Every finding on record at Elkton Nursing and Rehabilitation Center

Based on observation, interview, and review of facility policy, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodations of resident needs and preferences for 7 out of 15 sampled residents, Resident (R)8, R9, R30, R32, R33, R36, and R49. R32 and R36 complained call lights were not answered timely. Additionally, observations on 07/22/2024, and 07/24/2025, revealed R8, R9, R30, R33, and R49's call light was out of reach, and inaccessible to the residents.Review of the facility policy titled, Resident Rights, undated, revealed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the facility policy titled, Placement of Call Light and Answering Call Light, undated, revealed the call light should be plugged in at all times, and when a resident is in bed or confined to a chair the call light shall be within reach of the resident. Further review of the policy revealed all defective call lights should be reported to the nurse supervisor promptly; and answer the resident's call light immediately. Review of the facility document titled, In-Service Training Report, dated 05/28/2025, revealed all call lights must be answered immediately by any available staff even if you are not assigned to that room or section. 1. Review of R32's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 01/21/2025 with diagnoses including fibromyalgia, major depressive disorder, gastroesophageal reflux disease without esophagitis, and cough, unspecified. Review of R32's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference date (ARD) of 05/14/2025, revealed the facility assessed R32 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review revealed R32 was assessed as ambulation not attempted, and as always incontinent of bowel and bladder. Continued review revealed the facility assessed the resident as receiving oxygen therapy. Review of R32's Comprehensive Care Plan, revealed a focus area stating the resident would have no substantiated false accusations/allegations through next assessment date. Date Initiated: 01/27/2025, Revised on: 05/13/2025, Target Date: 08/06/2025. Interventions included: Abuse policy is to be followed with each allegation as indicated; Allow resident to discuss feelings of anger, powerlessness, and frustration as needed; and Allow resident to express thoughts without judgement from facility staff. All interventions were initiated on 01/27/2025 and revised on 04/07/2025. Observation of R32, on 07/22/2025 at 12:34 PM, revealed she was in bed and was receiving oxygen at 3.5 liters per minute per nasal cannula. During an interview with R32, on 07/22/2025 at 12:34 PM, she stated at times her call light went off for over an hour before staff would come to her room to answer it. R32 stated at times staff (could not recall which staff) would just stand outside her room looking at her like she had the plague. She stated she was told by one of the nurses (could not recall which nurse) that most staff were banned from her room. She stated she did not want anyone banned from her room. R32 further stated the nurses on both sides of the building would not enter her room. In further interview with R32, on 07/22/2025 at 12:34 PM, she stated she was having trouble breathing and her oxygen (saturation) was low. She stated staff would not come to her room to help her. R32 stated she begged someone to call the ambulance. She further stated she started screaming to get someone back to her room. R32 stated she felt panicked when staff did not answer her call light timely. During an interview with SRNA3 and SRNA5, on 07/25/2025 at 10:45 AM, they both stated sometimes they would have to go find people that were allowed in R32's room, unless it was an emergency as the resident would only allow certain staff to care for her. They could not recall a specific incident related to staff not answering her call light timely. However, further interview revealed it was important for staff to answer R32's call light quickly in case there was an emergency. During an interview with SRNA2, on 07/25/2025 at 10:50 AM, she stated R32 would only allow a handful of people in her room. Also, there had to be two people minimum to go into her room because of her history of making accusations against staff. However, SRNA2 stated it was important for staff to answer R32's call light quickly to keep her calm. During an interview with Licensed Practical Nurse (LPN)4, on 07/25/2025 11:00 AM, she stated only certain staff were allowed in R32's room, unless it was an emergency. In further interview, she stated R32 would have panic attacks thinking that her oxygen saturations were low, and staff would try to calm her down. However, LPN4 stated it was important for staff to answer R32's call light quickly to keep her from panicking. 2. Review of R36's Face Sheet, revealed the facility admitted the resident on 05/22/2024, with diagnosis including cerebral infarction, hemiplegia affecting left side, dysphagia, and type 2 diabetes. Review of R36's quarterly MDS Assessment, dated 06/28/2025, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating intact cognition. Continued review of the MDS, revealed the facility assessed the resident as requiring substantial/maximal assistance with mobility, dressing, bathing, and toileting. Further, the facility assessed the resident as always incontinent of bowel and bladder. During an interview with R36, on 07/22/2025 at 3:33 PM, she stated one morning before night shift left, staff assisted her up in her wheelchair around 6:20 AM. She stated shortly after, she had a bowel movement while up in the chair. R36 stated she rang the call light which took a long time for an aide to answer, and then the aide told her it was change of shift and she would have to wait for dayshift to assist her. R36 could not recall the date of the incident nor the name of the aide who told her she would have to wait. In further interview, R36 stated it always took forever for her call light to be answered during shift change. She stated most days and nights it took well over an hour for someone to answer her call light. During an interview with SRNA3 and SRNA5, on 07/25/2025 at 10:45 AM, they both stated they were unaware of R36 having to wait for incontinence care or wait a long time for the call light to be answered. During an interview with SRNA2, on 07/25/2025 at 10:50 AM, she stated she could not recall an incident when R36 had a bowel movement in the wheelchair. Per interview, residents should not have to wait a long time for the call lights to be answered or for incontinence care to be provided. During an interview with SRNA6, on 07/25/2025 at 10:55 AM, she stated she could not recall an incident where R36 had to wait a long time for incontinