that SRNA #1 reported Resident #1's fall to them on 07/27/2020. Interview with LPN #4 on 08/04/2020 at 12:05 PM revealed on 07/28/2020, she was concerned about Resident #1 because the resident was usually up walking, and on that morning the resident would not get out of bed or eat breakfast. LPN #4 stated Resident #1 reported falling the night before and hitting the sink. The LPN assessed Resident #1 and found bruising present to the resident's right shoulder. LPN #4 stated she asked the resident if he/she told anybody about the fall when it occurred and the resident stated yeah. LPN #4 stated she immediately notified the resident's physician and obtained an order for [REDACTED]. Interview with the DON on 08/05/2020 at 10:00 AM, revealed she had completed the fall investigation for Resident #1 on 07/28/2020. The DON stated she had interviewed LPN #2 and LPN #3, but had not interviewed SRNA #1 and SRNA #7. The DON stated after LPN #2 and LPN #3 told her they were not aware of Resident #1 sustaining a fall, she concluded the investigation and took no further action. The DON stated SRNA #1 was required to notify the nurse immediately after the resident reported the fall on 07/27/2020. However, the DON stated because she had not spoken to SRNA #1 regarding Resident #1's fall, she was not aware that the SRNA had reported the fall as required, but the nursing staff had taken no action to assess or treat Resident #1 after sustaining the fall on 07/27/2020.

Based on interview, record review, and review of facility policies, it was determined the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one (1) of six (6) sampled residents (Resident #1). On 12/19/2019 at 6:40 PM, Resident #1 was permitted to sign out of the facility against medical advice (AMA) and travel home via a taxicab. Facility staff failed to assist Resident #1 with community services prior to his/her discharge on 12/19/2019; even though, Resident #1's right arm was immobilized, he/she had minimal function in his/her left arm and required assistance of staff with toileting, hygiene, and dressing. Per the hospital record, the resident experienced a fall on 12/19/2019, during the night after returning home and was unable to get up. The resident called Emergency Medical Services (EMS) the next morning (12/20/2019) and was transferred to the hospital where the resident was diagnosed with [REDACTED]. The facility's failure to ensure sufficient orientation for a safe and orderly discharge has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/30/2020, and was determined to exist on 12/19/2019 at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 01/30/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). An acceptable Allegation of Compliance was received on 02/05/2020, which alleged removal of Immediate Jeopardy on 02/07/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 02/07/2020, prior to exit on 02/12/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Discharge Planning Process revised on 07/29/2019, revealed the facility would ensure a discharge planning process was in place to address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate; and involving the resident, the resident's representative, and the interdisciplinary team in developing the discharge plan. The policy stated that the facility must develop and implement effective discharge planning processes that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Review of the Discharge without Physician Approval policy revised on 06/28/2018, revealed discharges against the advice of the attending physician would require a signed statement from the resident or responsible party to release the facility from responsibility for discharge. Continued review of the policy revealed if the resident chose to be discharged to a setting which did not appear to meet the post-discharge needs or appeared unsafe, the situation would be treated as a refusal of care and the facility would discuss the implications and risks of the discharge location with the resident and representative and attempt to determine why the destination was chosen; provide more suitable options to meet the resident's needs; document these discussions and despite being offered other options that could meet the resident's needs, the resident refusal of the option for an appropriate discharge setting; determine if a referral to Adult Protective Services (APS) or other state entity was necessary, and if so, the referral would be made at the time of discharge. Review of Resident #1's medical record revealed the facility admitted the resident on 11/22/2019 with [DIAGNOSES REDACTED]. Review of Resident #1'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 seven (7), indicating severe cognitive impairment. Further review of the MDS assessment revealed the resident required extensive assistance of one (1) staff member for toileting and hygiene, and extensive assistance of two (2) staff members for dressing. Resident #1 was further assessed to have limitations in range of motion (ROM) to both upper extremities. Continued review revealed there was no active discharge plan in place for Resident #1 to return to the community. According to the MDS, staff asked the resident and/or family if the resident wanted to speak with someone about returning to the community, and the answer was checked as no. Continued review of Resident #1's medical record revealed another BIMS assessment dated [DATE] at 1:56 PM that stated the resident had a BIMS score of 14, which indicated the resident was cognitively intact. However, interviews with State Registered Nurse Aide (SRNA) #1 on 01/27/2020 at 5:02 PM and SRNA #6 on 01/28/2020 at 5:10 PM revealed Resident #1 had poor decision making skills and required assistance with toileting, hygiene, and dressing. In addition, an interview with LPN #3 on 01/27/2020 at 4:27 PM revealed Resident #1 did not make safe choices and did not feel the resident was capable of caring for himself/herself at home without assistance because the resident did not have use of the right arm and very limited use of the left arm. Review of a Speech Therapy Discharge Summary dated 12/20/2019 revealed Resident #1 was receiving cognitive treatment that included cueing hierarchy to increase reasoning and sequencing skills to improve judgement and safety to return home safely. In addition, the Speech Therapist was utilizing compensatory strategies (calendar) to increase orientation skills independently and cueing hierarchy to improve functional memory skills, reasoning, and safety/sequencing with activities of daily living (ADL). Further review revealed Resident #1 exhibited cognitive deficits in the areas of sequencing and reasoning and was unable to increase the resident's skills with implementing cues. The Speech Therapist documented that Resident #1 was unsafe to walk by himself/herself and was educated to wait for assistance prior to walking. According to the note, the Speech Language Pathologist (SLP) would have recommended supervision for the resident at home as he/she was unable to safely be by himself/herself. Interview with the SLP on 01/28/2020 at 4:07 PM revealed Resident #1 had poor cognitive skills and was very impulsive. She stated Resident #1 likely had a BIMS score of 14, however; that assessment did not assess the resident's decision making skills. She stated based on Resident #1's Saint Louis University Mental Status (SLUMS) Examination on 11/25/2019, his/her score was nine (9), indicating Dementia. The SLP stated Resident #1 would require a caregiver once he/she was discharged home to help with medications and ADL care. She also stated that Resident #1 had agreed that he/she would need help at home once he/she was discharged . Review of an Occupational Therapy (OT) Discharge Summary dated 12/20/2019 revealed Resident #1 still required assistance with cutting his/her food and with setting up his/her meal. In addition, the resident required maximum assistance or was dependent on someone to wash his/her hair, and could not reach his/her posterior perineal area (bottom) to clean himself/herself. Further review of the OT Discharge Summary revealed Resident #1 had been educated regarding shoulder precautions and had verbalized understanding, yet was observed not following precautions at times. Review of the Barthel Index (a scale used to measure performance in ADL care) dated 12/19/2019 completed by the Occupational Therapist (OT), revealed Resident #1 needed help with personal care; needed some help with toileting, but could do some things alone; needed help with cutting food; walked with the help of one (1) person; was dependent on someone for dressing; needed help whether verbal, physical, or a carrying aid with stairs; and was dependent on someone for bathing. Interview with the OT on 01/28/2020 at 3:55 PM revealed Resident #1 had poor safety awareness. She stated due to Resident #1's right arm being immobilized and having limited range of motion in his/her left arm, if the resident fell , he/she could not catch himself/herself. She stated Resident #1 had shoulder precautions and was aware what his/her precautions were, but chose not to follow them. Interview with the Physical Therapy Assistant (PTA) on 01/28/2020 at 4:00 PM revealed Resident #1 had poor safety awareness and decision making skills. She stated Resident #1 sustained a few falls while at the facility and was instructed that he/she would require assistance of staff to ambulate to and from smoke breaks and therapy sessions; however, she stated the resident often refused to utilize staff assistance with ambulation. The PTA stated that she had recently attended a care conference when Resident #1's POA expressed concern with the resident's lack of safety awareness and decision making skills. She stated Resident #1's POA felt that he/she could not be at home without assistance due to his/her mental awareness and physical barriers (very limited use of his/her left arm and his/her right arm in an immobilizer). Review of a Nursing Progress Note for Resident #1 dated 12/19/2019 at 7:05 PM, revealed Resident #1 left the facility AMA at 6:40 PM via taxi. The Release of Responsibility for Discharge AMA form was signed by the resident and the form indicated that the resident's family and the physician were notified. Further review of the progress note revealed staff documented that the resident was aware of the potential risks involved with leaving the facility AMA. Review of the Release of Responsibility for Discharge AMA form revealed Resident #1 signed himself/herself out of the facility on 12/19/2019 (not timed) and released the facility, Administration, staff, and physician from all responsibility from any consequences that may result from leaving the facility under these circumstances. Further review revealed Resident #1 was discharging himself/herself at his/her own insistence and against the advice of the facility staff and without the authority of his/her physician and that Resident #1 was informed of the dangers to his/her health and/or safety if he/she left. There was no documented evidence that the facility discussed the implications and risks of the discharge location with the resident, attempted to determine why the destination was chosen, or provided more suitable options to meet the resident's needs as required by the facility's AMA policy. In addition, there was no evidence the facility attempted discharge planning to ensure the resident had follow-up physician appointments, referrals to continue therapies, etc. Review of a Social Services Progress Note for Resident #1 dated 12/20/2019 at 1:04 PM revealed APS was notified of Resident #1's AMA discharge from the facility. There was no evidence a referral to APS was made at the time of discharge as required by the facility's AMA policy. Interview with Licensed Practical Nurse (LPN) #1 on 01/28/2020 at 10:04 AM revealed she cared for Resident #1 on 12/19/2019, and the resident signed out of the facility AMA at 6:40 PM. According to the LPN, she informed the resident of the risks of leaving; however, she stated that the resident was intent on leaving and no other arrangements/referrals were made. Interview with the Social Services Director (SSD) on 01/28/2020 at 5:25 PM revealed she performed a BIMS assessment on Resident #1 on 12/19/2019 after the resident stated she was leaving the facility. She stated Resident #1 scored a 14; therefore, it was determined that the resident had the mental capacity to make his/her own decisions, which included signing out of the facility AMA. However, further interview revealed that although she was aware that Resident #1 did not have good safety awareness, could not physically take care of himself/herself, and was at high risk for falls, she did not conduct any discharge planning or make any attempts to ensure the resident received a referral to continue therapies or to ensure the resident had follow-up appointments. She further stated she did not notify APS of the resident's discharge until the next day because she was not at the facility when the resident left on 12/19/2019. Interview with the Director of Nursing (DON) on 01/28/2020 at 6:09 PM revealed Resident #1 was permitted to sign out AMA. According to the DON, she felt the resident was cognitively intact and could make decisions regarding his/her care. She stated she left the facility before Resident #1 left AMA and was not aware of referrals if any, were made for Resident #1. Interview with the Administrator on 01/28/2020 at 6:43 PM revealed Resident #1 did not want to be at the facility any longer and was permitted to sign himself/herself out AMA. She stated she was not aware that any referrals were made for the resident, other than referral to APS the following day, 12/20/2019. Interview with the Medical Director on 01/28/2020 at 5:40 PM revealed the facility informed him that Resident #1 wanted to leave AMA. He stated they told him that the resident had a BIMS score of 14, therefore; the facility could not keep the resident against his/her will. He stated he was not overly familiar with Resident #1's history because he had only seen the resident since admission to the facility. However, the Medical Director stated that he had questioned the validity of BIMS assessments in the past, stating the assessment did not always truly assess a resident's cognitive status. Review of a hospital record for Resident #1 dated 12/20/2019, the day after the resident left the facility AMA, the resident presented to the emergency department (ED) via emergency medical services (EMS) at 3:30 PM due to right shoulder and upper arm pain. The triage note stated that the resident fell last night, 12/19/2019, but unable to get up and did not call EMS until this morning 12/20/2019 for assistance getting up off the floor. The record revealed that Resident #1 was wearing a sling/swath to the right arm, but the arm was not supported. Review of the ED General Exam dated 12/20/2019 at 3:40 PM revealed Resident #1 fell on [DATE] at home and was experiencing pain to his/her right arm. Review of a Computed Tomography (CT) Scan on 12/20/2019, revealed the resident had a comminuted fracture involving the right humeral head (shoulder area) and the plate and screw fixation of the right humerus was displaced. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/07/2020: 1. On 12/19/19, Resident #1 was placed assisted back to the facility and placed on 1:1 supervision until the Resident was discharged against medical advice (AMA) at 6:40 PM. 2. A head count of facility residents was conducted on 12/19/19 and completed on 12/20/19 by each unit nurse via medication administration documentation. All residents were accounted for in the facility. 3. The Maintenance Director and Assistant Maintenance Director checked all exit doors on 12/20/19 to ensure they were secured, and that the delayed egress was functioning properly. All exit doors were key coded and functioning. 4. All residents that were identified to be at risk for elopement were re-assessed for elopement potential by the facility Care Consultant on 01/14/2020. At that time, 15 residents were identified to be at risk for elopement. The facility Care Consultant completed new elopement assessments on 100 percent of the facility residents beginning on 01/14/2020 and was completed on 01/16/2020. 5. On 01/16/2020, one (1) resident was identified as exhibiting exit seeking behavior and determined to be an elopement risk by the Unit Manager (UM). The resident's comprehensive care plan and State Registered Nurse Aide (SRNA) care plan was updated to include risk of elopement. On 01/16/2020 the resident's picture was taken and added to the elopement binders per facility policy by the Social Services Director (SSD), UM, and facility Care Consultant. 6. The Minimum Data Set (MDS) Coordinator and facility Care Consultant reviewed and updated all care plans with any changes found on the elopement assessments on 01/15/2020 and 01/16/2020. 7. The SSD and the facility Care Consultant reviewed the elopement binders for accuracy and updated the binders to reflect the current elopement assessments completed on 01/16/2020. 8. The Behavioral management care plans for the residents identified to be at risk for elopement were updated to include interventions for wandering/exit seeking behaviors on 01/16/2020. 9. On 01/15/2020, the Regional Vice President (RVP) and the Maintenance Assistant completed environmental rounds to identify any safety issues that included door functionality and secured windows. No concerns were identified during the performed rounds. 10. The Technology Enhanced Learning System (TELS), the facility's online maintenance system that tracks door checks, was reviewed to ensure all doors had been checked for locking, alarms, maglock, and delayed egress for the last 30 days by the facility Care Consultant and Maintenance Director on 01/14/2020 with any issues identified addressed. 11. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above and family members of residents with BIMS scores of seven (7) and below were interviewed to determine prior knowledge of elopement or safety concerns beginning on 01/15/2020 and completed on 01/17/2020. The interviews were performed by the Chaplain, Social Services Director (SSD), Marketing Director, Activities Directory, Dietary Services Manager, Central Supply, and Business Office Manager with no concerns identified. 12. A 30-day look-back was completed for all events that had occurred in the facility and 24 hour report for residents exhibiting exit seeking behaviors on 01/15/2020 by the facility Care Consultant and the Risk Manager. No concerns were identified related to exit seeking behaviors or elopement. 13. On 01/15/2020 and 01/16/2020, the Risk Manager initiated a 30-day look-back of nurses' notes for residents exhibiting exit seeking behaviors and/or elopements, with no concerns identified. 14. discharged resident records were audited for the past 60 days on 01/31/2020 by the Regional Vice President (RVP) and facility Care Consultant to ensure no other residents were discharged AMA without consent and no concerns were identified. 15. The facility's Independent Risk Manager began audits on 01/31/2020 of all current Power of Attorney (POA) documents on file to ensure no instances of resident/POA's rights were violated. The audit was completed on 02/03/2020 with no identified concerns. 16. On 01/16/2020, the Central Supply Clerk verified that all currents residents identified to be at risk for elopement were wearing Wanderguard bracelets and the bracelets were functioning properly. One resident identified to be at risk for elopement refused to wear a Wanderguard bracelet and the facility developed a behavior management plan to address wandering/exit seeking behaviors with interventions to decrease episodes. In addition, the facility redefined the entry and exit doors to the building utilizing two (2) doors as entry/exit with only staff members having access to the door codes. All exit doors were monitored by staff and a staff member must enter the door code to allow visitors to exit the facility. 17. The facility Care Consultant reviewed all residents identified to be at risk for elopement to ensure the residents had physician orders [REDACTED]. Any identified issues were addressed during the audits. 18. On 01/15/2020, the Maintenance Director reset all exit door codes in the facility and staff would only have access to door codes for two (2) doors that would be utilized for entering and exiting the facility. 19. The Director of Nursing (DON), Unit Manager (UM), SSD, Dietary Manager, MDS Coordinators, Plant Operations Director, Quality of Life Director, Central Supply Director, and the Chaplain received education on 1/14/2020 by the facility Care Consultant on the following policies: Elopement; Missing Resident; Door Codes/Alarms Process; Accidents/Incidents; Safety and Supervision; Abuse; Resident Rights; Care Plans; Professional Standards; Behavior Management; and Quality Assurance/Performance improvement (QAPI). Education was performed face to face in order to facilitate discussion and questions. Department administrative managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If a manager did not score 100 percent (%) on post-tests, the manager was immediately re-educated, and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by facility Care Consultant or the RVP. 20. The Administrator, DON, and Department Managers educated all staff on the above policies and procedures beginning on 01/14/2020 and completed training on 01/17/2020. Education would be ongoing after 01/17/2020 to ensure all employees not educated by 01/17/2020 would be educated prior to working the floor. Active employees including employees on vacation, Family and Medical Leave Act (FMLA), or other leave would receive education prior to returning to work and would complete a post-test and receive a score of 100%. Education regarding the elopement policy and procedure would be included in the orientation process for all newly hired staff members effective 01/17/2020 with a post-test administered. No newly hired employee would be allowed to work until elopement education was provided. Employees will be immediately re-educated, and posttest re-administered if a score of 100% is not reached on their previous attempt. 21. The Independent Risk Manager educated the RVP and the facility Care Consultant on the policy for Discharge without Physician Approval to include AMA discharge/legal notification with a post-test to ensure adequate understanding of policy with a score of 100% obtained on 1/31/2020. 22. The Administrator, DON, UM, SSD, MDS Coordinators, Maintenance Director, Quality of Life Director, Restorative Nurse Manager, Medical Records Nurse, Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and Marketing Director were educated on 01/31/2020 by the facility Care Consultant/RVP on Discharge without Physician Approval to include AMA discharge and legal representative notification. This included a guideline which guided the nurse in steps to perform when a resident requested to leave AMA to include: notification of the resident's Physician and Responsible Party (RP); discussion of RP's participation in the discharge; discussion with the resident and RP of Physician recommendations; and if necessary, contacting the Administrator or DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal Counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. The training was performed face to face in order to facilitate discussion and questions. Department Administrative Managers were not permitted to work until the education was provided, a post-test administered related to Discharge without Physician Approval and 100% score obtained. If a manager did not score 100% on the posttest, the manager was immediately re-educated, and a post-test was re-administered until a 100% score was achieved. This process continued until all managers obtained a 100% score on the posttest. All post-tests were reviewed for compliance by the facility Care Consultant or RVP. 23. The DON, UM, and Medical Records Nurse re-educated licensed nurses on the policy for Discharge without Physician Approval and a post-test completed for all licensed nurses on the current working schedule by 02/03/2020, which included a guideline that assisted licensed nurses in steps to perform when a resident requested to discharge from the facility AMA. The guideline also included Physician and RP notification; discussions of RP participation in the discharge; discussion with the resident and RP regarding Physician recommendations; and if necessary, contacting the Administrator and DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. Education would continue after 02/03/2020, to ensure all nurses not educated by 02/03/2020 were educated prior to working the floor. Active employees, including anyone on vacation, FMLA, or other leave would receive education prior to returning to work and would complete a post-test scoring 100%. Education regarding discharge without Physician Approval to include AMA Discharge and Legal Notification, as well as a post-test, was included in the orientation process for all newly hired nurses effective 02/3/2020. No newly hired employee would be permitted to work until AMA discharge education is provided and a post-test score of 100% was achieved. If an employee does not score 100% on the post-test, re-education would occur and the post-test re-administered until a score of 100% is achieved. 24. The Nurse Managers and/or the facility Care Consultant reviewed Nursing Notes, Twenty-Four Hour Clinical Reports, Social Services Notes, and Discharge Summaries to ensure all appropriate steps were taken to ensure adequate/safe discharge occurred beginning on 02/01/2020 and continuing through 02/05/2020. 25. Beginning 02/05/2020, the facility Care Consultant educated the interdisciplinary team (IDT) including but not limited to: the Administrator, DON, UM, Medical Records Nurse, SSD, Rehabilitation Service Manager, Dietary Director, Chaplain, Quality of Life Director, MDS Coordinators, Admissions Coordinator, and BOM on the Discharge Planning Process and Policy. Ensuring a discharge plan was in place to address each resident's discharge goals and needs, including care giver support and referrals to local agencies as appropriate. As well as involving the resident and family in the discharge planning with revision as needed. Once the IDT members were sufficiently trained, they then proceeded to educate all licensed nurses and therapists on the Discharge Planning Process and Policy. Education would continue after 02/06/2020, to ensure all IDT members, licensed nurses, and therapist that had not received education before 02/06/2020, would receive education prior to working the floor. Active employees, employees on vacation, FMLA, or other leave, would receive education prior to working their next scheduled shift providing direct resident care. Education regarding the Discharge Planning Process and Policy was included in the orientation process for all newly hired nurses, therapist, and IDT members effective 02/06/2020. 26. Beginning 01/15/2020, all exit doors were checked for proper function to ensure that the doors alarmed, all egresses function properly, system code and keypad operations functioned, as well as checking a wander guard to ensure the doors remained locked and the alarm sounded daily by a member of nursing staff, Department Managers, or Plant Operations. This would remain ongoing and any concerns would be immediately reported to Administrator and Plant Operations Director. Beginning 01/14/2020, the maintenance staff checked doors daily and department head weekend manager checked them on the weekends and would continue ongoing. 27. An elopement drill was completed on 01/14/2020, by the Maintenance Director and was conducted daily on random shifts, for one week and weekly for 4 weeks by the Administrator, DON, or Department Head Managers. The drill would then be conducted quarterly, thereafter. The drills were performed on different shifts and weekends to ensure that stakeholders were following the Missing Resident Policy and Procedure. Specifically, actions taken when a door sounds to include: responding to active door alarms, walking outside perimeter by the alarming door to ensure no resident is observed outside of resident care are unattended, reporting the missing resident to the charge nurse, and initiating a facility headcount. 28. The DON or UM monitored all residents, including new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decreasing to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors beginning 01/18/2020. New admissions would be assessed for elopement risk and any resident identified at risk would be added to the facility elopement books. The following clinical systems will be reviewed daily Monday through Friday by the DON or UM to ensure no resident is at risk that has not been identified by the facility: events in Matrix Care began 01/14/2020; Clinical Summary 24 Hour Report; Nursing Notes; review new admissions/readmissions for elopement assessments updating care plans and elopement books when needed; new/worsening exit seeking and/or wandering behavior tracking; care plan interventions for identified new/worsening exit seeking and/or wander behaviors; and on 02/01/2020, monitoring all discharged resident records to ensure the new process was followed for AMA discharges. The DON/Administrator was onsite on weekends since the incident occurred to provide oversight and to ensure the daily reviews had been completed, as outlined in the AOC. 29. Beginning 01/18/2020 and continuing for two (2) weeks, five (5) employees per shift for a total of ten (10) employees per day would complete an elopement test and score 100%. Beginning 02/02/2020 and continuing for one (1) week, three (3) employees per shift for a total of six (6) employees per day, would complete an elopement test and score 100%. Beginning 02/09/2020 and continuing for one (1) week, two (2) employees per shift for a total of four (4) employees per day would complete an elopement test and score 100%. Beginning 02/16/2020 and continuing for one (1) week, one (1) employee per shift for a total of two (2) employees per day, would complete an elopement test and score 100%. Beginning on 02/23/2020 and continuing for four (4) weeks, one (1) employee per week would complete an elopement test and score 100%. Beginning 03/01/2020 and continuing four (4) weeks, one (1) employee would complete an elopement test and score 100% every other week. If an employee did not score 100%, the employee would be reeducated and retested until a score of 100% was obtained. 30. A nurse from the regional team/corporate office and/or the VP of Operations was available on-site or by phone Monday through Friday, since 01/13/2020. Regional resources were available by phone during the weekend as needed. The Administrator or DON were on-site on weekends beginning 01/13/2020, to ensure continued compliance with audits established by QAPI Committee. The nurses from the regional team or home office were assisting the DON and UM with initiated audits recommended from the QAPI committee. Oversight was conducted in the form of reviewing the admini

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure the decisions of the resident's legal representative or Power of Attorney (POA) were honored for one (1) of six (6) residents (Resident #1). Resident #1 had a POA and documentation was on file at the facility. However, on 12/19/2019, the facility permitted Resident #1 to sign himself/herself out of the facility against medical advice (AMA) even though Resident #1's POA disagreed with the resident/facility's decision. Review of a hospital record, revealed after returning to his/her home on 12/19/2019, Resident #1 experienced a fall during the night and was unable to get up. The resident was able to call Emergency Medical Services (EMS) the next morning (12/20/2019), was transferred to the hospital, and diagnosed with [REDACTED]. The facility's failure to ensure resident rights were protected and the decisions of the resident's legal representative were honored has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/30/2020, and was determined to exist on 12/19/2019 at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 01/30/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). An acceptable Allegation of Compliance was received on 02/05/2020, which alleged removal of Immediate Jeopardy on 02/07/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 02/07/2020, prior to exit on 02/12/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Phone interview and email from the current Administrator on 02/21/2020 at 6:18 PM revealed the facility did not have a policy addressing decision making by the resident, the resident's responsible party, or the resident's POA. Review of Resident #1's medical record revealed the facility admitted the resident on 11/22/2019 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed the resident executed a Durable Power of Attorney dated 12/28/2010. Review of the DPOA revealed Resident #1 had appointed his/her two daughters to serve as Power of Attorneys. The DPOA granted either daughter the right to remove and place me in such hospitals, institutions or places as they may deem best for my personal care, comfort, benefit and safety. The DPOA also stated, It is to be distinctly understood that this Power of Attorney grants authority to either (daughter) to act on my behalf as set forth herein and does not require that they act jointly although they may choose to do so. The DPOA also stated, This Durable Power of Attorney shall not be affected by my subsequent disability or incapacity, or by the lapse of time; and I do hereby state that it is my intent that the authority conferred herein shall be exercisable notwithstanding my subsequent disability or incapacity, and notwithstanding the lapse of time. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) indicating the resident was severely cognitively impaired. Review of Resident #1's Elopement Risk Evaluation, dated 11/26/2019, revealed the resident was at risk for elopement due to being independently mobile, having poor decision making skills, demonstrating exit-seeking behavior, wandering oblivious to safety needs, and the ability to exit the facility. Interview with the Medical Records Nurse on 01/28/2020 at 10:48 AM and an interview with Visitor #2 on 01/28/2020 at 4:17 PM revealed on 12/19/2019 at approximately lunch time (exact time unknown) Resident #1 left the facility without staff knowledge. Further interview with the Medical Records Nurse revealed she heard Resident #1 state she wanted to leave the facility approximately one (1) week prior to the incident, but heard staff tell the resident that he/she had to complete therapy before going home. Continued review of Resident #1's medical record revealed a Nursing Progress Note dated 12/19/2019 at 7:05 PM, stating Resident #1 left the facility AMA at 6:40 PM via taxi, and the resident's family and physician was notified of the AMA discharge. Review of a Release of Responsibility for Discharge AMA form revealed Resident #1 signed out of the facility on 12/19/2019 (not timed) and released the facility, facility Administration, facility staff, and the resident's physician from all responsibility from any consequences that may result from leaving the facility under these circumstances. Further review revealed Resident #1 was discharging him/herself at his/her own insistence and against the advice of the facility staff and without the authority of his/her physician. The form also stated Resident #1 was informed of the danger to his/her health and/or safety if the resident left the facility. Interview with the Social Services Director (SSD) on 01/28/2020 at 5:25 PM revealed she performed a BIMS assessment on Resident #1 on 12/19/2019 at 1:56 PM, approximately one (1) hour after the resident was assisted back to the facility after eloping. The SSD stated the resident was insistent that he/she was going home and a BIMS assessment was conducted. The SSD stated at that time Resident #1 scored a fourteen (14) on the BIMS assessment, indicating the resident was cognitively intact. Therefore, the SSD stated it was determined Resident #1 had the mental capacity to make his/her own decisions, included signing out of the facility AMA. Further interview with the SSD revealed Resident #1 had previously voiced the desire to sign out of the facility AMA, but because the resident's BIMS score was seven (7) at that time, the wishes of the POA were followed and the resident was not permitted to leave the facility. However, according to the SSD, because Resident #1's BIMS score had improved, it was decided the POA was no longer permitted to make decisions for the resident. The SSD stated no further assessments or review of the POA document was made prior to allowing the resident to discharge from the facility AMA. Interview with Resident #1's POA on 01/28/2020 at 9:07 AM and on 01/29/2020 at 9:34 AM revealed she along with her sister were Co-POAs for Resident #1. She stated the facility contacted her on 12/19/2019 (sometime after lunch), stating Resident #1 wanted to sign out of the facility AMA. The POA stated she told the Administrator and SSD, that she did not want the resident to sign out of the facility AMA, and did feel it was a good idea because Resident #1 could not physically take care of himself/herself at home, and that the resident was not capable of making safe decisions. The POA stated the Administrator and SSD told her that it was no longer her decision because Resident #1 had scored a fourteen (14) on the BIMS assessment and was therefore able to make his/her own decisions. Continued interview with Resident #1's POA revealed the facility had contacted her earlier in the day on 12/19/2019 regarding allowing the resident to leave the facility with a friend. She stated she told staff at that time the resident could not leave the facility with anyone other than a staff or a family member and that time they let me make the decision, but just hours later they decided it was okay for (him/her) to sign out AMA and take a taxi home. Interviews with State Registered Nurse Aide #1 on 01/27/2020 at 5:02 PM, and on 01/28/2020 at 5:10 PM with SRNA #6, 4:00 PM with the Physical Therapy Assistant and 4:07 PM with the Speech Language Pathologist (SLP), all revealed Resident #1 had poor safety awareness and decision making skills. The SLP stated the resident had poor cognitive skills and was very impulsive. The SLP also stated that Resident #1 likely had a BIMS score of 14, however, that assessment did not assess decision-making skills. Interview with the Director of Nursing (DON) on 01/28/2020 at 6:09 PM revealed when the SSD assessed Resident #1 on 12/19/2019 to have a BIMS score of fourteen (14), that determined the resident was cognitively intact, and therefore could make his/her own decisions. Therefore, the DON stated when the resident expressed a desire to leave the facility the resident was permitted to sign out AMA. The DON stated Resident #1's POA was notified and told the facility that she did not want the resident to sign out AMA and did not think it was a good idea. However, the DON stated she told the POA that she felt the resident was cognitively intact and could make decisions regarding care. Interview with the Administrator on 01/28/2020 at 6:43 PM revealed Resident #1 was cognitively capable of making decisions for himself/herself. She stated Resident #1 did not want to be at the facility any longer and the facility permitted the resident to sign out AMA. The Administrator stated the facility utilizes the BIM scores in order to determine who can make decisions for residents. The Administrator stated unless the resident had a guardian, the POA was not utilized for decisions unless the resident was determined to be cognitively impaired, per the BIMS assessment. Further interview with the Administrator revealed when Resident #1 was initially admitted to the facility on [DATE], he/she was assessed to be cognitively impaired, therefore the facility utilized Resident #1's POA at that time. However, when Resident #1 was reassessed on 12/19/2019 the resident's BIMS score was fourteen (14), which indicated the resident was cognitively intact and no longer required a POA for decisions at that time. Interview with the Medical Director on 01/28/2020 at 5:40 PM revealed the facility informed him that Resident #1 was requesting to leave AMA, and told him the resident had a BIMS score of fourteen (14) and therefore, the facility could not keep the resident against his/her will. The Medical Director stated that BIMS assessments did not truly assess a resident's cognitive status. He stated he has had patients in the past that he knew were not cognitively intact yet had memorized the questions and answers to the BIMS assessment. Review of a hospital record for Resident #1 dated 12/20/2019 revealed the resident sustained [REDACTED]. Further review of the hospital record revealed Resident #1 was subsequently diagnosed with [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/07/2020: 1. On 12/19/19, Resident #1 was placed assisted back to the facility and placed on 1:1 supervision until the Resident was discharged against medical advice (AMA) at 6:40 PM. 2. A head count of facility residents was conducted on 12/19/19 and completed on 12/20/19 by each unit nurse via medication administration documentation. All residents were accounted for in the facility. 3. The Maintenance Director and Assistant Maintenance Director checked all exit doors on 12/20/19 to ensure they were secured, and that the delayed egress was functioning properly. All exit doors were key coded and functioning. 4. All residents that were identified to be at risk for elopement were re-assessed for elopement potential by the facility Care Consultant on 01/14/2020. At that time, 15 residents were identified to be at risk for elopement. The facility Care Consultant completed new elopement assessments on 100 percent of the facility residents beginning on 01/14/2020 and was completed on 01/16/2020. 5. On 01/16/2020, one (1) resident was identified as exhibiting exit seeking behavior and determined to be an elopement risk by the Unit Manager (UM). The resident's comprehensive care plan and State Registered Nurse Aide (SRNA) care plan was updated to include risk of elopement. On 01/16/2020 the resident's picture was taken and added to the elopement binders per facility policy by the Social Services Director (SSD), UM, and facility Care Consultant. 6. The Minimum Data Set (MDS) Coordinator and facility Care Consultant reviewed and updated all care plans with any changes found on the elopement assessments on 01/15/2020 and 01/16/2020. 7. The SSD and the facility Care Consultant reviewed the elopement binders for accuracy and updated the binders to reflect the current elopement assessments completed on 01/16/2020. 8. The Behavioral management care plans for the residents identified to be at risk for elopement were updated to include interventions for wandering/exit seeking behaviors on 01/16/2020. 9. On 01/15/2020, the Regional Vice President (RVP) and the Maintenance Assistant completed environmental rounds to identify any safety issues that included door functionality and secured windows. No concerns were identified during the performed rounds. 10. The Technology Enhanced Learning System (TELS), the facility ' s online maintenance system that tracks door checks, was reviewed to ensure all doors had been checked for locking, alarms, maglock, and delayed egress for the last 30 days by the facility Care Consultant and Maintenance Director on 01/14/2020 with any issues identified addressed. 11. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above and family members of residents with BIMS scores of seven (7) and below were interviewed to determine prior knowledge of elopement or safety concerns beginning on 01/15/2020 and completed on 01/17/2020. The interviews were performed by the Chaplain, Social Services Director (SSD), Marketing Director, Activities Directory, Dietary Services Manager, Central Supply, and Business Office Manager with no concerns identified. 12. A 30-day look-back was completed for all events that had occurred in the facility and 24 hour report for residents exhibiting exit seeking behaviors on 01/15/2020 by the facility Care Consultant and the Risk Manager. No concerns were identified related to exit seeking behaviors or elopement. 13. On 01/15/2020 and 01/16/2020, the Risk Manager initiated a 30-day look-back of nurses' notes for residents exhibiting exit seeking behaviors and/or elopements, with no concerns identified. 14. discharged resident records were audited for the past 60 days on 01/31/2020 by the Regional Vice President (RVP) and facility Care Consultant to ensure no other residents were discharged AMA without consent and no concerns were identified. 15. The facility's Independent Risk Manager began audits on 01/31/2020 of all current Power of Attorney (POA) documents on file to ensure no instances of resident/POA's rights were violated. The audit was completed on 02/03/2020 with no identified concerns. 16. On 01/16/2020, the Central Supply Clerk verified that all currents residents identified to be at risk for elopement were wearing Wanderguard bracelets and the bracelets were functioning properly. One resident identified to be at risk for elopement refused to wear a Wanderguard bracelet and the facility developed a behavior management plan to address wandering/exit seeking behaviors with interventions to decrease episodes. In addition, the facility redefined the entry and exit doors to the building utilizing two (2) doors as entry/exit with only staff members having access to the door codes. All exit doors were monitored by staff and a staff member must enter the door code to allow visitors to exit the facility. 17. The facility Care Consultant reviewed all residents identified to be at risk for elopement to ensure the residents had physician orders [REDACTED]. Any identified issues were addressed during the audits. 18. On 01/15/2020, the Maintenance Director reset all exit door codes in the facility and staff would only have access to door codes for two (2) doors that would be utilized for entering and exiting the facility. 19. The Director of Nursing (DON), Unit Manager (UM), SSD, Dietary Manager, MDS Coordinators, Plant Operations Director, Quality of Life Director, Central Supply Director, and the Chaplain received education on 1/14/2020 by the facility Care Consultant on the following policies: Elopement; Missing Resident; Door Codes/Alarms Process; Accidents/Incidents; Safety and Supervision; Abuse; Resident Rights; Care Plans; Professional Standards; Behavior Management; and Quality Assurance/Performance improvement (QAPI). Education was performed face to face in order to facilitate discussion and questions. Department administrative managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If a manager did not score 100 percent (%) on post-tests, the manager was immediately re-educated, and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by facility Care Consultant or the RVP. 20. The Administrator, DON, and Department Managers educated all staff on the above policies and procedures beginning on 01/14/2020 and completed training on 01/17/2020. Education would be ongoing after 01/17/2020 to ensure all employees not educated by 01/17/2020 would be educated prior to working the floor. Active employees including employees on vacation, Family and Medical Leave Act (FMLA), or other leave would receive education prior to returning to work and would complete a post-test and receive a score of 100%. Education regarding the elopement policy and procedure would be included in the orientation process for all newly hired staff members effective 01/17/2020 with a post-test administered. No newly hired employee would be allowed to work until elopement education was provided. Employees will be immediately re-educated, and posttest re-administered if a score of 100% is not reached on their previous attempt. 21. The Independent Risk Manager educated the RVP and the facility Care Consultant on the policy for Discharge without Physician Approval to include AMA discharge/legal notification with a post-test to ensure adequate understanding of policy with a score of 100% obtained on 1/31/2020. 22. The Administrator, DON, UM, SSD, MDS Coordinators, Maintenance Director, Quality of Life Director, Restorative Nurse Manager, Medical Records Nurse, Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and Marketing Director were educated on 01/31/2020 by the facility Care Consultant/RVP on Discharge without Physician Approval to include AMA discharge and legal representative notification. This included a guideline which guided the nurse in steps to perform when a resident requested to leave AMA to include: notification of the resident's Physician and Responsible Party (RP); discussion of RP's participation in the discharge; discussion with the resident and RP of Physician recommendations; and if necessary, contacting the Administrator or DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal Counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. The training was performed face to face in order to facilitate discussion and questions. Department Administrative Managers were not permitted to work until the education was provided, a post-test administered related to Discharge without Physician Approval and 100% score obtained. If a manager did not score 100% on the posttest, the manager was immediately re-educated, and a post-test was re-administered until a 100% score was achieved. This process continued until all managers obtained a 100% score on the posttest. All post-tests were reviewed for compliance by the facility Care Consultant or RVP. 23. The DON, UM, and Medical Records Nurse re-educated licensed nurses on the policy for Discharge without Physician Approval and a post-test completed for all licensed nurses on the current working schedule by 02/03/2020, which included a guideline that assisted licensed nurses in steps to perform when a resident requested to discharge from the facility AMA. The guideline also included Physician and RP notification; discussions of RP participation in the discharge; discussion with the resident and RP regarding Physician recommendations; and if necessary, contacting the Administrator and DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. Education would continue after 02/03/2020, to ensure all nurses not educated by 02/03/2020 were educated prior to working the floor. Active employees, including anyone on vacation, FMLA, or other leave would receive education prior to returning to work and would complete a post-test scoring 100%. Education regarding discharge without Physician Approval to include AMA Discharge and Legal Notification, as well as a post-test, was included in the orientation process for all newly hired nurses effective 02/3/2020. No newly hired employee would be permitted to work until AMA discharge education is provided and a post-test score of 100% was achieved. If an employee does not score 100% on the post-test, re-education would occur and the post-test re-administered until a score of 100% is achieved. 24. The Nurse Managers and/or the facility Care Consultant reviewed Nursing Notes, Twenty-Four Hour Clinical Reports, Social Services Notes, and Discharge Summaries to ensure all appropriate steps were taken to ensure adequate/safe discharge occurred beginning on 02/01/2020 and continuing through 02/05/2020. 25. Beginning 02/05/2020, the facility Care Consultant educated the interdisciplinary team (IDT) including but not limited to: the Administrator, DON, UM, Medical Records Nurse, SSD, Rehabilitation Service Manager, Dietary Director, Chaplain, Quality of Life Director, MDS Coordinators, Admissions Coordinator, and BOM on the Discharge Planning Process and Policy. Ensuring a discharge plan was in place to address each resident's discharge goals and needs, including care giver support and referrals to local agencies as appropriate. As well as involving the resident and family in the discharge planning with revision as needed. Once the IDT members were sufficiently trained, they then proceeded to educate all licensed nurses and therapists on the Discharge Planning Process and Policy. Education would continue after 02/06/2020, to ensure all IDT members, licensed nurses, and therapist that had not received education before 02/06/2020, would receive education prior to working the floor. Active employees, employees on vacation, FMLA, or other leave, would receive education prior to working their next scheduled shift providing direct resident care. Education regarding the Discharge Planning Process and Policy was included in the orientation process for all newly hired nurses, therapist, and IDT members effective 02/06/2020. 26. Beginning 01/15/2020, all exit doors were checked for proper function to ensure that the doors alarmed, all egresses function properly, system code and keypad operations functioned, as well as checking a wander guard to ensure the doors remained locked and the alarm sounded daily by a member of nursing staff, Department Managers, or Plant Operations. This would remain ongoing and any concerns would be immediately reported to Administrator and Plant Operations Director. Beginning 01/14/2020, the maintenance staff checked doors daily and department head weekend manager checked them on the weekends and would continue ongoing. 27. An elopement drill was completed on 01/14/2020, by the Maintenance Director and was conducted daily on random shifts, for one week and weekly for 4 weeks by the Administrator, DON, or Department Head Managers. The drill would then be conducted quarterly, thereafter. The drills were performed on different shifts and weekends to ensure that stakeholders were following the Missing Resident Policy and Procedure. Specifically, actions taken when a door sounds to include: responding to active door alarms, walking outside perimeter by the alarming door to ensure no resident is observed outside of resident care are unattended, reporting the missing resident to the charge nurse, and initiating a facility headcount. 28. The DON or UM monitored all residents, including new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decreasing to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors beginning 01/18/2020. New admissions would be assessed for elopement risk and any resident identified at risk would be added to the facility elopement books. The following clinical systems will be reviewed daily Monday through Friday by the DON or UM to ensure no resident is at risk that has not been identified by the facility: events in Matrix Care began 01/14/2020; Clinical Summary 24 Hour Report; Nursing Notes; review new admissions/readmissions for elopement assessments updating care plans and elopement books when needed; new/worsening exit seeking and/or wandering behavior tracking; care plan interventions for identified new/worsening exit seeking and/or wander behaviors; and on 02/01/2020, monitoring all discharged resident records to ensure the new process was followed for AMA discharges. The DON/Administrator was onsite on weekends since the incident occurred to provide oversight and to ensure the daily reviews had been completed, as outlined in the AOC. 29. Beginning 01/18/2020 and continuing for two (2) weeks, five (5) employees per shift for a total of ten (10) employees per day would complete an elopement test and score 100%. Beginning 02/02/2020 and continuing for one (1) week, three (3) employees per shift for a total of six (6) employees per day, would complete an elopement test and score 100%. Beginning 02/09/2020 and continuing for one (1) week, two (2) employees per shift for a total of four (4) employees per day would complete an elopement test and score 100%. Beginning 02/16/2020 and continuing for one (1) week, one (1) employee per shift for a total of two (2) employees per day, would complete an elopement test and score 100%. Beginning on 02/23/2020 and continuing for four (4) weeks, one (1) employee per week would complete an elopement test and score 100%. Beginning 03/01/2020 and continuing four (4) weeks, one (1) employee would complete an elopement test and score 100% every other week. If an employee did not score 100%, the employee would be reeducated and retested until a score of 100% was obtained. 30. A nurse from the regional team/corporate office and/or the VP of Operations was available on-site or by phone Monday through Friday, since 01/13/2020. Regional resources were available by phone during the weekend as needed. The Administrator or DON were on-site on weekends beginning 01/13/2020, to ensure continued compliance with audits established by QAPI Committee. The nurses from the regional team or home office were assisting the DON and UM with initiated audits recommended from the QAPI committee. Oversight was conducted in the form of reviewing the administrative audit tools daily, since the event occurred, to ensure completion of audits. These audits included: elopement tests; elopement drills; reviewing elopement assessments on new admissions; reviewing nurses notes; reviewing event manager; reviewing twenty four hour reports for evidence of new or worsening wandering/exit seeking behavior; ensuring elopement books and care plans were updated when behaviors were identified; ensuring care plan interventions were being implemented on residents who had been assessed for risk of elopement; and reviewing facility established audits to ensure compliance with the plan created by facility QAPI committee. A nurse from the regional team or home office attended the facility's weekly AD-Hoc QA meetings. 31. A QAPI meeting was conducted on 01/14/2020 with the Facility Medical Director, Administrator, DON, facility Care Consultant, UM, SSD, MDS Coordinators, Plant Operations Director, and Dietary Manager in attendance. Immediate action taken, as well as the facility's plan to ensure compliance was discussed during the meeting. 32. A QAPI meeting was held on 01/31/2020, to discuss citations received on 01/30/2020 regarding implementing a plan to address the deficiencies cited at resident rights and discharge planning. 33. A weekly QAPI meeting would occur for four (4) weeks and began 01/20/2020, with the following attendees: The Administrator, DON, UM, SSD, MDS Coordinators, Plant Operations Director, Dietary Manager, and Medical Director. Results of all audits and post-tests would be reviewed and reported to the committee members during the QAPI meeting, to ensure compliance with the facility's ongoing plan. Any concerns identified would have recommendations for increased monitoring and/or education. The facility Care Consultant and RVP would attend to validate compliance with the plan. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 02/07/2020 as alleged: 1. Record review and interview with Licensed Practical Nurse (LPN) #1 on 02/12/2020 at 1:21 PM revealed Resident #1 was placed on 1:1 supervision after he/she was brought back into the building on 12/19/19 and continued on 1:1 supervision until he/she discharged against medical advice (AMA) at 6:40 PM. 2. Record review and interview with the Director of Nursing (DON) on 02/12/2020 at 3:00 PM revealed she completed a count of all facility residents on 12/20/19 via medication administration documentation and all residents were accounted for. 3. Record review and interview with the Maintenance Director and Assistant Maintenance Director on 02/12/2020 at 12:37 PM revealed they checked all exit doors that required a key code, to ensure they were locked, secured, and that the delayed egress was functioning properly. 4. Record review and interview with the facility Care Consultant on 02/12/2020 at 3:38 PM revealed she re-assessed all residents that were identified at risk for elopement on 01/14/2020, as well as completing 100% of elopement assessments by 01/16/2020. 5. Record review and interview with the Social Services Director (SSD) on 02/12/2020 at 12:53 PM, the Unit Manager (UM) on 02/12/2020 at 3:00 PM and the facility Care Consultant on 02/12/2020 at 3:38 PM revealed on 01/16/2020, one (1) resident was determined to be an elopement risk and that resident's care plan, State Registered Nurse Aide (SRNA) care plan, and the elopement books were updated to include the resident's risk for elopement and picture of the resident on 01/16/2020. 6. Record review and interview with the Minimum Data Set (MDS) Coordinator on 02/12/2020 at 1:48 PM and the facility Care Consultant on 02/12/2020 at 3:38 PM revealed they reviewed and updated

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of six (6) sampled residents received adequate supervision and assistance to prevent accidents. On 12/19/2019 between approximately 12:30 PM and 1:00 PM, Resident #1, who the facility had assessed to be at risk for elopement, cut off his/her Wanderguard bracelet, entered the exit code to the front door of the facility, and exited the facility without staff knowledge. Resident #1 crossed the main road in front of the facility and walked approximately 300 feet along the side of the road and was approximately four (4) four to five (5) houses down from the facility before staff reached the resident and assisted him/her back into the facility. However, the facility failed to assess the resident for injury after returning to the facility, failed to investigate the incident, and failed to document the incident in Resident #1's medical record. The facility's failure to ensure residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/30/2020, and was determined to exist on 12/19/2019 at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 01/30/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). An acceptable Allegation of Compliance was received on 02/05/2020, which alleged removal of Immediate Jeopardy on 02/07/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 02/07/2020, prior to exit on 02/12/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F551), 42 CFR 483.15 Admission, Transfer, and Discharge (F624), and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Elopement/Wandering policy, not dated, revealed the intent of the facility was to maintain resident safety by identifying residents who were at risk for wandering/elopement behavior. The policy stated that care plans and individual behavior plans would address wandering as a specific problem and approaches would be formulated, patterns identified (if any), and the causes determined. Review of the facility's Care of Wandering Resident policy dated 06/01/2015, revealed care would be planned to provide safety within the facility, reduce the risk of exit seeking behavior, identify, decrease or eliminate stressors that would trigger wandering, and preserve family support and unity as much as possible. Review of Resident #1's medical record revealed the facility admitted the resident on 11/22/2019, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7), indicating the resident had severe cognitive impairment. Continued review of the MDS revealed Resident #1 required the supervision of staff for ambulation. Further review of Resident #1's MDS assessment revealed the facility utilized a wander/elopement alarm for the resident. Review of Resident #1's Elopement Risk Evaluation, dated 11/26/2019, revealed the facility assessed the resident to be at risk for elopement due to the resident being independently mobile, having poor decision making skills, demonstrating exit-seeking behavior, wandering oblivious to safety needs, and the ability to exit the facility. Review of Resident #1's Comprehensive Plan of Care dated 11/26/2019, revealed interventions implemented to prevent elopement for Resident #1 included Resident #1 wearing a Wanderguard bracelet, staff ensuring the bracelet was in place, and monitoring Resident #1's behavior, including making verbal statements such as I'm leaving. Interview with SRNA #6 on 01/28/2020 at 5:10 PM revealed Resident #1 would talk about leaving the facility and asked her for help with packing. Interview with the Administrator on 01/28/2020 at 6:43 PM revealed she was in her office on 12/19/2019, when she heard the front door alarm sounding, went to the door, and observed Resident #1 along with the Medical Records Nurse outside. The Administrator stated Resident #1 had not crossed the road at that time; however, appeared upset so she went outside and the Medical Records Nurse and herself walked across the road with Resident #1, attempting to calm the resident down. Further interview with the Administrator revealed LPN #1 also eventually joined them and assisted with convincing Resident #1 to go back to the facility. Further interview with the Administrator revealed she did not consider Resident #1 exiting the building as an elopement because staff had visualized the resident the entire time the resident was outside the facility. Interview with the Medical Records Nurse on 01/28/2020 at 10:48 AM revealed on 12/12/2019, she was leaving the facility grounds via car and as she approached the entrance to the facility to pull out, she observed Resident #1 crossing the main road in front of the facility alone. The Medical Records Nurse stated there were no other staff outside the facility when she observed the resident crossing the road. The nurse stated due to physical disabilities, she was unable to run after the resident, so she stated she pulled her car to the front of the building and went inside. However, the nurse stated there was no one in the front office, so she went to the Administrator's office and told the Administrator that Resident #1 was outside unattended. The Medical Records Nurse stated at that time her and the Administrator both went back outside to get the resident. The nurse stated by the time the Administrator reached Resident #1, the resident had already crossed the main road and was approximately three (3) or four (4) houses down the street from the facility. The Medical Records Nurse stated that Resident #1 did not want to go back, but staff eventually persuaded the resident to return to the facility and go back inside. The nurse stated she did not know if Resident #1 was wearing a Wanderguard bracelet on 12/19/2019 but stated she did not recall the front door alarming when the resident was brought back inside through the door. Further interview with the Medical Records Nurse revealed she heard Resident #1 state she wanted to leave the facility approximately one (1) week prior to the incident, but heard staff tell the resident that he/she had to complete therapy before going home. Interview with Visitor #2 on 01/28/2020 at 4:17 PM revealed he was on his way to the facility to visit a family member on 12/19/2019 around lunch time (exact time unknown) when he observed Resident #1, who he recognized as a resident of the facility, across the street approximately five (5) or six (6) houses down from the facility. Visitor #2 stated Resident #1 was alone, and he observed no staff members outside the facility or near Resident #1 as he proceeded on to the facility and went inside. The Visitor stated when he entered the facility, he reported his sighting of Resident #1 to Licensed Practical Nurse (LPN) #4. Interview with LPN #4 on 01/28/2020 at 7:11 PM revealed she was working on 12/19/2019 between approximately 12:30 PM and 1:00 PM, when Visitor #2 told her that he had observed Resident#1 across the road approximately five (5) or six (6) houses down from the facility. LPN #4 stated she attempted to call the nurses' station where Resident #1 resided, but received no answer, she stated she then attempted to call the Administrators office, but again received no answer. LPN #4 stated she then physically walked to Resident #1's unit, and by the time she arrived at the unit, Resident #1 was back inside the building, and was with the Administrator and LPN #1. Interview with LPN #1 on 01/28/2020 at 10:04 AM revealed she was caring for Resident #1 on 12/19/2019. The LPN stated the resident did have exit seeking behaviors and would state that he/she was going home. LPN #1 stated that was why the resident wore a Wanderguard bracelet. LPN #1 stated she had observed Resident #1 sitting in the front lobby approximately five (5) minutes prior to the Dietary Manager reporting to her that Resident #1 was outside. LPN #1 stated when she last observed the resident in the lobby it was sometime around noon, and the resident was upset because the resident's POA would not allow the resident to leave the facility with a friend. LPN #1 stated she ran to the front lobby and went out the front door, which she stated was not alarming. The LPN stated she did not see the resident when she initially went outside; however, when she looked down the road to the left, she observed Resident #1, the Administrator, and the Medical Records Nurse across the road approximately 250 feet from the facility. LPN #1 stated when she ran to where the resident and staff were, and Resident #1 was visibly upset. She stated the Administrator and the Medical Records Nurse were trying to convince the resident to return to the facility, and eventually all three of them were able to talk the resident into going back to the facility. Continued interview with LPN #1 stated Resident #1 was very upset after returning to the facility, and stated her focused was on trying to calm the resident down and she did not conduct a physical assessment of the resident to check for injury or check to see if the resident was wearing the Wanderguard bracelet. Continued interview with LPN #1 revealed she was responsible for checking to ensure the resident's Wanderguard bracelet was in place during her shift, but had not yet conducted the check for first shift on 12/19/2019 prior to the resident exiting without staff knowledge sometime between 12:30 PM and 1:00 PM. LPN #1 stated she did not document Resident #1 exiting the facility because she had never had a resident leave before and was told by the Administrator it was not an elopement because someone had visualization of the resident the whole time. Interview with the Social Services Director (SSD) on 01/28/2020 at 5:25 PM revealed she was in her office when the Administrator, Medical Records Nurse, and LPN #1 were entering the building with Resident #1 on 12/19/2019 between 12:30 PM and 1:00 PM. The SSD stated the alarm did not sound when Resident #1 entered through the door. Further interview with the SSD revealed Resident #1 had attempted to leave the facility once prior to this incident. The SSD stated the resident had a friend come to get him/her, but staff would not allow the resident to leave. The SSD stated she told the friend that Resident #1 could not leave the facility without the authorization of the POA. The SSD stated she could not recall when the prior incident had occurred; however, there was no evidence of the incident documented in the resident's medical record. Interview with Resident #1's POA on 01/28/2020 at 9:07 AM and 01/29/2020 at 9:34 AM revealed she had spoken to facility staff earlier in the day on 12/19/2019, (exact time unknown) due to Resident #1 wanting to leave the facility with a friend for a medical appointment. However, the POA stated she had advised staff not to let the resident leave the facility with anyone other than herself or another family member. The POA stated a few hours after that (exact time unknown) Resident #1 used his/her personal cell phone to call and tell the POA that he/she had cut off the Wanderguard bracelet and exited the facility. Interview with the Director of Nursing (DON) on 01/28/2020 at 6:09 PM revealed she was at the opposite end of the building when it was reported to her that Resident #1 was outside the facility. The DON stated she immediately went outside of the facility through the closest exit door, which was at the backside of the building, and was told that Resident #1 was already back in the building. The DON stated she was told by a staff member that Resident #1 had cut off his/her Wanderguard bracelet and entered the code to front door (a numeric sequence that must be entered on a keypad to prevent the door from alarming when opened) and exited the building. However, the DON could not recall who it was that told her the Resident had cut the Wanderguard bracelet off. The DON stated she went to the Administrator's office, and the Administrator told her that Resident #1 had been in sight of a staff member at all times, and that she (the Administrator) had visualized the resident the entire time the resident was outside the facility. Therefore, according to the DON, the incident was not considered an elopement, and stated an investigation was not initiated to determine how the resident was able to remove the Wanderguard without staff knowledge, how the resident was able to gain knowledge of the access code to the door, or to determine if the resident's level of supervision was adequate to ensure the resident's safety in the future. Interview with the MDS Coordinator on 01/28/2020 at 5:00 PM, revealed she spoke with Resident #1 after the resident was back inside the building, and the Resident #1 told her that he/she had cut off the wander guard bracelet with nail clippers sometime during the evening of 12/18/2019. However, according to the MDS Coordinator no facility staff attempted to find the bracelet, and to her knowledge it was never located. Review of weather archives from wunderground.com, revealed the weather conditions on 12/19/2019, for the city where the facility was located was 33 degrees Fahrenheit at 12:00 PM and 36 degrees at 1:00 PM, skies were fair, and the wind was gusting to eight (8) miles per hour. Review of Resident #1's medical record revealed no evidence the facility assessed Resident #1 after the incident, made any documentation related to the incident in the resident's medical record or investigated the incident to determine how it had occurred. **The facility implemented the following actions to remove the Immediate Jeopardy on 02/07/2020: 1. On 12/19/19, Resident #1 was placed assisted back to the facility and placed on 1:1 supervision until the Resident was discharged against medical advice (AMA) at 6:40 PM. 2. A head count of facility residents was conducted on 12/19/19 and completed on 12/20/19 by each unit nurse via medication administration documentation. All residents were accounted for in the facility. 3. The Maintenance Director and Assistant Maintenance Director checked all exit doors on 12/20/19 to ensure they were secured, and that the delayed egress was functioning properly. All exit doors were key coded and functioning. 4. All residents that were identified to be at risk for elopement were re-assessed for elopement potential by the facility Care Consultant on 01/14/2020. At that time, 15 residents were identified to be at risk for elopement. The facility Care Consultant completed new elopement assessments on 100 percent of the facility residents beginning on 01/14/2020 and was completed on 01/16/2020. 5. On 01/16/2020, one (1) resident was identified as exhibiting exit seeking behavior and determined to be an elopement risk by the Unit Manager (UM). The resident's comprehensive care plan and State Registered Nurse Aide (SRNA) care plan was updated to include risk of elopement. On 01/16/2020 the resident's picture was taken and added to the elopement binders per facility policy by the Social Services Director (SSD), UM, and facility Care Consultant. 6. The Minimum Data Set (MDS) Coordinator and facility Care Consultant reviewed and updated all care plans with any changes found on the elopement assessments on 01/15/2020 and 01/16/2020. 7. The SSD and the facility Care Consultant reviewed the elopement binders for accuracy and updated the binders to reflect the current elopement assessments completed on 01/16/2020. 8. The Behavioral management care plans for the residents identified to be at risk for elopement were updated to include interventions for wandering/exit seeking behaviors on 01/16/2020. 9. On 01/15/2020, the Regional Vice President (RVP) and the Maintenance Assistant completed environmental rounds to identify any safety issues that included door functionality and secured windows. No concerns were identified during the performed rounds. 10. The Technology Enhanced Learning System (TELS), the facility's online maintenance system that tracks door checks, was reviewed to ensure all doors had been checked for locking, alarms, maglock, and delayed egress for the last 30 days by the facility Care Consultant and Maintenance Director on 01/14/2020 with any issues identified addressed. 11. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above and family members of residents with BIMS scores of seven (7) and below were interviewed to determine prior knowledge of elopement or safety concerns beginning on 01/15/2020 and completed on 01/17/2020. The interviews were performed by the Chaplain, Social Services Director (SSD), Marketing Director, Activities Directory, Dietary Services Manager, Central Supply, and Business Office Manager with no concerns identified. 12. A 30-day look-back was completed for all events that had occurred in the facility and 24 hour report for residents exhibiting exit seeking behaviors on 01/15/2020 by the facility Care Consultant and the Risk Manager. No concerns were identified related to exit seeking behaviors or elopement. 13. On 01/15/2020 and 01/16/2020, the Risk Manager initiated a 30-day look-back of nurses' notes for residents exhibiting exit seeking behaviors and/or elopements, with no concerns identified. 14. discharged resident records were audited for the past 60 days on 01/31/2020 by the Regional Vice President (RVP) and facility Care Consultant to ensure no other residents were discharged AMA without consent and no concerns were identified. 15. The facility's Independent Risk Manager began audits on 01/31/2020 of all current Power of Attorney (POA) documents on file to ensure no instances of resident/POA's rights were violated. The audit was completed on 02/03/2020 with no identified concerns. 16. On 01/16/2020, the Central Supply Clerk verified that all currents residents identified to be at risk for elopement were wearing Wanderguard bracelets and the bracelets were functioning properly. One resident identified to be at risk for elopement refused to wear a Wanderguard bracelet and the facility developed a behavior management plan to address wandering/exit seeking behaviors with interventions to decrease episodes. In addition, the facility redefined the entry and exit doors to the building utilizing two (2) doors as entry/exit with only staff members having access to the door codes. All exit doors were monitored by staff and a staff member must enter the door code to allow visitors to exit the facility. 17. The facility Care Consultant reviewed all residents identified to be at risk for elopement to ensure the residents had physician orders [REDACTED]. Any identified issues were addressed during the audits. 18. On 01/15/2020, the Maintenance Director reset all exit door codes in the facility and staff would only have access to door codes for two (2) doors that would be utilized for entering and exiting the facility. 19. The Director of Nursing (DON), Unit Manager (UM), SSD, Dietary Manager, MDS Coordinators, Plant Operations Director, Quality of Life Director, Central Supply Director, and the Chaplain received education on 1/14/2020 by the facility Care Consultant on the following policies: Elopement; Missing Resident; Door Codes/Alarms Process; Accidents/Incidents; Safety and Supervision; Abuse; Resident Rights; Care Plans; Professional Standards; Behavior Management; and Quality Assurance/Performance improvement (QAPI). Education was performed face to face in order to facilitate discussion and questions. Department administrative managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If a manager did not score 100 percent (%) on post-tests, the manager was immediately re-educated, and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by facility Care Consultant or the RVP. 20. The Administrator, DON, and Department Managers educated all staff on the above policies and procedures beginning on 01/14/2020 and completed training on 01/17/2020. Education would be ongoing after 01/17/2020 to ensure all employees not educated by 01/17/2020 would be educated prior to working the floor. Active employees including employees on vacation, Family and Medical Leave Act (FMLA), or other leave would receive education prior to returning to work and would complete a post-test and receive a score of 100%. Education regarding the elopement policy and procedure would be included in the orientation process for all newly hired staff members effective 01/17/2020 with a post-test administered. No newly hired employee would be allowed to work until elopement education was provided. Employees will be immediately re-educated, and posttest re-administered if a score of 100% is not reached on their previous attempt. 21. The Independent Risk Manager educated the RVP and the facility Care Consultant on the policy for Discharge without Physician Approval to include AMA discharge/legal notification with a post-test to ensure adequate understanding of policy with a score of 100% obtained on 1/31/2020. 22. The Administrator, DON, UM, SSD, MDS Coordinators, Maintenance Director, Quality of Life Director, Restorative Nurse Manager, Medical Records Nurse, Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and Marketing Director were educated on 01/31/2020 by the facility Care Consultant/RVP on Discharge without Physician Approval to include AMA discharge and legal representative notification. This included a guideline which guided the nurse in steps to perform when a resident requested to leave AMA to include: notification of the resident's Physician and Responsible Party (RP); discussion of RP's participation in the discharge; discussion with the resident and RP of Physician recommendations; and if necessary, contacting the Administrator or DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal Counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. The training was performed face to face in order to facilitate discussion and questions. Department Administrative Managers were not permitted to work until the education was provided, a post-test administered related to Discharge without Physician Approval and 100% score obtained. If a manager did not score 100% on the posttest, the manager was immediately re-educated, and a post-test was re-administered until a 100% score was achieved. This process continued until all managers obtained a 100% score on the posttest. All post-tests were reviewed for compliance by the facility Care Consultant or RVP. 23. The DON, UM, and Medical Records Nurse re-educated licensed nurses on the policy for Discharge without Physician Approval and a post-test completed for all licensed nurses on the current working schedule by 02/03/2020, which included a guideline that assisted licensed nurses in steps to perform when a resident requested to discharge from the facility AMA. The guideline also included Physician and RP notification; discussions of RP participation in the discharge; discussion with the resident and RP regarding Physician recommendations; and if necessary, contacting the Administrator and DON for notification of legal counsel (if the POA was not agreeable with the discharge). Legal counsel would give direction regarding any resident discharged AMA and the POA's authority with this process. Education would continue after 02/03/2020, to ensure all nurses not educated by 02/03/2020 were educated prior to working the floor. Active employees, including anyone on vacation, FMLA, or other leave would receive education prior to returning to work and would complete a post-test scoring 100%. Education regarding discharge without Physician Approval to include AMA Discharge and Legal Notification, as well as a post-test, was included in the orientation process for all newly hired nurses effective 02/3/2020. No newly hired employee would be permitted to work until AMA discharge education is provided and a post-test score of 100% was achieved. If an employee does not score 100% on the post-test, re-education would occur and the post-test re-administered until a score of 100% is achieved. 24. The Nurse Managers and/or the facility Care Consultant reviewed Nursing Notes, Twenty-Four Hour Clinical Reports, Social Services Notes, and Discharge Summaries to ensure all appropriate steps were taken to ensure adequate/safe discharge occurred beginning on 02/01/2020 and continuing through 02/05/2020. 25. Beginning 02/05/2020, the facility Care Consultant educated the interdisciplinary team (IDT) including but not limited to: the Administrator, DON, UM, Medical Records Nurse, SSD, Rehabilitation Service Manager, Dietary Director, Chaplain, Quality of Life Director, MDS Coordinators, Admissions Coordinator, and BOM on the Discharge Planning Process and Policy. Ensuring a discharge plan was in place to address each resident's discharge goals and needs, including care giver support and referrals to local agencies as appropriate. As well as involving the resident and family in the discharge planning with revision as needed. Once the IDT members were sufficiently trained, they then proceeded to educate all licensed nurses and therapists on the Discharge Planning Process and Policy. Education would continue after 02/06/2020, to ensure all IDT members, licensed nurses, and therapist that had not received education before 02/06/2020, would receive education prior to working the floor. Active employees, employees on vacation, FMLA, or other leave, would receive education prior to working their next scheduled shift providing direct resident care. Education regarding the Discharge Planning Process and Policy was included in the orientation process for all newly hired nurses, therapist, and IDT members effective 02/06/2020. 26. Beginning 01/15/2020, all exit doors were checked for proper function to ensure that the doors alarmed, all egresses function properly, system code and keypad operations functioned, as well as checking a wander guard to ensure the doors remained locked and the alarm sounded daily by a member of nursing staff, Department Managers, or Plant Operations. This would remain ongoing and any concerns would be immediately reported to Administrator and Plant Operations Director. Beginning 01/14/2020, the maintenance staff checked doors daily and department head weekend manager checked them on the weekends and would continue ongoing. 27. An elopement drill was completed on 01/14/2020, by the Maintenance Director and was conducted daily on random shifts, for one week and weekly for 4 weeks by the Administrator, DON, or Department Head Managers. The drill would then be conducted quarterly, thereafter. The drills were performed on different shifts and weekends to ensure that stakeholders were following the Missing Resident Policy and Procedure. Specifically, actions taken when a door sounds to include: responding to active door alarms, walking outside perimeter by the alarming door to ensure no resident is observed outside of resident care are unattended, reporting the missing resident to the charge nurse, and initiating a facility headcount. 28. The DON or UM monitored all residents, including new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decreasing to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors beginning 01/18/2020. New admissions would be assessed for elopement risk and any resident identified at risk would be added to the facility elopement books. The following clinical systems will be reviewed daily Monday through Friday by the DON or UM to ensure no resident is at risk that has not been identified by the facility: events in Matrix Care began 01/14/2020; Clinical Summary 24 Hour Report; Nursing Notes; review new admissions/readmissions for elopement assessments updating care plans and elopement books when needed; new/worsening exit seeking and/or wandering behavior tracking; care plan interventions for identified new/worsening exit seeking and/or wander behaviors; and on 02/01/2020, monitoring all discharged resident records to ensure the new process was followed for AMA discharges. The DON/Administrator was onsite on weekends since the incident occurred to provide oversight and to ensure the daily reviews had been completed, as outlined in the AOC. 29. Beginning 01/18/2020 and continuing for two (2) weeks, five (5) employees per shift for a total of ten (10) employees per day would complete an elopement test and score 100%. Beginning 02/02/2020 and continuing for one (1) week, three (3) employees per shift for a total of six (6) employees per day, would complete an elopement test and score 100%. Beginning 02/09/2020 and continuing for one (1) week, two (2) employees per shift for a total of four (4) employees per day would complete an elopement test and score 100%. Beginning 02/16/2020 and continuing for one (1) week, one (1) employee per shift for a total of two (2) employees per day, would complete an elopement test and score 100%. Beginning on 02/23/2020 and continuing for four (4) weeks, one (1) employee per week would complete an elopement test and score 100%. Beginning 03/01/2020 and continuing four (4) weeks, one (1) employee would complete an elopement test and score 100% every other week. If an employee did not score 100%, the employee would be reeducated and retested until a score of 100% was obtained. 30. A nurse from the regional team/corporate office and/or the VP of Operations was available on-site or by phone Monday through Friday, since 01/13/2020. Regional resources were available by phone during the weekend as needed. The Administrator or DON were on-site on weekends beginning 01/13/2020, to ensure continued compliance with audits established by QAPI Committee. The nurses from the regional team or home office were assisting the DON and UM with initiated audits recommended from the QAPI committee. Oversight was conducted in the form of reviewing the administrative audit tools daily, since the event occurred, to ensure completion of audits. These audits included: elopement tests; elopement drills; reviewing elopement assessments on new admissions; reviewing nurses notes; reviewing event manager; reviewing twenty four hour reports for evidence of new or worsening wandering/exit seeking behavior; ensuring elopement books and care plans were updated when behaviors were identified; ensuring care plan interventions were being implemented on residents who had been assessed for risk of elopement; and reviewing facility established audits to ensure compliance with the plan created by facility QAPI committee. A nurse from the regional team or home office attended the facility's weekly AD-Hoc QA meetings. 31. A QAPI meeting was conducted on 01/14/2020 with the Facility Medical Director, Administrator, DON, facility Care Consultant, UM, SSD, MDS Coo

Based on interview, record review, review of the facility's investigations, and review of the facility's policies, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. The facility assessed Resident #1 to require the assistance of two (2) staff members for transfers with the use of a mechanical lift. On 02/20/18 at approximately 8:00 PM State Registered Nurse Aide (SRNA) #1 attempted to transfer Resident #1 from a shower chair to the resident's bed without the assistance of another staff person and without the use of a mechanical lift, which resulted in the resident sustaining a left femur fracture. The findings include: Review of the facility policy titled Safe Lifting and Movement of Resident, with a review date of 06/01/15, revealed the facility utilizes appropriate techniques and devices to lift and move residents in order to protect the safety and well-being of staff and residents. Review of Resident #1's medical record revealed the facility admitted the resident on 08/04/08 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment, dated 01/23/18, revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers along with the use of a mechanical lift. Review of Resident #1's care plan, dated 03/13/15, revealed the resident required the assistance of two (2) staff members with a mechanical lift for transfers. Interview on 03/05/18 with SRNA #1 at 12:40 PM revealed she had given Resident #1 a shower on 02/20/18 and took the resident back to his/her room in a shower chair. She stated she was attempting to transfer the resident from the shower chair to his/her bed and the shower chair flipped out from under the resident. She stated she held the resident under his/her arms to keep the resident from falling to the floor until help could arrive to assist her. She stated she knew Resident #1 required the assistance of two (2) staff members with a mechanical lift for transfers; however, she stated she was in a hurry and she did not ask for assistance to transfer the resident. Interview with SRNA #2 on 03/05/18 at 3:21 PM revealed she worked with SRNA #1 on 02/20/18 and SRNA #1 did not ask for assistance to transfer Resident #1 to his/her bed. SRNA #2 stated she had just finished providing care to another resident when she heard someone yelling for help. She stated she went to Resident #1's room and found SRNA #1 holding Resident #1 under his/her arms against the bed. Further interview revealed she assisted SRNA #1 and LPN #1 in transferring Resident #1 to his/her bed. Furthermore, she stated Resident #1 required the use of a mechanical lift for transfers with two (2) staff members to assist, and this was on the resident's plan of care. She stated she was not sure why SRNA #1 attempted to transfer the resident without assistance. Interview with LPN #1 on 03/05/18 at 3:26 PM revealed she was working on 02/20/18 and heard someone yelling for assistance while she was performing medication administration. She stated she went into Resident #1's room and found SRNA #1 holding Resident #1 under his/her arms against the bed. She stated she assisted the resident onto his/her bed and assessed the resident for injury. LPN #1 stated that Resident #1 did not complain of pain initially; however, the resident started complaining of pain in his/her left leg at approximately 1:00 AM. Further interview with LPN #1 revealed she attempted to page the resident's physician but was unable to reach him. Continued interview revealed she reached the Nurse Practitioner at approximately 7:00 AM and received an order for [REDACTED]. Interview with the Director of Nursing (DON) on 03/06/18 at 12:45 PM revealed that LPN #1 called her on the evening of 02/20/18 and reported to her that SRNA #1 attempted to transfer Resident #1 without assistance and without the use of the mechanical lift. Further interview revealed SRNA #1 was trained on safe resident transfers and the use of the mechanical lift and she was unsure why SRNA #1 attempted to transfer the resident without the lift. ***The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was assessed for injury and pain by the charge nurse on 02/20/18. The family and the physician were notified of the incident on 02/20/18. The resident began complaining of pain on 02/21/18. The Nurse Practitioner gave an order for [REDACTED]. Resident #1 returned to the facility with orders to follow up with an orthopedic surgeon on 02/26/18. 2. All residents were assessed for proper transfer assistance on 02/21/18 by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). All residents who required transfer assistance with a mechanical lift were assessed for proper size of lift sling on 02/21/18 by the DON and ADON. All comprehensive care plans and Certified Nursing Assistant (CNA) care plans for residents utilizing a mechanical lift for transfers were audited for appropriate type of lift and sling size on 02/21/18 by the DON, ADON, Staff Development Coordinator (SDC), and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 02/22/18. All comprehensive care plans and CNA care plans were audited for appropriate assistance required for transfer on 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were corrected immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. Pain assessments were completed on all residents by 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. 3. All nursing staff were trained on proper use of mechanical lifts and ensuring proper sling size in accordance with manufacturer guidelines and the policy by 02/28/18 by the DON, SDC, or Restorative Nurse. All new hires will be educated on proper use of mechanical lifts and proper sling size prior to working the floor and at least annually thereafter. All nursing staff were educated on utilizing the care plan for providing appropriate care to residents by 02/28/18 by the SDC and Unit Managers. All new nursing staff new hires will be educated on following the care plan to provide appropriate care upon hire and at least annually thereafter. All licensed staff were educated regarding pain assessments. 4. The DON, Unit Managers, Charge Nurses, and/or Manager on Duty will monitor care delivery and compare to the care plan for ten (10) residents per day for one (1) week beginning on 02/23/18. If no issues are identified, then monitoring will be reduced to five (5) residents per day for one (1) week, then four (4) residents three (3) times per week, then four (4) residents once per week. Any issues identified will be corrected immediately, education provided on the spot, and reported to Quality Assurance Committee at the next review. All Change of Condition, new admissions, and new orders will be reviewed daily Monday through Friday in the Clinical White Board meeting by the DON, ADON, SDC, and/or Unit Managers for any pain related issues. Random pain audits will be completed by the DON, ADON, and or Unit Managers for ten (10) residents per day for one (1) week. If no issues are identified, then audits will be reduced to four (4) residents three (3) times per week, and then four (4) residents once per week. Results will be reviewed for further recommendations in the weekly Quality Assurance meeting for four (4) weeks, then monthly thereafter. All care plans will be updated accordingly with new orders. Any incidents or accidents involving the transfer of residents, with or without the use of a lift, will be reviewed Monday through Friday in the Morning Clinical White Board meeting by the DON, ADON, Unit Managers, and/or SDC. A Root Cause Analysis will be used to determine the root cause of the incident, the care plan will be updated accordingly, and staff will be educated on changes. The State Registered Nursing Aide (SRNA) that was involved in the incident and transferred the resident without assistance was suspended on 02/21/18. A Quality Assurance Process Improvement meeting will be held weekly for four (4) weeks beginning 02/22/18 to review any issues identified and further recommendations regarding the above stated plan, and then monthly thereafter. 5. Date of alleged compliance - 03/01/18. ****The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the record for Resident #1 revealed the resident was evaluated and treated for [REDACTED]. Review of the hospital record revealed the resident was not a candidate for operative intervention due to the resident being nonambulatory prior to the accident and with other medical problems. 2. Review of facility documentation revealed that all residents were assessed for proper transfer assistance and residents who required the use of a sling were assessed for proper size of lift sling on 02/21/18. Interview with the ADON on 03/13/18 at 11:43 AM revealed that she assisted the DON with the assessments to ensure residents were receiving the appropriate amount of assistance with transfers. Review of audit forms revealed comprehensive care plans and CNA care plans were audited for appropriate lift type/sling size on 02/21/18. Interview with the DON on 03/13/18 at 12:11 PM revealed that she and the ADON audited all comprehensive care plans to ensure residents had care plans in place for appropriate transfers. Review of Pain Assessments revealed that all residents were reassessed for pain on 02/28/18 by the DON, ADON, and the Unit Manager. Interviews with the Unit Manager on 03/13/18 at 11:24 AM, the ADON on 03/13/18 at 11:43 AM, and the DON on 03/13/18 at 12:11 PM revealed the Pain assessments were completed on 02/28/18. 3. Review of Inservice Sign-in Sheets revealed that in-services were conducted on 02/21/18 regarding the proper use of the mechanical lift and utilizing the care plan for providing appropriate care to residents. Further review of the facility documentation revealed that all facility staff were trained from 02/21/18 through 02/28/18 to ensure all staff received the training prior to working their next shift. Interviews with CNA #7 and CNA #8 on 03/13/18 at 11:51 AM and 11:57 AM respectively revealed they had received training regarding following the care plan of each resident and use of the mechanical lift. Further review of in-service documentation revealed licensed staff were educated regarding pain assessments. Interviews with LPN #3 and RN #3 on 03/13/18 at 12:04 PM and 12:08 PM verified that they had been educated regarding the facility policy and how to do pain assessments. 4. Review of care delivery audits revealed care delivery audits were initiated on 02/23/18 and were ongoing. Further review of the facility documentation revealed pain audits had been conducted and pain was being monitored according to the facility plan. Review of Quality Assurance (QA) meeting minutes revealed the QA Committee met on 02/22/18 to develop a plan related to the deficient practice and met again on 02/28/18 and 03/07/18 to review progress toward the correction of the deficient practice. Interview with the facility Administrator on 03/13/18 at 12:22 PM revealed that the QA Committee was meeting weekly to monitor the progress. 5. The state survey agency verified that the deficient practice was corrected as alleged on 03/01/18.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided for one (1) of three (3) sampled residents (Resident #1). On 02/20/18 at approximately 8:00 PM, Resident #1 sustained a fall. Review of the physician orders [REDACTED]. On 02/21/18 at approximately 1:00 AM Resident #1 began complaining of pain in his/her left leg with movement. Licensed Practical Nurse (LPN) #1 paged the on-call physician; however, he did not answer the page. LPN #1 did not attempt to notify the on-call physician again until approximately 6:12 AM on 02/21/18. At approximately 7:04 AM on 02/21/18, LPN #1 reported to Advanced Practice Registered Nurse (APRN) #1 that the resident was complaining of pain in his/her left leg and that the resident had [MEDICAL CONDITION] to his/her left knee. APRN #1 ordered Tylenol 500 milligrams (mg) every six (6) hours for pain and ordered an x-ray of the resident's left leg, which later revealed a [MEDICAL CONDITION]. The resident continued to complain of pain in his/her left leg; however, the resident did not receive any medication for pain until 12:00 PM on 02/21/18. The findings include: Review of the facility's policy titled Pain Management, not dated, revealed each resident identified with pain would have ongoing assessments, a monitoring system, and a specific plan of care to address the issues. Review of the facility's policy titled Change in Condition, reviewed 06/25/15, revealed the facility would assess and document changes in a resident's health in an effective and efficient manner to relay assessment information to the physician. Review of Resident #1's medical record revealed the facility admitted the resident on 08/04/08 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment, dated 01/23/18, revealed what did the assessment say about pain. Review of Resident #1's care plan dated 03/13/15, revealed the facility identified the resident was at risk for pain related to [MEDICAL CONDITION] and decreased mobility. The facility developed care plan interventions that required staff to report changes in pain, location and type, administer medications as ordered, and monitor for effectiveness of medication. Review of Resident #1's physician orders [REDACTED]. Continued review of the MAR indicated [REDACTED]. Although facility staff documented the resident was free of pain on 02/20/18 and 02/21/18, interviews with staff revealed the resident began complaining of pain with movement following the fall on 02/20/18 at approximately 8:00 PM. Review of Resident #1's left knee x-ray dated 02/21/18 revealed the resident had a left femur fracture with slight displacement. Interviews with State Registered Nurse Aide (SRNA) #1 on 03/05/18 at 12:40 PM and SRNA #2 at 3:21 PM revealed the resident immediately began complaining of pain in his/her left knee after SRNA #1 attempted to transfer the resident without assistance or the use of a mechanical lift on 02/20/18 at approximately 8:00 PM. Interview with SRNA #1 revealed she left work shortly after the incident because she was upset. Interview with SRNA #2 revealed Resident #1 continued to complain of pain with movement each time she attempted to provide care to the resident on the evening of 02/20/18 and into the morning of 02/21/18. She stated she reported the pain to LPN #1 every time the resident complained of pain. Furthermore, she stated LPN #1 came and assessed the resident's leg; however, the resident did not have pain medication ordered for administration. Interview with LPN #1 on 03/05/18 at 3:26 PM revealed she was working on 02/20/18 and heard someone yelling for assistance while she was performing medication administration. She stated she went into Resident #1's room and found SRNA #1 holding Resident #1 under his/her arms against the bed. She stated she assisted the resident onto his/her bed and assessed the resident for injury. LPN #1 stated that Resident #1 did not complain of pain initially; however, the resident started complaining of pain in his/her left leg at approximately 1:00 AM on 02/21/18. Further interview with LPN #1 revealed she attempted to page the resident's physician but was unable to reach him. Continued interview revealed she reached the Nurse Practitioner at approximately 7:00 AM and received an order for [REDACTED]. Interview with Unit Manager (UM) #1 on 03/06/18 at 12:22 PM revealed she was covering for a nurse that called in on 02/20/18. She stated LPN #1 called the unit she was working on and reported the incident to her. She stated LPN #1 asked her to look at Resident #1's leg that night. She stated that at approximately 1:00 AM she assessed Resident #1's knee. UM #1 stated the resident's knee was slightly swollen but the resident did not complain of pain when she palpated the resident's leg. Further interview revealed she told LPN #1 to call the on-call physician and report to him that the resident's knee was slightly swollen. Continued interview with UM #1 revealed she was not aware that LPN #1 had not spoken to the on-call physician. She stated that if she knew that LPN #1 had not received a response from the on-call physician she would have told her to contact the Medical Director. Furthermore, she stated that if she was unable to reach the Medical Director she should have sent the resident to the emergency room for evaluation. Interview with the Director of Nursing (DON) on 03/06/18 at 12:45 PM revealed that LPN #1 reported to her that Resident #1 did not immediately complain of pain following the incident that occurred on 02/20/18. The DON stated that when she came to the facility on the morning of 02/21/18 staff reported to her that the resident complained of positional pain throughout the night and that LPN #1 contacted the on-call physician and received an order for [REDACTED].#1 was unable to reach the on-call physician. She stated if she had been made aware she would have contacted the Medical Director. Continued interview with the DON revealed that if the Medical Director was unreachable she would have expected LPN #1 to send the resident to the emergency room for evaluation. ***The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was assessed for injury and pain by the charge nurse on 02/20/18. The family and the physician were notified of the incident on 02/20/18. The resident began complaining of pain on 02/21/18. The Nurse Practitioner gave an order for [REDACTED]. Resident #1 returned to the facility with orders to follow up with an orthopedic surgeon on 02/26/18. 2. All residents were assessed for proper transfer assistance on 02/21/18 by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). All residents who required transfer assistance with a mechanical lift were assessed for proper size of lift sling on 02/21/18 by the DON and ADON. All comprehensive care plans and Certified Nursing Assistant (CNA) care plans for residents utilizing a mechanical lift for transfers were audited for appropriate type of lift and sling size on 02/21/18 by the DON, ADON, Staff Development Coordinator (SDC), and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 02/22/18. All comprehensive care plans and CNA care plans were audited for appropriate assistance required for transfer on 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were corrected immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. Pain assessments were completed on all residents by 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. 3. All nursing staff were trained on proper use of mechanical lifts and ensuring proper sling size in accordance with manufacturer guidelines and the policy by 02/28/18 by the DON, SDC, or Restorative Nurse. All new hires will be educated on proper use of mechanical lifts and proper sling size prior to working the floor and at least annually thereafter. All nursing staff were educated on utilizing the care plan for providing appropriate care to residents by 02/28/18 by the SDC and Unit Managers. All new nursing staff new hires will be educated on following the care plan to provide appropriate care upon hire and at least annually thereafter. All licensed staff were educated regarding pain assessments. 4. The DON, Unit Managers, Charge Nurses, and/or Manager on Duty will monitor care delivery and compare to the care plan for ten (10) residents per day for one (1) week beginning on 02/23/18. If no issues are identified, then monitoring will be reduced to five (5) residents per day for one (1) week, then four (4) residents three (3) times per week, then four (4) residents once per week. Any issues identified will be corrected immediately, education provided on the spot, and reported to Quality Assurance Committee at the next review. All Change of Condition, new admissions, and new orders will be reviewed daily Monday through Friday in the Clinical White Board meeting by the DON, ADON, SDC, and/or Unit Managers for any pain related issues. Random pain audits will be completed by the DON, ADON, and or Unit Managers for ten (10) residents per day for one (1) week. If no issues are identified, then audits will be reduced to four (4) residents three (3) times per week, and then four (4) residents once per week. Results will be reviewed for further recommendations in the weekly Quality Assurance meeting for four (4) weeks, then monthly thereafter. All care plans will be updated accordingly with new orders. Any incidents or accidents involving the transfer of residents, with or without the use of a lift, will be reviewed Monday through Friday in the Morning Clinical White Board meeting by the DON, ADON, Unit Managers, and/or SDC. A Root Cause Analysis will be used to determine the root cause of the incident, the care plan will be updated accordingly, and staff will be educated on changes. The State Registered Nursing Aide (SRNA) that was involved in the incident and transferred the resident without assistance was suspended on 02/21/18. A Quality Assurance Process Improvement meeting will be held weekly for four (4) weeks beginning 02/22/18 to review any issues identified and further recommendations regarding the above stated plan, and then monthly thereafter. 5. Date of alleged compliance - 03/01/18. ****The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the record for Resident #1 revealed the resident was evaluated and treated for [REDACTED]. Review of the hospital record revealed the resident was not a candidate for operative intervention due to the resident being nonambulatory prior to the accident and with other medical problems. 2. Review of facility documentation revealed that all residents were assessed for proper transfer assistance and residents who required the use of a sling were assessed for proper size of lift sling on 02/21/18. Interview with the ADON on 03/13/18 at 11:43 AM revealed that she assisted the DON with the assessments to ensure residents were receiving the appropriate amount of assistance with transfers. Review of audit forms revealed comprehensive care plans and CNA care plans were audited for appropriate lift type/sling size on 02/21/18. Interview with the DON on 03/13/18 at 12:11 PM revealed that she and the ADON audited all comprehensive care plans to ensure residents had care plans in place for appropriate transfers. Review of Pain Assessments revealed that all residents were reassessed for pain on 02/28/18 by the DON, ADON, and the Unit Manager. Interviews with the Unit Manager on 03/13/18 at 11:24 AM, the ADON on 03/13/18 at 11:43 AM, and the DON on 03/13/18 at 12:11 PM revealed the Pain assessments were completed on 02/28/18. 3. Review of Inservice Sign-in Sheets revealed that in-services were conducted on 02/21/18 regarding the proper use of the mechanical lift and utilizing the care plan for providing appropriate care to residents. Further review of the facility documentation revealed that all facility staff were trained from 02/21/18 through 02/28/18 to ensure all staff received the training prior to working their next shift. Interviews with CNA #7 and CNA #8 on 03/13/18 at 11:51 AM and 11:57 AM respectively revealed they had received training regarding following the care plan of each resident and use of the mechanical lift. Further review of in-service documentation revealed licensed staff were educated regarding pain assessments. Interviews with LPN #3 and RN #3 on 03/13/18 at 12:04 PM and 12:08 PM verified that they had been educated regarding the facility policy and how to do pain assessments. 4. Review of care delivery audits revealed care delivery audits were initiated on 02/23/18 and were ongoing. Further review of the facility documentation revealed pain audits had been conducted and pain was being monitored according to the facility plan. Review of Quality Assurance (QA) meeting minutes revealed the QA Committee met on 02/22/18 to develop a plan related to the deficient practice and met again on 02/28/18 and 03/07/18 to review progress toward the correction of the deficient practice. Interview with the facility Administrator on 03/13/18 at 12:22 PM revealed that the QA Committee was meeting weekly to monitor the progress. 5. The state survey agency verified that the deficient practice was corrected as alleged on 03/01/18.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to require the assistance of two (2) staff members and use of a mechanical lift for transfers. Resident #1 sustained a fall on 02/20/18 when State Registered Nurse Aide (SRNA) #1 attempted by herself to transfer Resident #1 from his/her shower chair to his/her bed and without using a mechanical lift, which resulted in Resident #1 sustaining a mildly displaced [MEDICATION NAME] femoral metaphysis (narrow portion of the long bone in the upper leg). The findings include: Review of the facility's policy, Care Plans-Comprehensive, 10/31/17, revealed a person-centered comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Continued review of the policy revealed each resident's care plan was designed to aid in preventing and reducing declines in the resident's functional status and/or functional levels. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident's goals. Review of Resident #1's medical record revealed the facility admitted the resident on 08/04/08 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment, dated 01/23/18, revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers. Review of Resident #1's care plan, originally dated 03/13/15, revealed the resident required the assistance of two (2) staff members with a mechanical lift for transfers. Review of the facility's investigation for Resident #1 dated 02/20/18 at 8:00 PM revealed SRNA #1 was transferring Resident #1 from the shower chair to the bed when the shower chair slid out from under the resident and SRNA #1 held onto the resident under his/her arms with the resident's torso against the bed. Licensed Practical Nurse (LPN) #1 and SRNA #2 assisted SRNA #1 to transfer the resident to his/her bed. Interview on 03/05/18 with SRNA #1 at 12:40 PM revealed she had given Resident #1 a shower and took the resident back to his/her room in a shower chair. She stated she was attempting to transfer the resident from the shower chair to his/her bed and the shower chair flipped out from under the resident. She stated she held the resident under his/her arms to keep the resident from falling to the floor until help could arrive to assist her. She stated she knew Resident #1 required the assistance of two staff members with a mechanical lift for transfers; however, she stated she was in a hurry and decided to do it alone. Further interview revealed she had been trained on safe resident transfers in the past. On 03/05/18 at 3:21 PM an interview with SRNA #2 revealed she worked with SRNA #1 on 02/20/18. She stated SRNA #1 did not ask for assistance to transfer Resident #1 to his/her bed. SRNA #2 stated she had just finished providing care to another resident when she heard someone yelling for help. She went to Resident #1's room and SRNA #1 was holding Resident #1 under his/her arms against the bed. Further interview revealed she assisted SRNA #1 and LPN #1 in transferring Resident #1 to his/her bed. Furthermore, she stated Resident #1 required the use of a mechanical lift for transfers with two (2) staff members to assist for as long as she could remember. She stated she was not sure why SRNA #1 attempted to transfer the resident without assistance. She stated that she knew how much assistance a resident required because it was on the resident's plan of care. Interview with LPN #1 on 03/05/18 at 3:26 PM revealed she was working on 02/20/18. She stated she was performing medication pass when she heard someone yelling for assistance. She went into Resident #1's room and found SRNA #1 holding Resident #1 under his/her arms against the bed. She stated she assisted the resident onto his/her bed and assessed the resident for injury. LPN #1 stated that Resident #1 did not complain of pain initially; however, the resident started complaining of pain in his/her left leg at approximately 1:00 AM. Further interview with LPN #1 revealed she attempted to page the resident's physician but was unable to reach him. Continued interview revealed she reached the Nurse Practitioner at approximately 7:00 AM and received an order for [REDACTED]. Interview with the Director of Nursing (DON) on 03/06/18 at 12:45 PM revealed LPN #1 called and reported the incident with Resident #1 and SRNA #1 on 02/20/18. The DON stated that SRNA #1 should not have attempted to transfer Resident #1 without assistance and the mechanical lift. She stated the resident was care planned to receive assistance from two (2) staff members and the use of a mechanical lift for transfers. The DON further stated that staff were expected to review the resident's plan of care at the beginning of each shift to ensure the resident received the required amount of assistance. Further interview revealed SRNA #1 was trained on safe resident transfers and the use of the mechanical lift. ***The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was assessed for injury and pain by the charge nurse on 02/20/18. The family and the physician were notified of the incident on 02/20/18. The resident began complaining of pain on 02/21/18. The Nurse Practitioner gave an order for [REDACTED]. Resident #1 returned to the facility with orders to follow up with an orthopedic surgeon on 02/26/18. 2. All residents were assessed for proper transfer assistance on 02/21/18 by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). All residents who required transfer assistance with a mechanical lift were assessed for proper size of lift sling on 02/21/18 by the DON and ADON. All comprehensive care plans and Certified Nursing Assistant (CNA) care plans for residents utilizing a mechanical lift for transfers were audited for appropriate type of lift and sling size on 02/21/18 by the DON, ADON, Staff Development Coordinator (SDC), and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 02/22/18. All comprehensive care plans and CNA care plans were audited for appropriate assistance required for transfer on 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were corrected immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. Pain assessments were completed on all residents by 02/28/18 by the DON, ADON, and/or Unit Managers. Any concerns identified were addressed immediately and reported to the DON and reviewed in the Quality Assurance meeting on 03/07/18. 3. All nursing staff were trained on proper use of mechanical lifts and ensuring proper sling size in accordance with manufacturer guidelines and the policy by 02/28/18 by the DON, SDC, or Restorative Nurse. All new hires will be educated on proper use of mechanical lifts and proper sling size prior to working the floor and at least annually thereafter. All nursing staff were educated on utilizing the care plan for providing appropriate care to residents by 02/28/18 by the SDC and Unit Managers. All new nursing staff new hires will be educated on following the care plan to provide appropriate care upon hire and at least annually thereafter. All licensed staff were educated regarding pain assessments. 4. The DON, Unit Managers, Charge Nurses, and/or Manager on Duty will monitor care delivery and compare to the care plan for ten (10) residents per day for one (1) week beginning on 02/23/18. If no issues are identified, then monitoring will be reduced to five (5) residents per day for one (1) week, then four (4) residents three (3) times per week, then four (4) residents once per week. Any issues identified will be corrected immediately, education provided on the spot, and reported to Quality Assurance Committee at the next review. All Change of Condition, new admissions, and new orders will be reviewed daily Monday through Friday in the Clinical White Board meeting by the DON, ADON, SDC, and/or Unit Managers for any pain related issues. Random pain audits will be completed by the DON, ADON, and or Unit Managers for ten (10) residents per day for one (1) week. If no issues are identified, then audits will be reduced to four (4) residents three (3) times per week, and then four (4) residents once per week. Results will be reviewed for further recommendations in the weekly Quality Assurance meeting for four (4) weeks, then monthly thereafter. All care plans will be updated accordingly with new orders. Any incidents or accidents involving the transfer of residents, with or without the use of a lift, will be reviewed Monday through Friday in the Morning Clinical White Board meeting by the DON, ADON, Unit Managers, and/or SDC. A Root Cause Analysis will be used to determine the root cause of the incident, the care plan will be updated accordingly, and staff will be educated on changes. The State Registered Nurse Aide (SRNA) that was involved in the incident and transferred the resident without assistance was suspended on 02/21/18. A Quality Assurance Process Improvement meeting will be held weekly for four (4) weeks beginning 02/22/18 to review any issues identified and further recommendations regarding the above stated plan, and then monthly thereafter. 5. Date of alleged compliance - 03/01/18. ****The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the record for Resident #1 revealed the resident was evaluated and treated for [REDACTED]. Review of the hospital record revealed the resident was not a candidate for operative intervention due to the resident being nonambulatory prior to the accident and with other medical problems. 2. Review of facility documentation revealed that all residents were assessed for proper transfer assistance and residents who required the use of a sling were assessed for proper size of lift sling on 02/21/18. Interview with the ADON on 03/13/18 at 11:43 AM revealed that she assisted the DON with the assessments to ensure residents were receiving the appropriate amount of assistance with transfers. Review of audit forms revealed comprehensive care plans and CNA care plans were audited for appropriate lift type/sling size on 02/21/18. Interview with the DON on 03/13/18 at 12:11 PM revealed that she and the ADON audited all comprehensive care plans to ensure residents had care plans in place for appropriate transfers. Review of Pain Assessments revealed that all residents were reassessed for pain on 02/28/18 by the DON, ADON, and the Unit Manager. Interviews with the Unit Manager on 03/13/18 at 11:24 AM, the ADON on 03/13/18 at 11:43 AM, and the DON on 03/13/18 at 12:11 PM revealed the Pain assessments were completed on 02/28/18. 3. Review of Inservice Sign-in Sheets revealed that in-services were conducted on 02/21/18 regarding the proper use of the mechanical lift and utilizing the care plan for providing appropriate care to residents. Further review of the facility documentation revealed that all facility staff were trained from 02/21/18 through 02/28/18 to ensure all staff received the training prior to working their next shift. Interviews with CNA #7 and CNA #8 on 03/13/18 at 11:51 AM and 11:57 AM respectively revealed they had received training regarding following the care plan of each resident and use of the mechanical lift. Further review of in-service documentation revealed licensed staff were educated regarding pain assessments. Interviews with LPN #3 and RN #3 on 03/13/18 at 12:04 PM and 12:08 PM verified that they had been educated regarding the facility policy and how to do pain assessments. 4. Review of care delivery audits revealed care delivery audits were initiated on 02/23/18 and were ongoing. Further review of the facility documentation revealed pain audits had been conducted and pain was being monitored according to the facility plan. Review of Quality Assurance (QA) meeting minutes revealed the QA Committee met on 02/22/18 to develop a plan related to the deficient practice and met again on 02/28/18 and 03/07/18 to review progress toward the correction of the deficient practice. Interview with the facility Administrator on 03/13/18 at 12:22 PM revealed that the QA Committee was meeting weekly to monitor the progress. 5. The state survey agency verified that the deficient practice was corrected as alleged on 03/01/18.

Based on interview, record review, review of the facility's investigations, and review of the facility's policies, it was determined the facility failed to have systems in place to ensure falls were reported, documented, and thoroughly investigated to prevent further falls for three (3) of five (5) sampled resident (Residents #1, #2, and #5). Review of a list provided by the facility revealed there were thirty-seven (37) resident falls in the facility in the past thirty (30) days, with at least two (2) of the falls resulting in fractures. Resident #1 sustained a fall on [DATE], and the facility failed to document or report the fall to the resident's physician, and failed to assess the resident for injuries after the fall. Four (4) days later, on [DATE], after the resident had complaints of pain since [DATE], a bilateral x-ray of the resident's hips revealed a fracture of the right hip. The facility transferred the resident to the hospital where the resident's hip was surgically repaired. The resident returned to the facility under Hospice care and expired at the facility on [DATE]. The resident's physician stated the fall contributed to the resident's decline. The facility assessed Resident #2 to require the assistance of two (2) staff members and a bed alarm. However, on [DATE], Resident #2 sustained a fall while ambulating from the bathroom to the chair while only being assisted by one (1) staff member. During the investigation of the resident's fall, the facility failed to identify that the resident was not receiving the assessed amount of assistance when the fall occurred. Resident #2 sustained another fall on [DATE], which resulted in a hip fracture. The resident's bed alarm did not sound at the time of the fall because the alarm was broken. However, during the facility's investigation, they did not identify that the resident's bed alarm was broken at the time of the fall. The facility assessed Resident #5 to require the assistance of two (2) staff members for transfers and toileting. However, Resident #5 sustained a fall on [DATE] while one (1) staff member provided incontinence care to the resident while the resident was standing in the shower room. During the investigation, the facility failed to identify that the resident did not receive the assessed amount of assistance when the fall occurred. Resident #5 sustained another fall on [DATE], when he/she fell from a wheelchair and hit his/her head on the bathroom door, which resulted in an abrasion and hematoma to the right side of the resident's forehead. The facility had assessed the resident and developed a care plan for the use of a chair alarm. However, staff was not aware the resident required an alarm and the chair alarm was not on the resident's wheelchair to alert staff that the resident was getting up unassisted. The facility's investigation did not identify that the resident's chair alarm was not in place at the time of the fall. Resident #5 expired at the facility on [DATE] and according to the resident's provider, the fall may have contributed to the resident's death. The facility's failure to ensure falls were documented and thoroughly investigated has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Falls, reviewed [DATE], revealed if the resident sustained [REDACTED]. Review of the facility's policy titled, Accidents and Incidents- Investigating and Report, revealed accidents or incidents involving residents would be investigated and reported to the Administrator. Further review of the policy revealed the incident would be documented in the Event Manager (an electronic incident reporting system) and reported to the Administrator and/or Director of Nursing (DON). Continued review of the policy revealed the Nurse Supervisor or Charge Nurse was required to initiate and document the investigation of the accident or incident. Review of the facility's policy titled Change in Condition, reviewed [DATE], revealed the facility would assess and document changes in the resident's health in an effective and efficient manner to relay assessment information to the physician. The policy further revealed if the resident's condition did not appear to be life threatening, the facility staff should utilize the Situation, Background, Assessment, and Response (SBAR) Communication Form and notify the physician. Continued review of the policy revealed the SBAR Communication Form would serve as the nursing documentation for changes in condition. Review of the policy revealed conditions identified that would indicate a change in condition, utilization of the SBAR, and notification of the physician, included residents who had pain or sustained falls. Review of an Event Report provided by the facility revealed from [DATE] to [DATE], there were thirty-seven (37) resident falls in the facility in the thirty (30) day timeframe. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated [DATE] and finalized on [DATE], revealed Resident #1 had a fracture of the left (x-rays revealed the fracture was on the right side) femoral head and an investigation was initiated regarding the injury of unknown source. Further review of the investigation revealed staff reported that Resident #1 sustained a fall from his/her wheelchair on [DATE]; however, facility staff did not report or document the resident's fall when it occurred. The investigation revealed the nurse assigned to care for Resident #1 on the day the fall occurred continued to deny that Resident #1 sustained a fall. According to the investigation, a nurse that assisted Resident #1's nurse at the time of the fall initially denied the fall occurred, but then stated Resident #1 had fallen on [DATE] when questioned again by staff. Continued review of the investigation revealed Resident #1 verbalized complaints of right and left hip pain on [DATE] and was resisting care and swearing on [DATE]. The resident's physician was notified on [DATE] and ordered x-rays of the resident's hips. Review of Resident #1's Nursing Assessment and Fall Investigation revealed the resident fell in the dining room on [DATE]. Resident #1 was found on his/her knees in front of a wheelchair. Further review of the documentation revealed the nursing staff did not suspect the resident had an injury. Review of the documentation revealed Resident #1's family member and physician were not notified of the fall until [DATE]. Further review of the fall's investigation revealed the facility staff had not completed the form and the Investigative Summary section of the investigation form was not completed. There was no documented evidence the facility investigated why the fall may have occurred, or implemented interventions to prevent further falls. Review of Resident #1's Health Status Notes dated [DATE] at 3:28 PM revealed the Director of Nursing (DON) assessed Resident #1 because a Stop/Watch was completed by staff. The DON assessed the resident and noted the resident had increased pain to the hip joints and complaints of pain with palpation to the right buttock where the resident had received an injection the previous night. Continued review of Health Status Notes dated [DATE] at 2:30 PM completed by RN #1 revealed Resident #1 refused care from staff at times and was cursing at staff when asked to complete a task. Review of Health Status Notes dated [DATE] at 7:26 AM revealed staff notified Resident #1's family member that the resident had bilateral hip pain and x-rays of the hips had been ordered. Further review of the Notes revealed at 8:30 PM on [DATE] Resident #1 was transferred to the emergency room related to the results of the hip x-ray. Review of Resident #1's SBAR Communication Form dated [DATE], not timed, revealed the resident was assessed to have bilateral hip pain, which started on [DATE]. Further review of the Form revealed the resident's pain was new, continuous, and rated nine (9) on a scale of one to ten (,[DATE]), with ten (10) being the worst pain. Continued review of the Form revealed the resident had facial grimacing, worsening pain, and had his/her legs drawn up and staff was unable to evaluate abduction or adduction. Further review revealed that upon palpation the resident had facial grimacing and guarding. Review of the Form revealed Resident #1's Physician was unable to be reached on [DATE] when staff initially attempted to contact him, but at an unknown time, the physician was in the facility and gave an order for [REDACTED]. Review of Resident #1's hip x-rays dated [DATE] revealed the resident had an impacted right femoral neck fracture (hip fracture). Further review of Resident #1's Health Status Notes revealed at 8:30 PM on [DATE] Resident #1 was transferred to the emergency room related to the results of the hip x-ray. Interview on [DATE] at 5:06 PM with State Registered Nurse Aide (SRNA) #6 revealed she was working with Resident #1 on [DATE], the day the resident fell . SRNA #6 stated she heard Resident #1's alarm sound in the dining room and found the resident on the floor in front of a wheelchair. SRNA #6 stated Licensed Practical Nurse (LPN) #3 and LPN #4 responded to the resident's fall and came into the dining room right behind her. She stated they looked at the resident and assisted the resident back into the wheelchair. SRNA #6 stated she was not aware the fall had not been reported to administrative staff until she was questioned about Resident #1's injury. On [DATE] at 5:00 PM, an interview with LPN #3 revealed on [DATE] she was at her medication cart and heard an alarm sounding from the dining room. She stated she found Resident #1 on his/her knees in front of his/her wheelchair and LPN #4 (Resident #1's nurse) was standing beside the resident. LPN #3 stated she helped LPN #4 assist Resident #1 back into the wheelchair, and then she continued her medication pass. Continued interview revealed LPN #3 assumed since LPN #4 was Resident #1's nurse, she would report and document the fall appropriately. LPN #3 stated she was not aware LPN #4 had not documented and reported the fall until she was questioned as part of the investigation of the resident's hip injury. The interview further revealed she (LPN #3) denied Resident #1 had a fall initially when asked by administrative staff because she did not want to tell on a fell ow staff member, but later she admitted to the fall when questioned a second time. Interview on [DATE] at 5:06 PM with LPN #4 revealed she was assigned to provide care to Resident #1 on [DATE]. LPN #4 denied a fall occurred with Resident #1. Interview on [DATE] with SRNA #1 at 1:45 PM, and SRNA #9 on [DATE] at 12:16 PM, revealed the SRNAs worked with Resident #1 on [DATE] and [DATE] and the resident was not acting like his/her normal self. The SRNAs stated when they attempted to provide care for Resident #1 on [DATE], the resident continually complained of pain (yelled out), appeared to be in pain, and made statements multiple times, My hip's broke and I fell out of the door and hit my head but my hip hurts worse. SRNA #9 stated she reported their (the SRNAs') concerns about Resident #1 to the resident's nurse, Registered Nurse (RN) #1, multiple times, however, the RN never assessed the resident. SRNA #1 and SRNA #9 stated that at approximately 3:00 PM they completed a Stop and Watch Form which stated they had attempted to get RN #1 to assess Resident #1 for pain several times throughout the shift because the resident was not acting like himself/herself, but the RN had not assessed the resident. The SRNAs further stated they also documented on the Form that the resident was complaining of pain, appeared to be in pain, and the resident had reported he/she fell out of the door and hit (his/her) head, but (his/her) hip hurt worse. The interview further revealed the DON and RN #1 assessed the resident after the SRNAs completed the Stop and Watch Form and determined the resident's pain was from injections the resident was receiving. SRNA #1 revealed she also worked with Resident #1 the next day on [DATE], and the resident continued to yell out in pain and appeared to be in pain. SRNA #1 stated RN #1 was Resident #1's nurse again that day and the SRNA reported that the resident continued to appear to be in pain. However, the RN appeared to be aggravated with her when she made the reports. Interview on [DATE] at 2:32 PM with SRNA #2 revealed she worked with Resident #1 on [DATE] and the resident was in bed the entire day. However, any time staff touched the resident to provide incontinence care, the resident appeared to be in pain and would say Ouch or No, no, no. SRNA #2 stated Resident #1's complaints of pain were reported to RN #1. Interview on [DATE] at 1:39 PM with SRNA #10 revealed he was working on [DATE] when he was informed by facility staff (SRNA #6) that Resident #1 had fallen. The interview further revealed SRNA #10 returned to work on [DATE] and was told by an SRNA that the staff was worried about Resident #1 because the resident was having pain and the staff did not know why. Continued interview revealed SRNA #10 mentioned to SRNA #6 that the resident had fallen the previous weekend and SRNA #6 told him that he needed to report the fall because no one was aware that the resident had fallen. SRNA #10 stated he immediately went to RN #1 and reported that he had been told on Sunday ([DATE]) that Resident #1 had fallen. He stated he and RN #1 went to the DON immediately and reported that Resident #1 possibly had a fall on [DATE]. Interview on [DATE] at 1:38 PM and on [DATE] at 3:17 PM with RN #1 revealed the first time the RN was notified that Resident #1 was experiencing pain was when the SRNAs (SRNAs #1 and #9) brought the resident out of the shower room and the resident was complaining of hip pain and made the statement that he/she fell out of the door and hit (his/her) head. Continued interview revealed RN #1 looked' at the resident while he/she was in the wheelchair and the resident appeared to be fine. She instructed the SRNAs to take Resident #1 to lunch and she would assess the resident when the SRNAs put the resident back to bed. RN #1 revealed the SRNAs did a Stop and Watch related to Resident #1's pain and she and the DON assessed the resident. Further interview revealed they determined the pain was from arthritis and Rocephin (antibiotic) injections and did not notify Resident #1's Physician. The interview further revealed RN #1 worked with Resident #1 on [DATE] when SRNA #10 reported to her that Resident #1 had fallen the previous weekend. The SRNA and the RN immediately went to the DON and reported the information. RN #1 stated the DON stated that she would immediately initiate an investigation about the possible fall and would notify the physician of Resident #1's suspected fall and the resident's complaints of pain. Interview with the DON on [DATE] at 4:00 PM and on [DATE] at 12:21 PM revealed she denied RN #1 and SRNA #10 reported on [DATE] that the resident had sustained a fall the previous weekend. The DON stated that she would have immediately started an investigation, assessed the resident further, and obtained x-rays on that day. Further interview revealed the DON denied telling staff on [DATE] that she would initiate an investigation about a possible fall or contact the physician. There was no documented evidence that action was taken to investigate whether Resident#1 had a fall on [DATE], and there was no documented evidence the resident was reassessed due to the fall, or that the physician was notified. Interview on [DATE] at 1:07 PM with LPN #5 revealed she worked with Resident #1 the night of [DATE] and the resident stayed in the fetal position, refused to let staff straighten out his/her legs, and at times would scream out in pain when staff attempted to change or position him/her. Continued interview revealed the LPN attempted to contact the resident's physician, but was unable to reach the physician. She stated she contacted the DON to inform her of the resident's pain and that she was unable to reach the physician. LPN #5 stated the DON called back and informed her that she had reached the physician and had obtained an order for [REDACTED]. LPN #5 stated she put the order in for x-rays on [DATE] (no time documented for the order). Review of Resident #1's Discharge Summary dated [DATE] revealed the resident had surgery to repair the hip fracture and was discharged back to the facility on [DATE] under Hospice care. Interview with the Administrator on [DATE] at 2:20 PM revealed Resident #1 expired at the facility on [DATE]. Further interview with the DON on [DATE] at 4:00 PM, and [DATE] at 12:21 PM, revealed the facility was not aware Resident #1 had a fall until the resident's x-ray revealed the resident had a fracture. The facility investigated the injury of unknown origin and identified on [DATE] that the resident had fallen on [DATE], and it was not documented or reported to the resident's physician. Continued interview revealed SRNA #1 and SRNA #9 reported concerns that Resident #1's pain was not being assessed appropriately by RN #1 on [DATE] and the DON stated she instructed them to complete a Stop and Watch Form. The DON stated she and RN #1 assessed Resident #1 and determined the pain was due to IM injections and did not report the resident's pain to the physician. The DON stated the problem started when staff did not report and document Resident #1's fall on [DATE]. The interview further revealed the facility had identified through recent fall investigations that there was a problem with falls in the facility, which she felt was because nursing staff did not include thorough information on the nursing assessment when a fall occurred. Interview with the DON revealed that although she believed there was a problem, she did not always review or obtain further information, such as interviews with staff, or review resident care plans or assessments to attempt to determine the root cause of the falls. Interview on [DATE] at 1:56 PM with the Administrator revealed he was notified on [DATE] that Resident #1 had a fracture and an investigation into the injury of unknown origin was immediately initiated. The interview further revealed the facility had identified a possible problem with falls and the fall investigations within the last few falls. Continued interview revealed the Administrator did not always attend the daily clinical meeting where falls were discussed, and all problems with falls were not brought to his attention because the DON primarily dealt with the falls. Interview on [DATE] at 12:01 PM with Physician #2 revealed the physician denied that he ordered x-rays for Resident #1 and stated that he was not contacted about Resident #1's complaints of pain until after the facility had obtained the hip x-ray results. The interview further revealed the Physician would expect to be notified if a resident was experiencing pain that was new to a resident or if the resident had unrelieved pain. Physician #2 revealed he was not notified the resident had a fall the previous weekend ([DATE]) until [DATE]. According to the physician, Resident #1's health was declining prior to the resident's fall on [DATE]; however, the fall contributed to further decline in the resident's health. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was assessed to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Review of the comprehensive care plan for Activities of Daily Living (ADL) self-care deficit, initiated [DATE] and reviewed [DATE], revealed the facility failed to address how much assistance the resident required when he/she performed ADLs. Review of care plan interventions revealed Nursing staff to provide all ADL care to ensure daily needs are met. Further review of the comprehensive care plan revealed Resident #2 was at risk for falls related to injury as evidenced by a previous fall. The care plan was last reviewed on [DATE]. Review of the Certified Nursing Assistant (CNA) Assignment Sheet, not dated, revealed Resident #2 required assistance of two (2) staff members for mobility and transfers. Continued review of the assignment sheet revealed the interventions to prevent falls included a chair alarm, a sensor alarm to the bed, and staff should encourage the resident to obtain balance prior to transfers or locomotion. Review of the Nursing Assessment and Fall Investigation for Resident #2 revealed the resident sustained [REDACTED]. Further review of the assessment revealed Resident #2 lost (his/her) balance and fell back on the toilet. Review of the fall investigation revealed the new interventions that were implemented for prevention of further falls included staff reminded to encourage/remind resident to get balance prior to ambulating with assistance and two (2) staff members should provide assistance when ambulating utilizing a gait belt and a walker. However, the facility failed to identify that two staff members were not assisting the resident at the time of the resident's fall in accordance with Resident #2's CNA Assignment Sheet. Interview on [DATE] at 1:52 PM with the Activity Assistant (who also works as a SRNA) revealed on [DATE] she was the SRNA assigned to provide care to Resident #2 at the time of the resident's fall. The interview further revealed she had assisted Resident #2 to the restroom by herself and was attempting to help the resident back to the bed without the assistance of another staff member. The Activity Assistant stated Resident #2 lost his/her balance and fell back onto the toilet. The interview revealed the Activity Assistant was not aware whether Resident #2 required one (1) or two (2) staff members to assist the resident, but stated the information was available on the CNA Assignment Sheet. The Activity Assistant revealed she was not educated related to Resident #2 not having the appropriate amount of assistance at the time of the fall. Interview on [DATE] at 2:12 PM with LPN #6 revealed the LPN was working with Resident #2 on the day the resident fell in the bathroom. LPN #6 stated she did not remember identifying that Resident #2 did not have the assessed level of assistance at the time of the fall, or that the information would have been included in the nursing assessment after the fall. Continued interview revealed Resident #2 had good days and bad days and the amount of assistance the resident needed for transfers and toileting was determined by the type of day the resident was having. LPN #6 stated the SRNAs were supposed to always use the assistance a resident was assessed to need. Interview on [DATE] at 4:16 PM with the Unit Manager, RN #4, revealed she assisted with the investigation of Resident #2's fall and she did not recall identifying that the resident did not have the required assistance at the time of the fall on [DATE]. RN #4 stated that if she had identified that a SRNA had provided care to a resident without the appropriate assistance, she would have re-educated the SRNA about following the resident's care plan at all times. Further review of Resident #1's care plan revealed the facility updated the resident's care plan on [DATE] with an intervention to educate staff to remind/encourage the resident to balance himself/herself before transfers and locomotion. The facility also revised the resident's care plan on [DATE], with interventions for a bed and chair alarm. Review of another Nursing Assessment and Fall Investigation for Resident #2 revealed the resident sustained [REDACTED]. The facility transferred the resident to the emergency room for an evaluation where it was determined that the resident had a hip fracture. Further review of the investigation revealed the facility identified that the precipitating factors to the resident's fall included confusion, noncompliance with safety interventions, and failure to utilize the call light. Continued review of the investigation revealed all recommended safety interventions were in place at the time of the fall and the resident's chart and care plan were audited to reflect that sensor (bed alarm) and pull tab (chair alarm) orders were being assessed every shift to ensure proper placement and functioning. Review of Resident #2's Medication Administration Record (MAR) dated February 2017 revealed the resident's bed alarm was required to be checked for placement and function every shift. Further review of the MAR revealed the bed alarm had been checked on [DATE] twice (by day shift and night shift). Interview on [DATE] at 3:46 PM with SRNA #5 revealed she worked with Resident #2 on [DATE]. She stated she had assisted Resident #2 to bed, but prior to leaving for the evening she heard the resident's bed alarm sounding. When she checked the resident, the resident was attempting to get out of bed. SRNA #5 stated she assisted Resident #2 to the restroom, then assisted the resident to a wheelchair and left the resident at the nurses' station. SRNA #5 denied there were any problems with Resident #1's alarm. Interview on [DATE] at 4:40 PM with SRNA #14 revealed she was working on [DATE] when Resident #2 had a fall and fractured his/her hip. She stated when she came on shift, Resident #2 was up in his/her wheelchair at the nurses' station, yelling that he/she wanted to go to bed. SRNA #14 stated she assisted Resident #2 to bed and made sure the alarm was attached. Continued interview revealed a couple of hours later, SRNA #14 heard a big thud and went to Resident #2's room where the resident was found on the floor. SRNA #14 further stated Resident #2's alarm did not sound at the time of the fall and when she checked the alarm, she identified a plastic piece was broken off where the alarm pad was attached to the alarm box and the alarm was not functioning. The interview further revealed Resident #2 was transferred to the hospital. Interview on [DATE] at 9:05 PM with SRNA #8 revealed she was working with Resident #2 on [DATE], when she heard a thump from the nurses' station. She stated she went to the resident's room and found the resident on the floor. SRNA #8 stated Resident#2's alarm did not sound at the time of the fall. When staff checked the alarm, they identified the alarm pad was plugged into the box, but it was not secure because the plastic piece around the plug was broken. Interview on [DATE] at 3:12 PM with LPN #1 revealed she was standing in the hall at the medication cart and heard Resident #2 yell help me. When she looked up, she saw the resident fall and heard a loud thump. The interview further revealed LPN #1 immediately went to assess Resident #2 and he/she was complaining of hip pain. The LPN immediately called the resident's family, the doctor, and the ambulance service and transferred the resident to the hospital for an evaluation. Continued interview revealed Resident #2's bed alarm did not sound at the time of the fall. LPN #1 stated when she checked the alarm, the plastic piece that connected the pad to the alarm box was broken. She stated she did not recall if she had included the information about the alarm not sounding and being broken on the assessment. LPN #1 stated she remembered reporting this to the resident's family and to the Unit Manager, RN #4. Interview on [DATE] at 4:16 PM with the Unit Manager, RN #4, revealed she was not working at the time of Resident #2's fall; however, she assisted with the investigation of the fall. RN #4 stated she did report that the resident's alarm did not sound at the time of the fall during the daily morning clinical meeting. The interview further revealed RN #4 looked at Resident #2's alarm the morning after the fall and the alarm had already been replaced with a new one. Continued interview revealed if a resident's alarm was broken or did not sound at the time of a fall, the information should be included in the fall assessment and investigation. Interview on [DATE] at 12:21 PM with the DON revealed she was informed that when Resident #2 fell on [DATE], the resident lost his/her balance. The DON stated at that time, the intervention that they added about educating staff to remind the resident to obtain his/her balance seemed like an appropriate intervention. The DON stated she did not think the facility had identified that Resident #2 only had one (1) staff member assisting him/her at the time of the fall and if they had, at the very least, the staff member would have been educated to use the proper amount of assistance at all times. The DON stated she could not remember if the facility identified Resident #2's alarm was not functioning at the time of the fall on [DATE]. When the DON reviewed the fall investigation, she stated she felt like the facility had identified that the alarm was not functioning, even though the investigation stated that all recommended safety devices were in place and there was no mention that the alarm did not sound. Interview on [DATE] at 1:56 PM with the Administrator revealed he was unsure of the specifics about Resident #2's fall on [DATE]; however, all SRNAs were supposed to carry the CNA Assignment Sheet with them at all times, should be aware of the assistance each resident required, and should provide that level of assistance. The Administrator stated he was in the morning meeting on [DATE] (the day after Resident #2's fall) when the resident's daughter pu(TRUNCATED)

Based on interview, record review, review of facility policies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of a list of residents who had fallen in the past thirty (30) days ([DATE] through [DATE]) revealed there were thirty-seven (37) resident falls in the facility in the thirty (30) day timeframe. Review of fall investigations revealed the facility failed to thoroughly investigate falls for three (3) of five (5) sampled residents. Resident #1 sustained a fall in the facility on [DATE], but staff did not document the fall and a fall investigation was not initiated until [DATE], after the resident had complaints of pain for three (3) days and was diagnosed with [REDACTED]. Resident #1 had surgical repair of the hip, but expired at the facility on [DATE], after returning from the hospital under Hospice care. Resident #2 sustained falls on [DATE] and [DATE]. On [DATE], staff failed to provide the assessed level of assistance with ambulation and the resident fell . On [DATE], the resident's bed alarm was broken and did not sound to alert staff when the resident attempted to get up unassisted. The resident got up unassisted and fell , sustaining a [MEDICAL CONDITION]. The facility conducted investigations of both falls, but failed to identify the failures. Resident #5 sustained two falls ([DATE] and [DATE]) when staff failed to provide the assessed level of assistance/follow the resident's care plan. On [DATE], Resident #5 fell from a wheelchair and hit his/her head on the bathroom door. The resident sustained [REDACTED]. Staff was not aware the resident required a chair alarm to alert staff when the resident attempted to get up unassisted. The alarm was not in place when the resident fell on [DATE]; however, the facility investigated the fall and failed to identify that the resident's chair alarm was not in place at the time of the fall. Resident #5 expired at the facility on [DATE]. According to Resident #5's health care provider, the resident's falls could have contributed to the resident's death. The facility's failure to ensure the facility was administered effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's Job Description updated [DATE] revealed the Administrator's responsibilities were to lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Review of the facility policy titled Accidents and Incidents- Investigating and Report, revealed accidents or incidents involving residents would be investigated and reported to the Administrator. Resident #1 sustained a fall on [DATE], and the facility failed to document or report the fall to the resident's physician, and failed to assess the resident for injuries after the fall. Four (4) days later, on [DATE], after the resident had complaints of pain since [DATE], a bilateral x-ray of the resident's hips revealed a [MEDICAL CONDITION] hip. The resident was transferred to the hospital where he/she had surgery to repair the fracture. Resident #1 returned to the facility on [DATE] under the care of Hospice. Resident #1 expired at the facility on [DATE]. According to the resident's physician, the resident declined after the fall. The facility assessed Resident #2 to require the assistance of two (2) staff members and a bed alarm. However, on [DATE], Resident #2 sustained a fall while ambulating from the bathroom back to the chair while only being assisted by one (1) staff member. During the investigation of the resident's fall, the facility failed to identify that the resident was not receiving the assessed amount of assistance when the fall occurred. Resident #2 sustained another fall on [DATE], which resulted in a hip injury. The resident's bed alarm did not sound at the time of his/her fall because the alarm was broken. However, during the facility's investigation, they did not identify that the resident's bed alarm was broken at the time of the fall. Resident #5 sustained a fall on [DATE] while one (1) staff member provided incontinence care to the resident while the resident was standing in the shower room. However, the facility had assessed the resident to require the assistance of two (2) staff members for transfers and toileting. During the investigation, the facility failed to identify that the resident did not receive the assessed amount of assistance when the fall occurred. Resident #5 sustained another fall on [DATE], when the resident fell from a wheelchair and hit his/her head on the bathroom door, which resulted in an abrasion and hematoma to the right side of the resident's forehead. The resident's chair alarm did not sound at the time of the fall because the chair alarm was not on the resident's wheelchair. Staff was not aware the resident required a chair alarm. The facility's investigation did not identify that the resident's chair alarm was not in place at the time of the fall. Resident #5 expired at the facility on [DATE]. According to Resident #5's health care provider, the resident's falls could have contributed to the resident's death. An interview with the Administrator on [DATE] at 1:56 PM revealed falls were discussed in the daily morning clinical meeting; however, he did not always attend the meeting. Even though the facility's policy states falls would be investigated and reported to the Administrator, the Administrator stated he was not notified about every fall investigation. He stated the Director of Nursing (DON) was in charge of ensuring falls were investigated thoroughly and at times would mention concerns to him that were identified related to falls. The Administrator stated results of the morning meetings were discussed in QA monthly, which the Administrator attended; however, there was no evidence the facility had identified falls were not being investigated thoroughly. Review of the Event Report dated [DATE] revealed from [DATE] through [DATE] facility residents sustained thirty-seven (37) falls. Although the Administrator stated in interview on [DATE] at 1:56 PM that the facility had identified the increased number of falls, he could provide no evidence that the facility had implemented corrective action to prevent further falls. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders, to include residents who experience a fall. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures so they could train direct care staff. The interviews further revealed the administrative staff had to complete a post-test. 4) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated facility administrative staff on completion of fall investigations and determining the root cause of a fall. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on completing fall investigations and determining the root cause of falls and had to pass a post-test after the training with a score of 100%. 5) Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed after the administrative staff were trained they were assigned shifts and groups of direct care staff to educate about the policies and procedures. 6) Review of facility documentation, beginning on [DATE], revealed facility direct care staff were trained and had to pass a post-test by administrative staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were trained on the following areas: care plan policy and procedures which included following the care plan and care cards and ensuring all resident interventions were in place; accident and incident policy and procedures including reporting all falls, ensuring the fall nursing assessment and investigation were thorough, and gathering information to attempt to determine the root cause of falls; change in condition policy and procedures which included reporting all changes in the resident's condition and Stop and Watch forms; pain policy and procedures which included assessing appropriately for pain and notification to the physician of pain; and the QAPI policy and procedures which included reporting problems to administrative staff. 7) Review of facility documentation revealed after direct care staff were provided education the staff had to complete a post-test. Further review of tests revealed all staff passed with a 100% score. Review of the documentation revealed any staff that had not work and had not been trained were notified by letter that they would not be permitted to work until the education and post-test were completed. Interview on [DATE] at 1:00 PM with the Administrator revealed no staff member had been permitted to work without receiving education prior to the beginning(TRUNCATED)

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective Quality Assurance program that developed and implemented appropriate plans of action to correct identified quality deficiencies. Review of a list the facility provided of residents who had fallen from [DATE] to [DATE] revealed there were thirty-seven (37) resident falls in the facility in the thirty (30) day timeframe. Review of five (5) residents who had fallen during that time period revealed the facility failed to report, document, and thoroughly investigate resident falls for three (3) of the residents (Residents #1, #2, and #5). Resident #1 sustained a [MEDICAL CONDITION] after a fall; however, the fall was not reported and investigated for five days. Resident #1 returned to the facility after hip surgery and expired at the facility on [DATE]. The resident's physician stated the resident's fall could have contributed to the resident's decline. Residents #2 and #5 sustained two (2) falls at the facility. The facility failed to identify during the fall investigation that the residents were not receiving the assessed level of supervision during one of the falls and failed to identify an alarm was not functioning/present to alert staff that the resident was attempting to get up unassisted during the second fall. Resident #5 expired at the facility on [DATE]. According to Resident #5's health care provider, the resident's falls could have contributed to the resident's death. The facility's failure to have an effective Quality Assurance program has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Falls, reviewed [DATE], revealed falls would be a standing agenda item for the Quality Assurance/Performance Improvement (QA/PI) Committee. The policy stated the Director of Nursing (DON) or designee was required to review tracking/trending of incidents of falls for the month at the monthly QA/PI meeting. The Committee was required to determine the course of action based on trends and review and revise actions as needed. Review of the facility's policy titled Accidents and Incidents- Investigating and Report, not dated, revealed accidents or incidents involving residents would be investigated and reported to the Administrator. Further review of the policy revealed the incident would be documented in the Event Manager (an electronic incident reporting system) and reported to the Administrator and/or Director of Nursing (DON). Continued review of the policy revealed the Nurse Supervisor or Charge Nurse was required to initiate and document the investigation of the accident or incident. Resident #1 sustained a fall on [DATE], and the facility failed to document or report the fall. Four (4) days later, on [DATE], after the resident had complaints of pain for three (3) days, a bilateral x-ray of the resident's hips revealed a [MEDICAL CONDITION] hip. Resident #2 sustained a fall on [DATE], while ambulating from the bathroom to bed while only being assisted by one (1) staff member. However, the facility had assessed the resident to require the assistance of two (2) staff members and a bed alarm. During the investigation, the facility failed to identify that the resident was not receiving the assessed amount of assistance when the fall occurred. Resident #2 sustained another fall on [DATE], which resulted in a hip injury. The resident's bed alarm did not sound at the time of the resident's fall because the alarm was broken. However, during the facility's investigation they did not identify that the resident's bed alarm was broken at the time of the fall. Resident #5 sustained a fall on [DATE] in the shower room while being assisted by only one (1) staff member. The facility had assessed the resident to need the assistance of two (2) staff members for personal hygiene and bathing. The fall investigation failed to identify that the resident was not assisted by two (2) staff members as the facility had assessed him/her to require. The resident sustained [REDACTED]. The resident's care plan required the resident to have a chair alarm to alert staff that the resident was attempting to get up unassisted. The resident did not have a chair alarm in place at the time of the fall and the staff was not aware the resident was supposed to have an alarm in place until after the fall occurred. During the fall assessment, the facility did not identify that the resident did not have the chair alarm in place at the time of the fall. Interview with the Director of Nursing (DON) on [DATE] at 12:21 PM and on [DATE] at 2:03 PM revealed the facility had identified through the recent falls that there was a problem with falls; however, there was no evidence the facility had implemented corrective action for the failures identified with Residents #1, #2, and #5's falls. The DON stated falls were discussed in daily morning meetings and the Unit Managers investigated the fall. The DON further stated she did not always review or obtain further information related to falls such as interviews with staff, resident care plans, or assessments to attempt to determine the root cause of the falls or to ensure the investigation was thorough. An interview with the Administrator on [DATE] at 1:56 PM revealed falls were discussed in the daily morning clinical meeting; however, he did not always attend the meeting. He stated the DON was in charge of ensuring falls were investigated thoroughly and would mention concerns to him at times that were identified related to falls. Results of the morning meetings were discussed in QA monthly, which the Administrator attended. However, there was no evidence the facility had identified that falls were not being investigated thoroughly. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders, to include residents who experience a fall. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures so they could train direct care staff. The interviews further revealed the administrative staff had to complete a post-test. 4) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated facility administrative staff on completion of fall investigations and determining the root cause of a fall. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on completing fall investigations and determining the root cause of falls and had to pass a post-test after the training with a score of 100%. 5) Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed after the administrative staff were trained they were assigned shifts and groups of direct care staff to educate about the policies and procedures. 6) Review of facility documentation, beginning on [DATE], revealed facility direct care staff were trained and had to pass a post-test by administrative staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were trained on the following areas: care plan policy and procedures which included following the care plan and care cards and ensuring all resident interventions were in place; accident and incident policy and procedures including reporting all falls, ensuring the fall nursing assessment and investigation were thorough, and gathering information to attempt to determine the root cause of falls; change in condition policy and procedures which included reporting all changes in the resident's condition and Stop and Watch forms; pain policy and procedures which included assessing appropriately for pain and notification to the physician of pain; and the QAPI policy and procedures which included reporting problems to administrative staff. 7) Review of facility documentation revealed after direct care staff were provided education the staff had to complete a post-test. Further review of tests revealed all staff passed with a 100% score. Review of the documentation revealed any staff that had not work and had not been trained were notified by letter that they would not be permitted to work until the education and post-test were completed. Interview on [DATE] at 1:00 PM with the Administrator revealed no staff member had been permitted to work without receiving education prior to the beginning of the staffs shift. 8) Review of facility documentation revealed post-tests were administered to direct care staff to ensure they retained the information received during the staff training. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were given a test or questioned daily by administrative staff to ensure they were knowledgeable about the facilities policies and procedures. 9) Record review revealed Resident #5 expired in the facility on

Based on interview, record review, and review of the facility's policy it was determined the facility failed to use the results of the assessment to develop the residents' comprehensive plans of care for three (3) of five (5) sampled residents (Residents #3, #4, and #5). Review of the Minimum Data Set (MDS) Assessments for Residents #3, #4, and #5 revealed the residents were assessed using the MDS for the level of assistance required to be provided by staff. However, review of the Comprehensive Care Plans for the residents revealed the information obtained from the assessments was not included on the residents' plans of care to guide the staff on the assistance each resident required. Residents #3, #4, and #5 sustained falls when the facility failed to ensure staff provided the assessed amount of assistance required. The facility's failure to ensure care plans were developed to prevent resident falls has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plans- Comprehensive, not dated, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Further review of the policy revealed the comprehensive care plan was based on a thorough assessment that included the Resident Assessment Instrument. Continued review of the policy revealed each resident's care plan was designed to aid in preventing and reducing declines in the resident's functional status and/or functional levels. 1. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the 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 nine (9), indicating the resident had moderate cognitive impairment and was interviewable. Further review revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers, hygiene, and toileting, and total assistance of two (2) staff members with bathing. Review of the Comprehensive Care Plan for Activities of Daily Living (ADL) self-care deficit dated [DATE] revealed the facility failed to address how much assistance the resident required for ADL care. Review of care plan interventions revealed the facility developed a care plan for Resident #5 that stated, Staff to provide only the amount of assistance/supervision to meet the resident's needs for all ADLs. Staff to assist with transfers as needed. Staff to assist with ambulation and/or locomotion as needed. Interview with the Director of Nursing (DON) on [DATE] at 4:00 PM revealed the facility could not retrieve Resident #5's Certified Nursing Assistant (CNA) Assignment Sheet from the computer because the resident was no longer a resident of the facility. Review of a Nursing Assessment for Resident #5 revealed the resident sustained [REDACTED]. State Registered Nursing Assistant (SRNA) #5 was attempting to put a brief on Resident #5 while he/she was standing in the shower room, and the resident's legs became weak and she had to assist the resident to the floor. The resident did not sustain an injury; however, the resident was not provided the assistance of two (2) staff members that he/she was assessed to require during hygiene and toileting. Interview with SRNA #5 on [DATE] at 4:50 PM revealed that she was assisting Resident #5 with putting on an incontinence brief when the resident stated that his/her legs were becoming weak. She stated she assisted the resident to the floor and pulled the emergency call light. Further interview revealed she knew the resident was assessed to require the assistance of two (2) staff members; however, she stated the nurse that was assisting her had to check on another resident whose fall alarm was sounding. She further stated that there was not enough staff to provide residents with the assistance they required for their care. Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 10:18 AM revealed she was the nurse that worked with SRNA #5 and Resident #5 on [DATE]. She stated she had left the shower room because there was a fall alarm sounding for another resident. LPN #6 stated while she was gone, she heard the emergency call light sounding in the shower room, and when she went in, she saw Resident #5 on the floor. She stated she assessed the resident and he/she did not have any injuries; then she and SRNA #5 assisted the resident off the floor and into a chair. She stated she was aware that Resident #5 needed the assistance of two (2) staff members for transfers; however, she stated it was manageable to care for Resident #5 with one (1) person. 2. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of seven (7), which indicated severe cognitive impairment, and the resident was not interviewable. Further review of the MDS revealed the facility assessed the resident to require the extensive assistance of two (2) staff members for transfers, hygiene, and toileting. Review of the Comprehensive Care Plan for ADL self-care deficit dated [DATE], revealed the facility failed to address the amount of assistance Resident #3 required with ADL care. Review of care plan interventions revealed Staff to provide only the amount of assistance/supervision to meet the resident's needs for all ADLs. Staff to assist with ambulation and/or locomotion as needed. Review of the CNA Assignment Sheet, not dated, revealed guidance to use one (1) person for assistance with transfers, mobility, and toileting. Interview with SRNA #16 on [DATE] at 3:01 PM revealed the resident won't do anything if there was only one person assisting the resident. Interview with SRNA #10 on [DATE] at 2:08 PM, revealed the resident required two (2) staff members to assist with ADLs because the resident could not participate enough for only one staff member. However, interview with SRNA #3 on [DATE] at 3:52 PM revealed she assisted the resident by herself and the resident did not require two (2) staff members to assist the resident with ADLs. Interview with LPN #7 on [DATE] at 3:02 PM revealed Resident #3 required the assistance of two (2) staff members for ADLs but had not had any falls related to staff failure to assist the resident. LPN #7 stated information related to resident care was on the comprehensive care plan and nurses were expected to look at care plans at the beginning of each shift; however, she did not always have a chance to review care plans because she did not have enough time. 3. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment and that he/she was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require the assistance of two (2) staff members for transferring and hygiene and one (1) staff member for toileting, bathing, and ambulation. Review of the Comprehensive Care Plan for self-care deficit dated [DATE] revealed the facility failed to address how much assistance Resident #4 required to perform ADLs. The resident's care plan stated, I need assistance with all daily care. Assist me with toileting and perineal care as needed. Review of the CNA assignment sheet revealed the facility failed to address how much assistance the resident required with transfers, mobility, and toileting. Interview with SRNA #16 on [DATE] at 3:01 PM revealed Resident #4 required one staff person to assist with transfers. However, interview with SRNA #10 on [DATE] at 2:08 PM revealed the resident required two (2) staff members to assist with transfers. According to SRNA #3 on [DATE] at 3:52 PM, Resident #4 required one staff member's assistance on a good day and required the assistance of two staff members on a bad day. Interview with LPN #12 on [DATE] at 3:25 PM revealed she was aware that Resident #4 required the assistance of two (2) staff members for most of his/her care. She stated she gets resident information from the comprehensive care plan and tried to review the care plan if there was a change in the resident's condition. She further stated she did not always look at the care plan at the beginning of shift because she did not have the time. Interview on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM and MDS Coordinator #2 at 5:15 PM revealed the comprehensive care plan was formulated based on the comprehensive assessment and information obtained about ADLs, along with staff and therapy staff interviews. The interviews further revealed they did not put the specific amount of assistance required by a resident for ADLs on the resident's care plan. They stated the amount of assistance required by a resident could change daily and the MDS Coordinators did not have time to review and update each resident's comprehensive care plan daily. Interview on [DATE] at 12:21 PM with the Director of Nursing (DON) revealed residents' comprehensive care plans were formulated, reviewed, and revised by the MDS Coordinators using information obtained from the comprehensive assessment, staff and therapy interviews, and ADL information that was documented by SRNAs. The interview further revealed the amount of assistance needed by a resident could change daily so the comprehensive care plan ADL information was very general but the information on the CNA Care Card (CNA care plan) was more specific to guide the nursing assistants with the resident's care. Interview on [DATE] at 1:56 PM with the Administrator revealed the MDS Coordinators developed the care plans based on the resident's assessment, information from the Kiosk about assistance required for ADLs, and interviews with staff about the assistance a resident required. The Administrator stated the CNA Care Card further guides the care provided to the residents. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders [REDACTED]. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM reveale(TRUNCATED)

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined the facility failed to ensure the plan of care was revised after a resident sustained [REDACTED].#1). On [DATE], Resident #1 sustained a fall with injury; however, the facility failed to document or report the fall to the physician or administrative staff. Resident #1 began complaining of hip pain on [DATE] and was found to have a [MEDICAL CONDITION] related to the fall on [DATE]. Resident #1 was transferred to the hospital for treatment on [DATE] and returned to the facility on [DATE]. However, there was no evidence the facility revised Resident #1's care plan with interventions regarding the resident's fall or [MEDICAL CONDITION]. Resident #1 expired at the facility on [DATE] after being readmitted to the facility under the care of Hospice. The facility's failure to ensure care plans were revised after resident falls has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plans- Comprehensive, not dated, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Continued review of the policy revealed each resident's care plan was designed to aid in preventing and reducing declines in the resident's functional status and/or functional levels. The policy revealed care plans were revised as information about the resident and the resident's condition changed and the Nurse/Interdisciplinary Team was responsible for reviewing and updating care plans. The policy stated the care plan should reflect the current status of the resident and would be updated with changes in the resident's condition. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Review of Resident #1's care plan revealed the resident was at risk for falls related to injury due to a balance deficit, weakness, and a history of falls. The care plan was last updated on [DATE]. Further review revealed no documented evidence of a fall after [DATE]. Review of the facility's investigation, dated [DATE] and finalized on [DATE], revealed the facility received x-ray results for Resident #1 on [DATE], which revealed the resident had a [MEDICAL CONDITION] (x-rays revealed the fracture was on the right side) femoral head. The facility initiated an investigation due to the injury of unknown source. However, the facility identified through the investigation that Resident #1 had sustained a fall on [DATE] that was not documented or reported. Review of a Nursing Assessment and Fall Investigation for Resident #1 revealed the resident had a fall on [DATE] at 11:15 AM in the dining room. The assessment revealed the resident was found in front of a wheelchair on his/her knees and an injury was not suspected at the time of the fall. Further review of Resident #1's care plan revealed no documented evidence the facility revised the resident's care plan related to the [DATE] fall or [MEDICAL CONDITION]. Interview with the Administrator on [DATE] at 2:20 PM revealed Resident #1 expired at the facility on [DATE]. Interview with Minimum Data Set (MDS) Coordinator #1 on [DATE] at 4:57 PM, and with MDS Coordinator #2 on [DATE] at 5:15 PM, revealed staff usually reviewed resident falls the day after a fall occurred in the Morning Clinical Meeting and updated the care plan at that time. They stated they discussed how Resident #1 may have sustained a [MEDICAL CONDITION] during a morning meeting, but they did not revise the resident's care plan once they identified that the resident had fallen. Interview on [DATE] at 12:21 PM with the Director of Nursing (DON) revealed all resident falls were discussed each morning during a clinical meeting and they revised the care plans if needed. The interview further revealed they had talked about Resident #1's fall that occurred on [DATE] at the meeting on [DATE]; however, the focus had been on the investigation and determining what happened to the resident. Continued interview with the DON revealed she was not aware Resident #1's care plan had not been updated and interventions were not implemented related to the fall and fracture. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders [REDACTED]. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures so they could train direct care staff. The interviews further revealed the administrative staff had to complete a post-test. 4) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated facility administrative staff on completion of fall investigations and determining the root cause of a fall. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on completing fall investigations and determining the root cause of falls and had to pass a post-test after the training with a score of 100%. 5) Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed after the administrative staff were trained they were assigned shifts and groups of direct care staff to educate about the policies and procedures. 6) Review of facility documentation, beginning on [DATE], revealed facility direct care staff were trained and had to pass a post-test by administrative staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were trained on the following areas: care plan policy and procedures which included following the care plan and care cards and ensuring all resident interventions were in place; accident and incident policy and procedures including reporting all falls, ensuring the fall nursing assessment and investigation were thorough, and gathering information to attempt to determine the root cause of falls; change in condition policy and procedures which included reporting all changes in the resident's condition and Stop and Watch forms; pain policy and procedures which included assessing appropriately for pain and notification to the physician of pain; and the QAPI policy and procedures which included reporting problems to administrative staff. 7) Review of facility documentation revealed after direct care staff were provided education the staff had to complete a post-test. Further review of tests revealed all staff passed with a 100% score. Review of the documentation revealed any staff that had not work and had not been trained were notified by letter that they would not be permitted to work until the education and post-test were completed. Interview on [DATE] at 1:00 PM with the Administrator revealed no staff member had been permitted to work without receiving education prior to the beginning of the staffs shift. 8) Review of facility documentation revealed post-tests were administered to direct care staff to ensure they retained the information received during the staff training. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were given a test or questioned daily by administrative staff to ensure they were knowledgeable about the facilities policies and procedures. 9) Record review revealed Resident #5 expired in the facility on [DATE]. 10) Review of Resident #1's medical record revealed the facility reviewed and revised the fall investigation related to the fall on [DATE], re-assessed the resident for pain, re-assessed the resident's fall risk assessment, updated and ensured the resident's care plan and SRNA care plan met the resident's needs and facility staff ensured the physician and responsible party were aware of the findings of the evaluations and assessments. Review of Resident #2's medical record revealed the facility reviewed and revised the fall investigation related to the falls on [DATE] and on [DATE], re-assessed the resident for pain, re-assessed the resident's fall risk assessment, updated and ensured the resident's care plan and SRNA care plan met the resident's needs and facility staff ensured the physician and responsible party were aware of the findings of the evaluations and assessments. Interview on [DATE] at 2:03 PM with the DON revealed the fall investigations for Resident #1 and #2 were reviewed and the residents were assessed for pain, fall risk, to ensure staffing levels(TRUNCATED)

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for three (3) of five (5) sampled residents (Residents #1, #2, and #5). The facility assessed and care planned Resident #1 to be at risk for pain. Staff was required to report changes in the resident's pain location and type and monitor the resident for the effectiveness of medication. However, on [DATE] Resident #1 started experiencing pain that the State Registered Nurse Aides (SRNAs) stated was not normal for the resident. The SRNAs stated the resident was yelling out, My hip's broke! and appeared to be in pain each time staff provided care for the resident. The SRNAs reported the resident's pain to nursing staff. However, nursing staff failed to report the changes to the resident's physician as required by the care plan. Resident #1 continued to have pain and on [DATE] (two days later) the facility ordered hip x-rays which revealed the resident had a [MEDICAL CONDITION]. The resident was transferred to the hospital and was under Hospice care upon readmission to the facility. Resident #1 expired at the facility on [DATE]. The facility assessed Resident #2 to require the assistance of two (2) staff members for transfers and toileting and developed a care plan that stated the resident required two (2) staff members to assist with mobility and transfers. Resident #2 sustained a fall on [DATE] while ambulating with assistance of one (1) staff member from the bathroom to the resident's chair. Staff interviews revealed the staff was aware Resident #2 was assessed to require assistance of two (2). However, the staff stated they did not always utilize two (2) staff members when assisting the resident as required by the resident's care plan. The facility updated Resident #5's care plan on [DATE] with an intervention for a bed and chair alarm. Resident #5 sustained a fall on [DATE] when the resident fell from a wheelchair in his/her room. The resident hit his/her head on the bathroom door causing an abrasion and hematoma to the right side of his/her forehead. Interviews with staff members that were present when the resident fell revealed a chair alarm was not being utilized prior to the resident's fall to alert staff when the resident was attempting to get up unassisted. Staff members stated they were not aware the resident's care plan required the resident to have a chair alarm. Resident #5 expired at the facility on [DATE], two (2) days after the fall. The facility's failure to ensure care plans were implemented to prevent resident falls has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plans- Comprehensive, not dated, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Further review of the policy revealed the comprehensive care plan was based on a thorough assessment that includes the Resident Assessment Instrument (RAI). Continued review of the policy revealed each resident's care plan was designed to aid in preventing and reducing declines in the resident's functional status and/or functional levels. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Review of Resident #1's care plan, last reviewed on [DATE], revealed the facility identified the resident was at risk for pain related to hip pain and decreased mobility. The facility developed care plan interventions that required staff to report changes in the resident's pain location and type, administer medications as ordered, and monitor for effectiveness of medication. Review of Resident #1's Situation, Background, Assessment, and Response (SBAR) Communication Form dated [DATE], no time documented, revealed the facility assessed the resident to have bilateral hip pain which started on [DATE] (the first documented date that the resident had pain was [DATE]). The resident's pain was new, continuous, and rated a nine (9) on a scale of one to ten (,[DATE]), with ten (10) being the worst pain. The Form stated Resident #1 had facial grimacing and the pain had worsened. The resident was in bed with both of his/her legs drawn up, and the writer was unable to evaluate abduction or adduction. Further review of the Form revealed upon palpation the resident had facial grimacing and guarding. Review of the Form revealed initially Resident #1's Physician was unable to be reached; however, at an unknown time the physician was in the facility and gave an order for [REDACTED].>Review of Resident #1's bilateral hip x-ray results dated [DATE] revealed the resident had an impacted right femoral neck fracture ([MEDICAL CONDITION]). Interview on [DATE] with State Registered Nurse Aide (SRNA) #1 at 1:45 PM and SRNA #9 at [DATE] at 12:16 PM revealed Resident #1 was not acting like his/her normal self on [DATE] and [DATE]. The SRNAs stated when they attempted to get Resident #1 up for his/her shower on the morning of [DATE], the resident yelled out, My hip's broke, and appeared to be in pain each time they attempted to move the resident's legs to the side of the bed. SRNA #9 stated she informed Registered Nurse (RN) #1 that Resident #1 was in pain and had told them that his/her hip was broken. However, RN #1 did not assess the resident or give the SRNAs guidance. The SRNAs got Resident #1 up to a wheelchair to take the resident to the shower room and informed RN #1 again of Resident #1's complaints of pain. The RN instructed them to take the resident to the shower room and the RN stated she would assess the resident in the shower room. However, the RN did not assess the resident. Further interview with the SRNAs revealed Resident #1 yelled out and appeared to be in pain when the SRNAs washed the resident's legs and private area. SRNA #9 stated she requested RN #1 to come to the shower room and assess the resident because the resident continued to complain of pain but RN #1 never came to assess the resident. SRNA #1 and SRNA #9 stated they completed a Stop and Watch Form because the RN did not assess the resident's pain. The interview further revealed the DON and RN #1 came to assess Resident #1 and they determined the resident's pain was from injections the resident was receiving. SRNA #1 stated she also worked with Resident #1 the next day, [DATE], and the resident continued to yell out in pain and appeared to be in pain when providing incontinence care. SRNA #1 stated RN #1 was Resident #1's Nurse again that day and the SRNA reported that the resident continued to appear to be in pain; however, the RN appeared to be aggravated with the SRNA when she made the reports. On [DATE] at 2:32 PM an interview with SRNA #2 revealed she worked with Resident #1 on [DATE] and the resident stayed in bed the entire day. SRNA #2 stated the resident appeared to be in pain and would say ouch or no, no, no when staff attempted to care for the resident. SRNA #2 stated the resident's complaints of pain were not normal for the resident and she reported the resident's pain to RN #1. However, RN #1 told the SRNA that she was aware of the resident's pain and it was caused by injections, and that other staff had filled out a Stop and Watch on the resident. Interview with RN #1 on [DATE] at 1:38 PM and [DATE] at 3:17 PM revealed she was not familiar with Resident #1's care and [DATE] was the first day she had worked with the resident. The interview revealed that the SRNAs that were caring for Resident #1 on [DATE] reported that the resident was complaining of hip pain and appeared to be in pain when they were bringing the resident out of the shower room. Continued interview revealed RN #1 looked at the resident while he/she was in a wheelchair and the resident appeared to be fine. RN #1 instructed the SRNAs to take Resident #1 to lunch and she would assess the resident when the SRNAs put the resident back to bed. However, the SRNAs completed a Stop and Watch related to Resident #1's pain and the DON came to assess the resident. RN #1 stated that she and the DON assessed the resident and determined the resident's pain was from arthritis and from [MEDICATION NAME] (antibiotic) injections. RN #1 stated she did not contact Resident #1's physician related to the pain because the cause of the pain had been determined and the resident was receiving Tylenol (a non-narcotic pain reliever) three (3) times per day. Further interview with RN #1 revealed that on [DATE], SRNA #10 reported that Resident #1 had a fall the previous weekend. The SRNA and the RN immediately went to the DON and reported the possible fall. RN #1 stated the DON said she would immediately initiate an investigation and would notify the physician of Resident #1's suspected fall and the resident's complaints of pain. However, there was no documented evidence the resident's pain was reported as required by the resident's care plan. On [DATE] at 1:07 PM, an interview with Licensed Practical Nurse (LPN) #5 revealed the LPN worked with Resident #1 the night of [DATE]. LPN #5 stated the resident stayed in the fetal position, refused to let staff straighten out his/her legs, and at times would scream out in pain. The LPN stated she attempted to contact the resident's physician. She stated she was unable to reach the physician and contacted the DON on the morning of [DATE]. LPN #5 stated the DON informed the LPN that she had reached the physician and had obtained an order for [REDACTED].>On [DATE] at 12:01 PM, Physician #2 stated staff did not notify him about Resident #1's complaints of pain until after the facility obtained hip x-rays and had the results that revealed the resident had a fracture, which was on the evening of [DATE] (two days after it was documented that the resident was having pain). The Physician further stated he expected the facility to notify him if a resident was experiencing new or unrelieved pain. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed the resident was assessed to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Review of the comprehensive care plan for Activities of Daily Living (ADL) self-care deficit, initiated [DATE] and reviewed [DATE], revealed the facility developed a care plan for Resident #2 that stated, Nursing staff to provide all ADL care to ensure daily needs are met. Review of the Certified Nursing Assistant (CNA) Assignment Sheet, not dated, revealed Resident #2 required assistance of two (2) staff members for mobility and transfers. Review of a Nursing assessment dated [DATE] at 9:30 AM revealed Resident #2 sustained a fall while ambulating with assistance of one (1) staff member from the bathroom to the resident's chair. Further review of the assessment revealed Resident #2 lost his/her balance and fell back on the toilet. Interview on [DATE] at 1:52 PM with the Activity Assistant (who also works as a SRNA) revealed on [DATE] she was the SRNA assigned to provide care to Resident #2 at the time of the resident's fall. The interview further revealed she had assisted Resident #2 to the restroom and was attempting to help the resident back to the bed without the assistance of another staff member. The interview revealed the Activity Assistant was not aware whether Resident #2 required one (1) or two (2) staff members to assist. Interviews on [DATE] with SRNA #5 at 3:46 PM and SRNA #8 at 9:05 PM, and on [DATE] with SRNA #10 at 1:39 PM, with the Activity Assistant (also works as a SRNA when needed) at 1:52 PM, SRNA #11 at 2:01 PM, and SRNA #14 at 4:40 PM revealed the staff members were aware Resident #2 was supposed to be a two (2) person assist for transfers and toileting; however, at times the staff would transfer the resident with only one (1) person to assist. The interviews further revealed at times Resident #1 was fine with only one person assisting him/her. The staff stated sometimes there was no other staff available to help transfer the resident and the staff had to assist the resident by themselves. Continued interviews revealed the staff would never transfer Resident #2 with only one (1) person to assist if they felt it was unsafe. Interview on [DATE] at 3:12 PM with Licensed Practical Nurse (LPN) #1, and [DATE] at 2:12 PM with LPN #6, revealed Resident #2 was assessed to require the assistance of two (2) staff members but at times if the resident was having a good day, he/she could be assisted by one (1) staff member. The interviews further revealed the LPNs were aware staff transferred and toileted the resident with only one (1) staff member assisting the resident, even though the resident's care plan required two (2) staff members to assist the resident. 3. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the 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 nine (9), indicating the resident had moderate cognitive impairment and was interviewable. Further review of the MDS revealed the facility assessed that the resident had one (1) fall without injury during the look back period. Review of the Fall Risk Evaluation performed on [DATE] revealed the facility assessed the resident's score as twenty-six (26), indicating the resident was at high risk for falls. Review of the comprehensive care plan for falls dated [DATE] revealed the facility revised the care plan on [DATE] with an intervention for a bed and chair alarm. Interview with the DON on [DATE] at 4:00 PM revealed Resident #5's CNA Assignment Sheet was not available for review. She stated it could not be retrieved from the facility's computer because the resident was no longer a resident there. Review of a Nursing assessment dated [DATE] at 10:05 AM revealed the resident sustained [REDACTED]. The resident hit his/her head on the bathroom door sustaining an abrasion and hematoma to the right side of his/her forehead. According to the investigation, the root cause of the resident's fall was that the chair alarm did not activate because the cord to the alarm was too long. Interview with SRNA #11 on [DATE] at 11:00 AM revealed she had just taken Resident #5 to his/her room and was assisting another resident when she heard a thump. She stated the resident was lying on the floor on his/her right side between the wheelchair and bathroom door. SRNA #11 stated the resident had a hematoma on his/her forehead and some abrasions to his/her knees and hand. She stated she went to get the resident's nurse, who assessed the resident. SRNA #11 stated the resident did not have a chair alarm at the time of his/her fall on [DATE], and she was not aware of the resident ever having a chair alarm until after the resident's fall on [DATE]. SRNA #11 stated that fall interventions were listed on the Activities of Daily Living (ADL) care plan; however, she had not looked at the resident's ADL care plan at the beginning of her shift. She stated there was not enough time to review care plans because the facility had been short-staffed. Further interview revealed she looked at the resident's ADL care plan after the resident fell and the chair alarm was listed as an intervention. Interview with SRNA #15 on [DATE] at 11:15 AM revealed she and SRNA #11 were assisting another resident when they heard a thump in Resident #5's room. She stated they went into the resident's room and found the resident on the floor between the bathroom and the resident's wheelchair, lying on his/her right side. SRNA #15 stated the resident did not have a chair alarm in place prior to his/her fall. According to SRNA #15, she reviewed the ADL care plan at the beginning of each shift and a chair alarm was not listed on Resident #5's ADL care plan prior to the resident's fall. Interview with Licensed Practical Nurse #9 on [DATE] at 10:40 AM revealed she was called to Resident #5's room on [DATE] by SRNA #11. She stated she found the resident lying on his/her right side next to the bathroom door, and the resident's wheelchair was beside the resident. She stated the resident had an abrasion to his/her right cheek and forehead, a skin tear to his/her left hand, and abrasions to his/her bilateral knees. Further interview revealed the resident did not have a chair alarm in place at the time of his/her fall. LPN #9 stated she was not aware the resident was supposed to have a chair alarm until she reviewed the resident's care plan after the resident fell , at which time she put a chair alarm on Resident #5's chair. LPN #9 stated she should look at the care plan at the beginning of her shift, but she did not have time to look at every resident's care plan. Further interview with LPN #9 revealed that the SRNA was responsible for ensuring resident alarms were in place and functioning. She stated that nurses did not have to check functioning and placement of alarms. However, review of Resident #5's Medication Administration Record [REDACTED]. Interview on [DATE] at 12:21 PM with the Director of Nursing (DON) revealed it was unacceptable for staff not to provide the appropriate assistance to residents. The DON stated if a resident was assessed to be a two (2) person assist then two (2) staff members should be assisting the resident. Continued interview revealed the facility provided SRNAs with resident care cards (CNA Assignment Sheets) each morning that identified the amount of assistance each resident required. SRNAs were required to read the resident care cards at the beginning of each shift so each staff member was aware of the assistance a resident required. The DON revealed she had not identified issues with staff not assisting residents as required. Interview on [DATE] at 1:56 PM with the Administrator revealed staff should be aware at all times of the amount of assistance a resident requires. The facility provided SRNAs with resident care cards at the beginning of each shift which identified the assistance each resident required and the care plan interventions. The interview further revealed the SRNAs were required to read the care cards at the beginning of each shift and keep the cards with them at all times as a reference, if needed. The Administrator stated if a resident required the assistance of two (2) staff members then two (2) staff members should assist the resident. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or(TRUNCATED)

Based on interview, record review, review of a facility investigation, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided consistent with the comprehensive care plan for one (1) of five (5) sampled residents (Resident #1). On [DATE], State Registered Nurse Aides (SRNAs) reported to Registered Nurse (RN) #1 that Resident #1 was complaining of pain and appeared to be in pain. However, the RN had not assessed the resident a few hours after the SRNAs reported the resident's pain. The SRNAs also reported the resident's pain to the Director of Nursing (DON). The DON and RN #1 assessed Resident #1 and determined the resident's pain was due to receiving intramuscular (IM) injections and did not notify the resident's physician of the pain. Staff interviews revealed Resident #1 continued to complain of pain and appeared to be in pain on [DATE] and on [DATE]; however, the resident's pain was not assessed and reported to the resident's physician. The resident continued to complain of pain and exhibit symptoms of pain. An x-ray of the resident's hips was ordered and obtained on [DATE], two (2) days after the resident started complaining of pain. According to the x-ray report, Resident #1 had a fractured right hip. Resident #1 was transferred to the hospital and required surgical repair of his/her hip. The resident returned to the facility under the care of Hospice, and passed away at the facility on [DATE]. The facility's failure to ensure pain management was provided for facility residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Pain Management, not dated, revealed each resident identified with pain would have ongoing assessments, a monitoring system, and a specific plan of care to address the issues. Review of the facility's policy titled Change in Condition, reviewed [DATE], revealed the facility would assess and document changes in a resident's health in an effective and efficient manner to relay assessment information to the physician. The policy further stated if the resident's condition did not appear to be life threatening, the facility staff should utilize the Situation, Background, Assessment, and Response (SBAR) Communication Form and notify the physician. Continued review of the policy revealed the SBAR Communication Form would serve as the nursing documentation for changes in condition. Review of the policy revealed conditions identified that would indicate a change in condition, utilization of the SBAR, and notification of the physician, would include pain. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident and determined the resident was cognitively impaired and unable to be interviewed. Further review of the assessment revealed the resident had occasional mild pain. Review of Resident #1's care plan, reviewed by the facility on [DATE], revealed the facility identified the resident was at risk for pain related to hip pain and decreased mobility. The facility developed care plan interventions that required staff to report changes in pain, location and type, administer medications as ordered, and monitor for effectiveness of medication. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's SBAR Communication (change in condition) Form dated [DATE], not timed, revealed the facility assessed the resident to have bilateral hip pain, which started on [DATE]. Further review of the Form revealed the resident's pain was new, continuous, and rated a nine (9) on a scale of one to ten (,[DATE]), with ten (10) being the worst pain. Further review of the Form revealed the resident was lying in bed with both legs drawn up and the writer was unable to evaluate abduction or adduction. The Form further revealed that upon palpation the resident had facial grimacing and guarding. Review of the Form revealed initially Resident #1's Physician was unable to be reached, but at an unknown time the physician was in the facility and gave an order for [REDACTED].>Review of Resident #1's bilateral hip x-ray dated [DATE] revealed the resident had an impacted right femoral neck fracture ([MEDICAL CONDITION]). Interview on [DATE] at 11:23 AM with the Radiology Assistant revealed the bilateral hip x-ray was ordered on [DATE] at 7:34 AM and the x-ray was obtained at 3:57 PM. The interview further revealed the x-ray was sent to the Radiologist to be read at 4:15 PM and the results were sent to the facility at 5:38 PM. Review of the facility's investigation, initiated on [DATE] and finalized on [DATE], revealed the facility received x-ray results for Resident #1 which revealed the resident had a [MEDICAL CONDITION] (x-rays revealed the fracture was on the right side) femoral head. Further review of the investigation revealed staff reported that on [DATE], Resident #1 sustained a fall from his/her wheelchair, which had not been documented or reported initially by facility staff. Continued review of the investigation revealed Resident #1 verbalized complaints of hip pain on [DATE], increased behaviors of resistance to care with swearing on [DATE], and complaints of bilateral hip pain on [DATE], at which time the physician was notified and an order received for a bilateral hip x-ray. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #1 at 1:45 PM, and with SRNA #9 on [DATE] at 12:16 PM, revealed the SRNAs worked with Resident #1 on [DATE] and [DATE]. The SRNAs stated the resident yelled, My hip's broke! and appeared to be in pain when they attempted to get the resident out of bed for a shower. SRNA #9 stated she notified Registered Nurse (RN) #1 that Resident #1 appeared to be in pain and the resident stated that his/her hip was broken. SRNA #9 stated the RN reported there had been nothing in report about the resident having a fall or being in pain and she (the RN) felt the resident was fine. Further interview revealed the RN did not come into the room to assess the resident or give the SRNAs guidance on how to provide care for the resident. Interviews revealed the SRNAs were unsure of the exact time that they initially reported the resident's pain to RN #1, but stated it was sometime during the morning on [DATE] (their shift started at 7:00 AM). The SRNAs stated they attempted to assist the resident from bed again, and the resident yelled out again, My hip's broke. SRNA #9 stated she informed RN #1 again that Resident #1 was complaining of pain and asked the RN to check on the resident. The RN stated she would check on the resident in a minute. SRNA #1 and SRNA #9 stated they waited about ,[DATE] minutes for RN #1 to assess the resident, but the RN never came to the resident's room. The staff then attempted again to get the resident out of bed. Further interview revealed the SRNAs stated Resident #1 continued to complain and appeared to be in pain when they got him/her out of bed and the resident stated, I fell out of the door and hit my head, but my hip hurts worse. The SRNAs stated they reported Resident #1's complaints of pain for the third time to RN #1 and the RN instructed them to take the resident to the shower room and she would come to the shower room to assess the resident. Further interview with the SRNAs revealed Resident #1 yelled out and appeared to be in pain when they washed the resident's legs and perineal area. SRNA #9 stated she asked RN #1 to come to the shower room and assess the resident because the resident continued to complain of pain; however, RN #1 never came to assess the resident. SRNA #1 and SRNA #9 stated RN #1 had not come to assess Resident #1 by around 3:00 PM, so SRNA #1 reported the resident's complaints of pain to another nurse and the nurse recommended the SRNAs fill out a Stop and Watch Form and report the issue to the DON. SRNA #1 and SRNA #9 stated they completed a Stop and Watch form, which stated they had attempted to get RN #1 to assess Resident #1 for pain several times throughout the shift because the resident was not acting like himself/herself, but the RN had not assessed the resident. They stated they documented that the resident was complaining of pain, appeared to be in pain, and that the resident reported he/she fell out of the door and hit (his/her) head but (his/her) hip hurt worse. The interview further revealed the DON assessed Resident #1, with RN #1 present, and determined the resident's pain was from injections the resident was receiving. Interview on [DATE] at 3:12 PM with Licensed Practical Nurse (LPN) #1 revealed she was working on [DATE] when SRNA #1 came to her that afternoon and reported that Resident #1 had complained of pain and had appeared to be in pain all day. SRNA #1 told the LPN that she reported the resident's pain to RN #1 (LPN #1 had witnessed the SRNAs report the resident's pain to RN #1). However, the RN had not assessed the resident. Continued interview revealed LPN #1 encouraged SRNA #1 to report the resident's pain to the DON. Review of Resident #1's Health Status Notes dated [DATE] at 3:28 PM revealed a Stop and Watch was completed because the resident was having pain. The DON assessed the resident to have increased pain to the hip joints and complaints of pain with palpation to the right buttock where an injection was administered the previous night. There was no documented evidence the resident's pain was reported to the physician as required by the resident's care plan. Interview on [DATE] at 1:07 PM with LPN #5 revealed she worked with Resident #1 on the night of [DATE] and the morning of [DATE]. She stated the staff could not keep the resident in his/her wheelchair or the bed. LPN #5 stated the resident continuously attempted to get up and he/she stayed awake all night. Further interview revealed the LPN did not think that this was a change in condition for the resident at that time because the resident attempted to get out of bed occasionally. However, the LPN stated that when she came in for night shift on [DATE] and the resident was obviously in pain, looking back she realized that the resident may have been in pain during the night of [DATE] and the morning of [DATE]. Review of Resident #1's pain assessments revealed LPN #5 assessed the resident to have no pain (rated a 0) on [DATE] at 2:35 AM or at 5:53 AM. In addition, RN #1 documented that the resident had no pain on [DATE] at 12:44 PM, even though SRNAs #1 and #9 had reported that the resident had pain multiple times on [DATE], and there was no documented evidence that RN #1 had assessed the resident. Further review of the pain assessment revealed Resident #1 was assessed to have pain on [DATE] at 4:05 PM rated at a three (3) on a scale of zero to ten (,[DATE]) with ten (10) being severe pain. Continued interview with SRNA #1 on [DATE] at 1:45 PM revealed she also worked with Resident #1 on [DATE] and the resident continued to yell out in pain and appeared to be in pain when staff assisted him/her with incontinence care. SRNA #1 stated RN #1 was Resident #1's nurse again that day when she reported that the resident continued to be in pain; however, the RN appeared to be aggravated with the SRNA when she made the reports. Interview on [DATE] at 2:32 PM with SRNA #2 revealed she worked with Resident #1 on [DATE] and the resident was in bed the entire day and would say Ouch or No, no, no any time staff touched him/her to assist with care. SRNA #2 stated it was not normal for Resident #1 to complain of pain and she reported to RN #1 that the resident was having pain. SRNA #2 stated the RN made the statement that she was aware of the resident's pain and it was caused by the resident receiving injections. Further review of Health Status Notes dated [DATE] at 2:30 PM revealed RN #1 documented that Resident #1 refused care from staff at times and was cursing at staff when asked to complete a task; however, there was no evidence RN #1 assessed and treated the resident's pain that was reported by the SRNAs. Continued interview with LPN #5 on [DATE] at 1:07 PM revealed she worked with Resident #1 on the night of [DATE]. She stated the resident stayed in the fetal position, refused to let staff straighten out his/her legs, and at times would scream out in pain when the staff would attempt to change or position him/her. Continued interview revealed the LPN attempted to contact the physician, but was unable to reach him. The next morning, the LPN contacted the DON to inform her of the resident's pain and that she was unable to reach the physician. LPN #5 stated the DON returned her call and stated she had reached the physician and had obtained the order for bilateral hip x-rays. The LPN stated she ordered the x-ray. However, there was no documented evidence the LPN assessed the resident's pain. Review of Resident #1's pain assessments revealed LPN #5 documented that Resident #1 had no pain on [DATE] at 6:40 PM. Review of Health Status Notes dated [DATE] at 7:26 AM revealed LPN #5 notified Resident #1's family member that the resident had bilateral hip pain and that x-rays of the resident's hips were ordered. Further review of the Notes revealed at 8:30 PM, Resident #1 was transferred to the emergency room related to the results of the hip x-ray. Interview on [DATE] at 1:38 PM and [DATE] at 3:17 PM with RN #1 revealed [DATE] was the first day the RN had worked with Resident #1 and she was not familiar with the resident. The interview further revealed the first time she was notified Resident #1 was experiencing pain was when the SRNAs brought the resident out of the shower room. RN #1 stated she looked at the resident while he/she was in the wheelchair and the resident appeared to be fine. She stated she instructed the SRNAs to take Resident #1 to lunch and she would assess the resident when they put the resident back to bed. RN #1 stated the SRNAs did a Stop and Watch related to Resident #1's pain and the DON came to assess the resident and determined the pain was from arthritis and from [MEDICATION NAME] (antibiotic) injections. She stated the resident was receiving Tylenol (a non-narcotic pain reliever) as scheduled three (3) times per day. RN #1 denied Resident #1's Physician was contacted about the resident's pain. The interview further revealed she also worked with Resident #1 on [DATE] and a SRNA reported to her that Resident #1 had a fall the previous weekend. She stated that she and the SRNA immediately went to the DON and reported the information. RN #1 stated the DON told her that she would immediately initiate an investigation and would notify the physician of Resident #1's suspected fall and the resident's complaints of pain. Interview on [DATE] at 12:01 PM with Physician #2 revealed the physician denied ordering the x-ray for Resident #1 and of being contacted about Resident #1's complaints of pain until after the facility had obtained the hip x-ray and had the results, which revealed the resident had a fracture. The interview further revealed the Physician would expect to be notified if a resident was experiencing pain that was new, or if the resident had unrelieved pain. Interview on [DATE] at 4:00 PM and [DATE] at 12:21 PM with the DON revealed on [DATE], SRNA #1 and SRNA #9 reported concerns that Resident #1 was in pain and was not being assessed by RN #1. The DON instructed the SRNAs to fill out a Stop and Watch Form. The interview revealed the DON was unable to locate the Stop and Watch form and did not remember exactly what the SRNAs documented, but remembered the SRNAs were concerned RN #1 had not assessed the resident's right hip pain and the resident had made a statement that he/she had fallen through the door and hit his/her head. Further interview with the DON revealed that she along with RN #1 assessed Resident #1 and the only time the resident appeared to have any discomfort (the resident was resting in bed with his/her eyes closed and the resident opened his/her eyes when the DON touched this area) was when the DON palpated over the resident's right buttock. The resident had received an intermuscular (IM) injection the previous night and he/she did not have any bruising or complaints of pain during the assessment so the DON and RN #1 determined the pain was from receiving IM injections. The DON stated the physician was not notified at that time because she felt like she had identified the source of the pain, staff was alternating the injection sites, and the resident had Tylenol scheduled three (3) times per day. The interview further revealed the physician should have been immediately notified of Resident #1's fall and of the resident's complaints of pain. Interview on [DATE] at 1:56 PM with the Administrator revealed he was made aware of Resident #1's fracture on [DATE]. The Administrator stated he was not a clinical person but he would expect nursing staff to notify the physician if a resident complained of pain that was not typical for the resident or continued pain that was not relieved with treatment. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain

Based on interviews, record review, and review of the facility policy, it was determined the facility failed to ensure sufficient nursing staff was available on a daily basis to meet the residents' needs for care and assistance and to promote each resident's physical, mental, and psychosocial well-being, thus enhancing their quality of life, for two (2) of five (5) sampled residents (Residents #2 and #5). Review of a facility fall nursing assessment and fall investigation revealed Residents #2 and #5 sustained falls while being assisted by only one (1) staff member; however, the residents were assessed to require the assistance of two (2) staff members. Interviews with facility direct care staff revealed when both residents fell there were only two (2) staff members (an aide and a nurse) on the Reflections Unit, where the residents resided, and there was not enough staff to assist the residents. When both falls occurred, the State Registered Nurse Aide (SRNA) was assisting the resident and the nurse was assisting another resident and was unavailable. Further interviews with direct care staff revealed the Reflections Unit was often only staffed with a nurse and an aide and at times there was not always help available for residents who required the assistance of two (2) staff persons. The facility's failure to ensure staffing was available to meet resident needs has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Acuity Based Staffing, not dated, revealed Acuity Based Staffing (ABS) was a nursing staffing model based on patient acuity. An interview with the facility Administrator on [DATE] at 1:07 PM revealed staffing was based on direct care staff's documentation of Activity of Daily Living (ADL) assistance that was provided for residents. 1. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the resident was assessed to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Review of the Certified Nursing Assistant (CNA) Assignment Sheet, not dated, revealed Resident #2 required assistance of two (2) staff members for bed mobility (when experiencing behaviors, but was independent if not experiencing behaviors), mobility and transfers with a gait belt and walker, and the resident was continent of bowel and bladder with incontinence episodes. Review of the Nursing Assessment for Resident #2 revealed the resident sustained [REDACTED]. Further review of the assessment revealed Resident #2 lost his/her balance and fell back on the toilet. Interview on [DATE] at 1:52 PM with the Activity Assistant (who also works as a SRNA) revealed she was assigned to provide care to Resident #2 at the time of the fall on [DATE]. The interview revealed the Activity Assistant had assisted Resident #2 to the restroom without the assistance of another staff member, and was attempting to help the resident back to bed without the assistance of another staff member, when the resident lost his/her balance and fell back onto the toilet. The interview revealed the Activity Assistant was not aware whether Resident #2 was supposed to be a one (1) or two (2) person assist, however, the Activity Assistant revealed she was the only SRNA on the unit at the time of the fall and the nurse could not assist her because she was helping another resident. Interviews on [DATE] with SRNA #5 at 3:46 PM, SRNA #8 at 9:05 PM, and on [DATE] with SRNA #10 at 1:39 PM, SRNA #11 at 2:01 PM, and SRNA #14 at 4:40 PM, revealed the staff members were aware Resident #2 was supposed to be a two (2) person assist for transfers and toileting; however, at times the staff transferred the resident with only one (1) staff person's assistance because there was not always a staff member available to assist for two (2) person assists. The staff stated the Reflections Unit was only staffed with an SRNA and a nurse, and the nurse was not available at times. The staff stated they did not have time to document the amount of assistance with ADL care that each resident required. Interview on [DATE] at 2:12 PM with LPN #6 revealed she was working with Resident #2 on the day the resident fell in the bathroom. The interview further revealed LPN #6 did not remember identifying that Resident #2 did not have the appropriate amount of assistance at the time of the fall. Continued interview revealed if the SRNA had asked the LPN for assistance, she would have assisted. LPN #6 stated at times the Reflections Unit was only staffed with a nurse and an SRNA and it was hard to give the assistance the residents needed because there was not enough staff. Interview on [DATE] at 4:16 PM with the Unit Manager, Registered Nurse (RN) #4, revealed she did not recall identifying that Resident #2 did not have the appropriate assistance at the time of the fall on [DATE]. The interview further revealed the facility always attempted to staff the Reflections Unit with three (3) staff members; however, staff did not come to work at times and sometimes staff from the unit would be pulled to help in other areas because things happen. 2. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to require extensive assistance of two (2) staff persons for transfers, hygiene, and toileting, and total assistance of two (2) staff persons with bathing. Review of the Nursing Assessment for Resident #5 revealed the resident sustained [REDACTED].#5 was attempting to put an incontinence brief on Resident #5 while the resident was standing in the shower room. The resident's legs became weak and the SRNA had to assist the resident to the floor. According to the nursing assessment, the resident did not sustain an injury. Interview with SRNA #5 on [DATE] at 4:50 PM revealed she was putting an incontinence brief on Resident #5 without assistance and the resident's legs became weak and she had to assist the resident to the floor. Further interview revealed she knew the resident was assessed to require the assistance of two (2) staff persons; however, there was not enough staff to provide the residents with the assistance they required for their care. SRNA #5 stated all the residents on the unit required assistance and there was a lot of times that she worked on the Reflections Unit as the only SRNA (review of the facility Resident Reporter revealed 17 residents resided on the Reflections Unit). Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 10:18 AM revealed she was the nurse that worked with SRNA #5 and Resident #5 on [DATE]. She stated she was aware that Resident #5 needed the assistance of two (2) staff persons for transfers. However, the Reflections Unit had been short-staffed a lot lately. She stated most of the time there was only one SRNA working on the unit and there was not enough staff to give the residents the assistance they required at all times. Interviews with SRNA #5 on [DATE] at 4:50 PM and SRNA #11 on [DATE] at 11:00 AM revealed residents were not receiving the assistance they were assessed to have during ADL care related to insufficient staff. Further interview with SRNA #5 revealed administrative staff had been made aware that residents were not receiving the assistance they required due to insufficient staff. Interviews with LPN #6 on [DATE] at 10:18 AM, LPN #9 at 10:40 AM, and LPN #12 at 3:25 PM revealed they acknowledged concerns that residents were not receiving the assistance they required with ADL care. The LPNs stated they tried to help the SRNAs when time allowed; however, there was not enough staff to always complete the task. Interview on [DATE] at 12:21 PM with the Director of Nursing (DON) revealed the facility staffing was based on acuity according to resident census and needs of the residents. The interview further revealed corporate staff was actually telling the DON that the facility had too much staff on each shift. The DON stated she did not feel there was a problem with not enough staff in the building; the staff may have just been helping somewhere else. The interview further revealed the Reflections Unit was always staffed with the Unit Manager, a nurse, and an aide during the day, and with at least one nurse and two (2) other staff persons such as nurses, medication aides, or aides on the evening and night shifts. Continued interview revealed the facility had not identified that there was not enough staff to assist residents with care. In addition, the DON stated she had not received complaints from staff about not being able to provide resident care; however, there were staff complaints that they could not always finish their charting. Interview on [DATE] at 1:56 PM and on [DATE] at 1:07 PM with the Administrator revealed he had not identified that there was not enough staff and there had been no specific complaints about staffing made to him. He stated the facility was always looking for staff. The interview further revealed two (2) weeks ago the facility was fully staffed; but, due to a recent incident, a couple of staff members were terminated and a couple of staff members quit so that left the facility looking for staff again. The Administrator stated they scheduled enough staff to care for residents; however, staff called in or did not show up to work at times, leaving the facility short on staff. He further stated they tried to get other staff to cover by having administrative staff provide resident care or attempting to get staff from a sister facility to cover. The Administrator stated they had also tried offering extra hourly pay for SRNAs and a bonus for nurses for picking up extra shifts. The Administrator revealed staffing was based on acuity, based on resident census, staff charting, and other areas. Continued interview revealed on paper the facility was overstaffed. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders, to include residents who experience a fall. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy an(TRUNCATED)

Based on interview, record review, review of the facility's investigations, and review of the facility's policies, it was determined the facility failed to ensure one (1) of five (5) sampled residents' medical records was complete (Resident #1). Facility staff observed Resident #1 on the floor in the dining room on [DATE]; however, the facility failed to document the fall in the resident's medical record. The facility's failure to ensure medical records were accurate has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Falls, reviewed [DATE], revealed if the resident sustained [REDACTED]. Review of the facility policy titled Accidents and Incidents- Investigating and Report, also revealed accidents or incidents involving residents would be documented in the Event Manager. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 5:06 PM an interview with State Registered Nurse Aide (SRNA) #6 revealed on [DATE], she heard an alarm sound in the dining room. SRNA #6 stated she found the resident on the floor in front of a wheelchair. SRNA #6 stated Licensed Practical Nurse (LPN) #3 and LPN #4 also responded to the alarm, looked at the resident, and assisted the resident back into the wheelchair. Interview with LPN #3 on [DATE] at 5:00 PM revealed she was at her medication cart on [DATE], when she heard an alarm sounding from the dining room. She stated she found Resident #1 on his/her knees in front of a wheelchair. She stated LPN #4 (Resident #1's nurse) was standing beside the resident. LPN #3 further stated she helped LPN #4 assist Resident #1 back into the wheelchair and LPN #3 continued with medication pass. LPN #3 stated she assumed since LPN #4 was Resident #1's nurse, she would document the fall appropriately. LPN #3 revealed she was not aware the LPN had not documented and reported the fall until she was questioned as part of the investigation of the resident's hip injury. However, record review revealed no documented evidence that Resident #1 sustained a fall on [DATE]. Interview on [DATE] at 5:06 PM with LPN #4 revealed the LPN was assigned to provide care to Resident #1 on [DATE], and denied a fall occurred with the resident. Review of a facility investigation dated [DATE] and finalized on [DATE], revealed Resident #1 had a fractured left (x-rays revealed the fracture was on the right side) femoral head and an investigation was initiated regarding the injury of unknown source. Further review of the investigation revealed staff reported that Resident #1 sustained a fall from his/her wheelchair on [DATE]; however, facility staff did not report or document the resident's fall when it occurred. The investigation revealed the nurse assigned to care for Resident #1 on the day the fall occurred continued to deny that Resident #1 sustained a fall. Continued review of the investigation revealed Resident #1 verbalized complaints of right and left hip pain on [DATE] and was resisting care and swearing on [DATE]. The resident's physician was notified on [DATE] and ordered x-rays of the resident's hips. Review of Resident #1's hip x-rays, dated [DATE], revealed the resident had an impacted right femoral neck fracture ([MEDICAL CONDITION]). Further review of Resident #1's Health Status Notes revealed at 8:30 PM on [DATE] Resident #1 was transferred to the emergency room related to the results of the hip x-ray. Interview with the DON on [DATE] at 4:00 PM and on [DATE] at 12:21 PM revealed the facility was not aware Resident #1 had a fall until [DATE], after the facility had initiated an investigation of the resident's [MEDICAL CONDITION]. The DON stated when a resident fell at the facility, the resident's nurse should document the details about the fall in Event Manager and should call the DON or supervisor on call. According to the DON, staff reviewed the documentation in Event Manager the morning after a fall during a clinical meeting to determine the cause of the fall and implement interventions to prevent falls. The DON stated the problem started when staff did not report and document Resident #1's fall on [DATE]. Interview on [DATE] at 1:56 PM with the Administrator revealed staff should have documented that Resident #1 sustained a fall on [DATE]. The Administrator stated the information should have been documented in the Event Manager. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started on [DATE] and was completed on [DATE]. 19) The nursing schedule is being reviewed daily by the ADM, DON, ADON, UM or Nursing Supervisor to assure that daily staffing levels are appropriate to meet resident care needs. 20) The DON is to ensure that any identified care delivery deficit is corrected immediately. Findings from the audits, evaluations, assessments, reviews, and interviews have been reported to the QAPI committee during the QAPI meeting on [DATE] by the DON or SCC for any needed changes, revisions, and/or recommendations to the facility's current plan. 21) The Administrator and DON completed education on [DATE] with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) regarding the completion of care delivery audits. The audits started on [DATE] and are ongoing until immediacy is lifted. The following audits are being conducted: A. Bed and Chair alarm audits ten (10) per shift each day until immediacy is lifted. Then five (5) per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. B. Random Pain assessments are being completed ten (10) per shift each day until the immediacy is lifted. Then five 5 per day for four (4) weeks, then three (3) per day for four (4) weeks, then three (3) per week for four (4) weeks. C. Random post education test will be completed five (5) per shift each day until immediacy is lifted. Then three (3) per shift per day for four (4) weeks, then one (1) per shift per day for four (4) weeks, and three (3) per week for four (4) weeks. D. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing documentation in the electronic medical record, electronic medication record, 24-hour report, pain assessments, change of condition, telephone orders for appropriate notification, care plan updates and SRNA care plan updates, for any resident with a change in condition, receiving new physician's orders, to include residents who experience a fall. The Administrator is responsible for oversight of the morning clinical meeting to validate compliance, with above stated actions and participation by the Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). E. During morning clinical meeting (Monday - Friday) the interdisciplinary team is reviewing any falls to assure root cause, investigation, appropriate interventions, pain, care plan updates and SRNA care plan updates and effectiveness of interventions. The Interdisciplinary team (CEO, DON, AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director) will review any residents who experience a fall daily in the morning clinical meeting for 72 hours to assure effectiveness of the added intervention. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. 22) The Administrator, AIT or the DON will make daily assignments for audits and review the assigned daily audits and discuss findings during a daily afternoon meeting with the department managers (AIT, ADON, SDC, UM, SSD, QOL director, Chaplain, Dietary Director, MDS Coordinators, Admissions Director). Identified care concerns are corrected immediately by the DON, ADON, SDC and or UM. 23) A Signature Care Consultant, Director of Clinical Operations, Regional Vice President of Operations or Regional Controller has been on-site since [DATE]. 24) The QAPI will review the findings from monitoring at each weekly meeting or as needed. Another QAPI meeting is scheduled on [DATE] to discuss and review current audits, progress and make any further recommendations with the Medical Director. The Administrator is providing oversight to assure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate administrative oversight of the QAPI meeting will be completed by the SCC (Signature Care Consultant), Director of Clinical Programs, Regional VP of Operations or member of the regional staff weekly, and daily by telephone until removal of immediacy beginning [DATE], then every other week for 4 weeks, then monthly. Weekly QAPI meetings will be scheduled [DATE], [DATE], and [DATE]. ***The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of facility documentation revealed the facility initially held a QAPI meeting on [DATE] to discuss the IJ and to formulate a plan for the removal of the IJ. Further review of facility documentation revealed the facility held another QAPI meeting on [DATE] to discuss the IJ, the effectiveness of the plan and to make any changes needed to the plan. Interviews on [DATE] at 2:32 PM with Registered Nurse (RN) #4 (Unit Manager); on [DATE] with Minimum Data Set (MDS) Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, Licensed Practical Nurse (LPN) #2 (Staff Development Coordinator (SDC)) at 8:35 PM, Assistant Director of Nursing (ADON) at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, Social Services Director (SSD) at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed since the IJ was identified the facility had held QAPI meetings to discuss the IJ, the plan to remove the IJ, discuss problems and make changes to the plan and to ensure the effectiveness of the plan. The interviews further revealed the facility had a daily morning meeting and an afternoon (stand down) meeting to discuss any problems that were identified daily as part of the QAPI process. 2) Review of facility documentation, dated [DATE], revealed all staff that was not working was notified by phone that the staff could not work until education and post-tests were completed. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM and on [DATE] with the Administrator in Training at 3:55 PM, the DON at 4:02 PM and the Administrator at 4:30 PM revealed staff that were working were trained immediately on areas related to the IJ and any staff not working were notified by phone that the education and post-test had to be completed prior to working. The interviews further revealed management staff was posted at each time clock to educate any staff members that had not yet been educated. 3) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated administrative and management staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures so they could train direct care staff. The interviews further revealed the administrative staff had to complete a post-test. 4) Review of facility documentation, dated [DATE], revealed the Regional Nurse Consultant educated facility administrative staff on completion of fall investigations and determining the root cause of a fall. Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed administrative staff were trained on completing fall investigations and determining the root cause of falls and had to pass a post-test after the training with a score of 100%. 5) Interviews on [DATE] with RN #4 (Unit Manager) at 2:32 PM; on [DATE] with MDS Coordinator #1 at 4:57 PM, MDS Coordinator #2 at 5:15 PM, LPN #2 SDC at 8:35 PM, ADON at 8:44 PM, LPN #14 (Unit Manager) at 8:51 PM, SSD at 9:00 PM, Activity Director at 9:09 PM; on [DATE] at 2:45 PM with the Regional Nurse Consultant (RNC) and on [DATE] with the Administrator in Training at 3:55 PM, the Director of Nursing at 4:02 PM and the Administrator at 4:30 PM revealed after the administrative staff were trained they were assigned shifts and groups of direct care staff to educate about the policies and procedures. 6) Review of facility documentation, beginning on [DATE], revealed facility direct care staff were trained and had to pass a post-test by administrative staff on the following: care plan policy and procedures, accident and incident policy and procedures, change in condition policy and procedures, pain policy and procedures and the QAPI policy and procedures. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were trained on the following areas: care plan policy and procedures which included following the care plan and care cards and ensuring all resident interventions were in place; accident and incident policy and procedures including reporting all falls, ensuring the fall nursing assessment and investigation were thorough, and gathering information to attempt to determine the root cause of falls; change in condition policy and procedures which included reporting all changes in the resident's condition and Stop and Watch forms; pain policy and procedures which included assessing appropriately for pain and notification to the physician of pain; and the QAPI policy and procedures which included reporting problems to administrative staff. 7) Review of facility documentation revealed after direct care staff were provided education the staff had to complete a post-test. Further review of tests revealed all staff passed with a 100% score. Review of the documentation revealed any staff that had not work and had not been trained were notified by letter that they would not be permitted to work until the education and post-test were completed. Interview on [DATE] at 1:00 PM with the Administrator revealed no staff member had been permitted to work without receiving education prior to the beginning of the staffs shift. 8) Review of facility documentation revealed post-tests were administered to direct care staff to ensure they retained the information received during the staff training. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #16 at 3:01 PM and SRNA #3 at 3:52 PM; on [DATE] with SRNA #15 at 11:03 AM, SRNA #11 at 11:25 AM, SRNA #9 at 11:45 AM, SRNA #20 at 1:45 PM, SRNA #18 at 2:08 PM, SRNA #2 at 3:41 PM, SRNA #17 at 3:55 PM, SRNA #10 at 4:05 PM, SRNA #19 at 4:18 PM, LPN #23 at 12:12 PM, LPN #10 at 1:31 PM, LPN #7 at 2:22 PM, and LPN #13 at 4:40 PM and RN #3 at 2:50 PM and on [DATE] at 12:15 PM with SRNA #21 revealed the staff were given a test or questioned daily by administrative staff to ensure they were knowledgeable about the facilities policies and procedures. 9) Record review revealed Resident #5 expired in the facility on [DATE]. 10) Review of Resident #1's medical record revealed the facility reviewed and revised the fall investigation related to the fall on [DATE], re-assessed the resident for pain, re-assessed the resident's fall risk assessment, updated and ensured the resident's care plan and SRNA care plan met the resident's needs and facility staff ensured the physician and responsible party were aware of the findings of the evaluations and assessments. Review of Resident #2's medical record revealed the facility reviewed and revised the fall investigation related to the falls on [DATE] and on [DATE], re-assessed the resident for pain, re-assessed the resident's fall risk assessment, updated and ensured the resident's care plan and SRNA care plan met the resident's needs and facility staff ensured the physician and responsible party were aware of the findings of the evaluations and assessments. Interview on [DATE] at 2:03 PM with the DON revealed the fall investigations for Resident #1 and #2 were reviewed and the residents were assessed for pain, fall risk, to ensure staffing le(TRUNCATED)

Based on interview, record review, review of the facility's investigations, and review of the facility's policies, it was determined the facility failed to notify the physician of resident falls, for two (2) of five (5) sampled residents (Residents #1 and #5). Resident #5's fall resulted in injury. The facility failed to notify the physician of the need to alter treatment, and the presence of acute pain for one (1) of five (5) sampled residents (Resident #1). Review of a facility investigation revealed Resident #1 sustained a fall on [DATE]; however, staff did not document or report the fall to the resident's Physician. Staff interviews and review of facility documentation revealed on [DATE] and [DATE], Resident #1 reported pain in his/her hips and showed signs and symptoms of pain. However, Resident #1's Physician was not notified of the pain until [DATE] at which time bilateral hip x-rays were ordered. Resident #1 had a [MEDICAL CONDITION] hip. The resident was transferred to the hospital where he/she had surgical repair of the hip. The resident returned to the facility on [DATE] under Hospice care and expired at the facility on [DATE]. Staff interviews and record review revealed Resident #5 sustained a fall on [DATE] at 10:05 AM and hit his/her head on the bathroom door. The facility documented that the Advanced Practice Registered Nurse (APRN) was notified of the fall; however, the facility failed to notify the resident's physician in accordance with the facility's policy that the resident had fallen. The resident expired on [DATE] at 11:21 PM. According to the APRN, the fall the resident sustained [REDACTED]. The facility's failure to ensure physicians were notified of falls and the need to alter treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.35 Nursing Services (353), 42 CFR 483.70 Administration (F490 and 514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (A(NAME)) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, during the validation of the A(NAME), the State Survey Agency (SSA) determined the facility had not revised all of the care plans, as per the facility's A(NAME), to ensure the care plans were accurate and reflective of each resident's assessed needs. After surveyor intervention, all care plans were reviewed and revised as needed on [DATE] and [DATE]. The SSA determined the Immediate Jeopardy was removed on [DATE], with the Scope and Severity lowered to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.21 Comprehensive Care Plans (F280 and F282), 42 CFR 483.24 Quality of Life (F309), and 42 CFR 483.35 Nursing Services (353). The Scope and Severity was lowered to E level at 42 CFR 483.25 Quality of Care (F323), 42 CFR 483.70 Administration (F490), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Change in Condition, reviewed by the facility on [DATE], revealed the facility would assess and document changes in the resident's health in an effective and efficient manner to relay assessment information to the physician. The policy further revealed if the resident's condition did not appear to be life threatening, the facility staff should utilize the Situation, Background, Assessment, and Response (SBAR) Communication Form and notify the physician. Continued review of the policy revealed the SBAR Communication Form would serve as the nursing documentation for changes in condition. Review of the policy revealed residents experiencing pain or who had sustained falls would indicate a change in condition, utilization of the SBAR, and notification of the physician. Review of the facility's policy titled Falls, reviewed [DATE], revealed if the resident sustained [REDACTED]. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to require extensive assistance of two (2) staff members for transfers, bed mobility, dressing, bathing, and toileting. Interview on [DATE] at 5:00 PM with Licensed Practical Nurse (LPN) #3 revealed on [DATE], she was at her medication cart and heard an alarm sounding from the dining room. LPN #3 stated she found Resident #1 on his/her knees in front of a wheelchair in the dining room. According to LPN #3, LPN #4 (Resident #1's Nurse) was standing beside the resident. LPN #3 stated she and LPN #4 assisted Resident #1 back into the wheelchair and she continued with her medication pass. She stated she assumed since LPN #4 was Resident #1's Nurse, LPN #4 would report and document the fall appropriately. LPN #3 was not aware LPN #4 had not reported the fall to the physician until she was questioned about the fall during the facility's investigation. Interview on [DATE] at 5:06 PM with LPN #4 revealed she was assigned to provide care for Resident #1 on [DATE]. LPN #4 denied the resident sustained [REDACTED]. However, interview with State Registered Nurse Aide (SRNA) #6 on [DATE] at 5:15 PM revealed she heard Resident #1's alarm sound in the dining room on [DATE]. She stated when she arrived in the dining room, Resident #1 was on the floor and LPN #3 and LPN #4 were present. She stated the LPNs assisted the resident back to a wheelchair and she left the area. Interview on [DATE] at 1:39 PM with SRNA #10 revealed the SRNA was working on [DATE] when he was informed by SRNA #6 that Resident #1 had fallen. SRNA #10 stated he was not aware the resident's fall had not been documented or reported to the resident's Physician until [DATE], when staff told him the resident was complaining of hip pain and was unsure of the cause of the pain. Review of Resident #1's medical record revealed there was no documented evidence of the resident's fall on [DATE] or that staff notified the resident's physician. Review of Resident #1's Health Status Notes dated [DATE] at 3:28 PM (two days after the resident's fall) revealed the Director of Nursing (DON) assessed the resident and noted the resident had increased pain to his/her hip joints and complaints of pain with palpation to the right buttock where the resident had received an injection the previous night. Further review of the Notes revealed the assessment was completed because a Stop/Watch was completed related to Resident #1's pain. There was no documented evidence the resident's physician was notified of the resident's pain. Review of the Health Status Notes dated [DATE] at 7:26 AM revealed Resident #1's family member was notified that the resident was having bilateral hip pain and that x-rays of both hips were being ordered. Review of Resident #1's SBAR Communication Form dated [DATE], not timed, revealed the resident was assessed to have bilateral hip pain which started on [DATE] (the first documented date in the Health Status Notes that the resident had pain was [DATE]). Further review of the Form revealed the resident's pain was new, continuous, and rated a nine (9) on a scale of one to ten (,[DATE]), with ten (10) being the worst pain. Continued review of the Form revealed the resident had facial grimacing and the pain had gotten worse. The Form stated the resident was lying in bed with both his/her legs drawn up, and the writer was unable to evaluate abduction or adduction; the resident had facial grimacing and guarding. Review of the Form revealed initially Resident #1's Physician could not be reached, but at an unknown time the physician was in the facility and gave an order for [REDACTED].>Review of Resident #1's bilateral hip x-ray results dated [DATE] revealed the resident had an impacted right femoral neck fracture ([MEDICAL CONDITION]). Further review of the Notes revealed at 8:30 PM on [DATE] Resident #1 was transferred to the emergency room related to the results of the hip x-ray. Review of the facility's investigation, initiated on [DATE] and finalized on [DATE], revealed the facility initiated an investigation for an injury of unknown source when they received x-ray results for Resident #1 that revealed the resident had a [MEDICAL CONDITION] (x-rays revealed the fracture was on the right side) femoral head. During the investigation, staff interviews revealed Resident #1 had sustained a fall from his/her wheelchair on [DATE], which had not been documented or reported by facility staff. Continued review of the investigation revealed Resident #1 verbalized complaints of pain in both hips on [DATE], had increased behaviors of resistance to care with swearing on [DATE], and complaints of bilateral hip pain on [DATE]. However, the physician was not notified until [DATE] and an order was received for bilateral hip x-rays. Interview on [DATE] with SRNA #1 at 1:45 PM and SRNA #9 on [DATE] at 12:16 PM revealed Resident #1 was not acting like his/her normal self on [DATE] and [DATE]. The SRNAs stated when they attempted to assist Resident #1 out of bed for a shower on the morning of [DATE], the resident yelled out, My hip's broke. The SRNAs stated the resident appeared to be in pain each time they attempted to care for the resident. SRNA #1 revealed she also worked with Resident #1 the next day, [DATE], and the resident continued to yell out in pain and appeared to be in pain when providing incontinence care. Interview on [DATE] at 2:32 PM with SRNA #2 revealed the SRNA worked with Resident #1 on [DATE]. SRNA #2 stated the resident was in bed the entire day and any time staff provided incontinence care, the resident appeared to be in pain and would say ouch or no, no, no. SRNA #2 stated the resident's complaints of pain were not normal for the resident and she reported the resident's pain to RN #1. However, RN #1 told the SRNA that she was aware of the resident's pain and it was caused by injections, and that other staff had filled out a Stop and Watch. Interview on [DATE] at 1:38 PM and [DATE] at 3:17 PM with RN #1 revealed [DATE] was the first day she had worked with Resident #1 and she was not familiar with the resident. RN #1 stated the SRNAs that were caring for Resident #1 on [DATE] reported that the resident was complaining of hip pain and appeared to be in pain when they were bringing the resident out of the shower room. However, she looked at the resident while he/she was in the wheelchair and the resident appeared to be fine. She instructed the SRNAs to take Resident #1 to lunch and she would assess the resident when the SRNAs assisted the resident back to bed. RN #1 stated she was made aware the SRNAs did a Stop and Watch related to Resident #1's pain when the Director of Nursing (DON) came to assess the resident. It was determined the resident's pain was from arthritis and from [MEDICATION NAME] (antibiotic) injections. RN #1 stated she did not contact Resident #1's physician related to the pain because the cause of the pain had been determined and the resident was receiving Tylenol (a non-narcotic pain reliever) three (3) times per day. She stated she also worked with Resident #1 on [DATE] and SRNA #10 reported that Resident #1 had a fall the previous weekend. She stated she and the SRNA immediately went to the DON and reported the possible fall. RN #1 stated the DON informed the RN that she would immediately initiate an investigation and would notify the physician of Resident #1's suspected fall and the resident's complaints of pain. However, review of Resident #1's medical record revealed no evidence the resident's physician was notified that the resident was having pain or had sustained a fall. Interview on [DATE] at 1:07 PM with Licensed Practical Nurse (LPN) #5 revealed she worked with Resident #1 the night of [DATE], and the resident stayed in the fetal position, refused to let staff straighten out his/her legs, and at times would scream out in pain when the staff would attempt to change or position him/her. Continued interview revealed the LPN attempted to contact the resident's physician but was unable to reach the physician and contacted the DON on the morning of [DATE] (time unknown). LPN #5 stated the DON informed her that she had reached the resident's physician, who ordered bilateral hip x-rays. LPN #3 stated she ordered the x-rays for Resident #1 on [DATE] (exact time unknown). Interview on [DATE] at 11:23 AM with the Radiology Assistant revealed bilateral hip x-rays were ordered on [DATE] at 7:34 AM and the x-ray was obtained at 3:57 PM. The interview further revealed the x-ray was sent to the Radiologist to be read at 4:15 PM and the results were sent to the facility at 5:38 PM. Interview on [DATE] at 12:01 PM with Physician #2 revealed he denied ordering x-rays for Resident #1. He stated the facility did not contact him about Resident #1's complaints of pain until after the facility had ordered x-rays and received the results that the resident had a fracture, which was on the evening of [DATE]. The Physician further stated he was not aware Resident #1 had sustained a fall on [DATE] until [DATE]. Physician #2 stated he would expect to be notified if a resident sustained [REDACTED]. Interview on [DATE] at 4:00 PM and on [DATE] at 12:21 PM with the DON revealed SRNA #1 and SRNA #9 reported concerns on [DATE] that Resident #1's pain was not being assessed appropriately by RN #1, and the DON instructed the SRNAs to fill out a Stop and Watch form. Further interview with the DON revealed she, along with RN #1, assessed Resident #1 and the only time the resident appeared to have any discomfort (the resident was resting in bed with his/her eyes closed and the resident opened his/her eyes when the DON touched this area) was when the DON palpated over the resident's right buttock where the resident had received an intramuscular (IM) injection the previous night. Continued interview revealed the resident did not have any bruising or complaints of pain during the assessment and the DON and RN #1 determined the pain was due to receiving IM injections. The DON stated the physician was not notified at this time because she felt like she had identified the source of the pain and the resident had Tylenol scheduled three (3) times per day. She stated the facility was not aware Resident #1 had a fall until after they initiated an investigation for an injury of unknown origin on [DATE], when the resident was diagnosed with [REDACTED].#1 and SRNA #10 reported on [DATE] that the resident had sustained a fall. She stated the facility did not identify that the resident had fallen on [DATE] until they interviewed SRNA #6 on [DATE] as part of their investigation. Further interview revealed the fall was not reported to the resident's physician until [DATE], when the facility identified that the resident had fallen. The DON stated the problem initiated when staff did not report and document Resident #1's fall on [DATE]. The interview further revealed the physician should have been immediately notified of Resident #1's fall and of the resident's complaints of pain. Interview on [DATE] at 1:56 PM with the Administrator revealed he was notified that Resident #1 had a fracture on [DATE]. The Administrator stated he expected staff to document and report all falls to the resident's physician and to the administrative staff on call. Continued interview revealed if a resident complained of pain that was not typical for the resident, or had continued pain, the resident's physician should be contacted about the pain. 2. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the 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 nine (9), indicating the resident had moderate cognitive impairment and was interviewable. Review of the fall investigation for Resident #5 revealed the resident sustained [REDACTED]. The resident hit his/her head on the bathroom door and sustained an abrasion and hematoma to his/her right forehead and cheek. Further review revealed Licensed Practical Nurse (LPN) #9 assessed the resident and called Advanced Practice Registered Nurse (APRN) #1 reporting that the resident had fallen and hit his/her head. APRN #1 gave orders to complete Neurological Checks for seventy-two (72) hours and to notify her of any changes in the resident's condition. There was no evidence that LPN #9 notified the resident's physician about the fall. Review of Resident #5's neurological check sheet revealed the facility started the checks on [DATE], and on [DATE] the resident started declining. Review of Nursing Notes dated [DATE] at 1:06 PM revealed the resident was noted to not be swallowing well at the noon meal. Further review revealed at 6:24 PM the resident was slow to respond to tactile stimuli. At 11:21 PM on [DATE] the resident was observed without respiration and apical pulse. Interview with LPN #9 on [DATE] at 10:40 AM revealed she notified APRN #1 when Resident #5 fell on [DATE] because she was on call for Physician #1. She stated she would have only called the Physician if he was the provider on call. Further interview revealed she reported to APRN #1 that Resident #5 had fallen in his/her room and hit his/her head on the bathroom door. She stated APRN #1 gave her orders to monitor the resident and start neurological checks for seventy-two (72) hours. Interview with APRN #1 on [DATE] at 12:04 PM revealed she could not recall if she had been notified of Resident #5's fall on [DATE]. She stated she received numerous calls and was unsure if she had been notified. She further stated that if she had been notified of the unwitnessed fall and the nurse reported that the resident had hit his/her head, she would have had the resident immediately sent to the emergency room for evaluation. Further interview with APRN #1 revealed she assessed the resident on [DATE] when nursing staff alerted her that the resident was slow to respond to stimuli. She stated she ordered a chest x-ray and laboratory tests. Further interview revealed that the fall the resident sustained [REDACTED]. An interview with the DON on [DATE] at 4:02 PM revealed Resident #5's Physician assigned call to APRNs that work for him and did not take calls during that time. The DON stated it was her understanding that the APRNs reported the information they received during phone calls to the physician. An interview with the Administrator on [DATE] at 4:30 PM revealed it was also his understanding that the APRNs reported the information from phone calls to the physician. Interview with Physician #1 on [DATE] at 11:49 AM revealed he was not aware Resident #5 fell on [DATE]. He stated he was not on call and that the APRN on call for him may have been notified, but he was not aware. He further stated that it was routine to order neurological checks when a resident hit their head. Further interview revealed that he trusted the APRNs' judgement and the decisions they made related to resident care. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) An initial Quality Assurance/Performance Improvement (QAPI) meeting was held on [DATE] to discuss current jeopardy citations, developing and executing plans, and consulting with the Medical Director for any further recommendations and plan for removal. The next weekly QAPI meeting with the Medical Director is scheduled for [DATE]. 2) All nursing staff was notified via phone [DATE] that they could not work until they completed training and passed a post-test with score of 100%. Managers were assigned to be at the time clock at shift change to prevent any employee from clocking in that had not received the required training. Signs were posted at the time clock to alert all staff that they could not work until they had taken the training and scored 100% on the post-test. 3) The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Central Supply Staff, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on [DATE] on the policies and procedures listed below in Section six (6). The training was performed face to face in order to facilitate discussion and question on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided and a post-test was completed with a 100% score. If the Manager did not score 100% on the post-test, he/she was immediately re-educated and the post-test was re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were completed and graded for 100% score on [DATE] by the Regional Nurse Consultant or VP of Clinical Operations. 4) Education was completed for the Interdisciplinary Team (IDT), which consists of the Chief Executive Officer (CEO), DON, ADON, SDC, UM, Social Service Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Rehab Services Manager, Admissions Director, and Dietary Director, regarding the completion of an investigation of the root cause of a fall on [DATE]. 5) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records Staff were educated on all policies and procedures (see Section 6), they were assigned to re-educate staff. The education began on [DATE] and is ongoing until 100% of employees are educated. 6) There were no facility policy or procedure changes. The following is the detailed and specific training on policies, procedures, and processes that was provided: A. Care plan policy and procedure to include: Appropriately updating and/or revising the resident's care plan by the Charge Nurse immediately following a fall or change in a resident's condition. Residents who experience a fall or a change of condition will be reviewed by the Interdisciplinary Team (CEO, DON, ADON, SDC, UM, Social Services Director (SSD), Chaplain, Quality of Life Director, MDS Coordinators, Admissions Director and Dietary Director) in the daily clinical meeting for further updates and revisions to their care plan based on the findings of an investigation and root cause analysis updates. The Root Cause Analysis process has been strengthened to include the CMS QAPI education and the 5 Whys tools based on education provided to the Interdisciplinary Team on [DATE] by the Director of Clinical Operations. As an addition to our process, licensed nurses and hands on caregivers are attending the falls portion of the clinical meeting to garner further information based on their knowledge of the residents to assure the most appropriate intervention is being added to the care plan. Revisions will then be completed by an IDT member. Following care plan interventions to include the specific level of assistance needed for each resident to assure safety and meet each resident's care needs. B. Accident and Incident Policy and Procedure to include: Identification and reporting to the Charge Nurse, DON, ADM along with notification of MD and POA. The education provided included what exactly constitutes an incident, thorough investigation, root cause, and what is considered an appropriate intervention. C. Change of Condition Policy and Procedure to include: What constitutes a change of condition Physician and Family notification Appropriate Documentation of Notification D. Pain: Providing care as per the care plan to assure resident pain needs are met How to identify signs and symptoms of pain Wong-baker pain scale Physician notification Pain interventions E. QAPI policy and procedure to include: What is QAPI Who makes up committee What is the process 7) A post-test was administered to validate knowledge and retention of provided education. If the employee did not score 100% on the post-test, then the employee was immediately re-educated and a post-test readministered. On [DATE], the SDC notified the remaining 27 employees that they would be taken off the schedule and could not work until education and a post-test were completed. Certified letters were sent out to 27 PRN staff that were on vacation, or on family medical leave and could not be contacted. No employee will be allowed to work until education is provided. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained. The facility does not utilize agency staff. 8) Staff post-tests, which include questions from the education provided, are being administered daily, starting on [DATE], by Regional Nurse Consultant, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, Medical Records, SDC, or Environmental Services Director to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. Results of the staff post-tests will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee will determine at what frequency the staff questionnaire will need to continue. 9) Resident #5 was assisted to the floor by the nursing assistant while attempting to place a brief on the resident after a shower on [DATE]. An assessment was completed and no injury or pain was identified. Resident # 5 expired on [DATE]. 10) Residents #1 and #2 had the following completed on [DATE] by the DON or SCC: A. Thorough fall investigation completed on both residents, B. Pain evaluation completed on both residents, C. Fall risk evaluation completed on both residents, D. Care plan and SRNA care plan updated to reflect resident current care needs of both residents, E. Assessed to assure that care plan/SRNA care plan were meeting the current care needs of both residents, F. Assessed to assure that staffing levels were appropriate to meet resident current care needs G. MD and POA notified of findings from evaluations and assessments on both residents. 11) All residents were assessed for pain by the DON, ADON, UMs, Nursing Supervisors, or SCC starting on [DATE] and completed by [DATE]. Any pain identified was immediately addressed to meet resident care needs; the care plan was updated as needed along with notification of the physician and POA. One resident was identified during pain assessments as having mild pain. A PRN [MEDICATION NAME] was administered and found to be effective to relieve the pain. No other findings of acute pain were identified. Documentation of the findings and the further notification of physicians and families are being monitored on a ledger in the Administrator's office. 12) A review of the last 30 days of the Electronic Medical records, Electronic Medication Record, and Telephone Orders was completed by SCC, Director of Clinical Operations, and Director of Clinical Compliance, starting on [DATE] and completed on [DATE] for appropriate notification. The DON, ADON, SDC, and/or the UM notified the physician and families if there was no documentation that they had been notified regarding a change in a resident's condition. The audit identified that one (1) family/POA did not receive appropriate notification of a change in orders/resident's change of condition. The Director of Nursing notified the family of the new order for eye drops on [DATE]. The Statement of Family Notification by the DON on [DATE] is being maintained in a binder in the Administrator's office. 13) All residents' falls were reviewed for the past 30 days by the DON, ADON, UMs, Nursing Supervisor or SCC to assure that thorough investigations were completed, root cause identified, pain evaluation completed, care plan and SRNA care plan updated with appropriate interventions, implemented interventions were in use and effective, and the MD along with the POA had been notified. This review started on [DATE] and was completed by [DATE]. The DON, ADON, SDC, and/or the UM notified the physician and family if there was no documentation that they had been notified regarding a change in a resident's condition. Findings identified that a thorough investigations were not consistently completed. Documentation of the findings and the further notification of physicians and families were being monitored on a ledger in the Administrator's office. 14) All residents' care plans and SRNA Care Plans were audited by the DON, ADON, MDS Coordinators, UMs, Nursing Supervisors, Social Services, Chaplain, or SCC to assure that care plans and SRNA Care Plans reflect current resident care needs. This audit started on [DATE] and was completed by [DATE]. Any concerns noted were immediately corrected by updating care plans and SRNA care plans to reflect current resident care needs. 15) All residents with BIMS scores of eight (8) or greater were interviewed to assure their care needs were being met. This was completed by the ADM, SSD, QOL, or SCC. This started on [DATE] and was completed by [DATE]. Any concerns identified were immediately corrected. 16) All residents with BIMS scores of seven (7 ) less were assessed to assure that their care needs were being met as outlined per the resident's care plan by the DON, ADON, UMs, Nursing Supervisor or SCC. This started on [DATE] and was completed by [DATE]. Care delivery audits were completed by the DON, ADON, SDC, and or UM utilizing each resident's care plan and the SRNA care plan. A visual observation was completed with comparison to the care plan and the SRNA care plan. Care delivery audits include completed observation of care being provided, as it occurred, for transfers, bathing, repositioning, eating, and/or dressing. 17) All residents ADL status (section G1 (A) ADL self-performance and G1 (B) ADL support provided) was re-assessed and care plans updated by the DON, ADON, UMs, Nursing Supervisors, MDS Coordinators or SCC to assure resident care needs are being met. This reassessment started on [DATE] and was completed by [DATE]. 18) All residents had a fall risk assessment completed by the DON, ADON, or MDS Coordinators. This started(TRUNCATED)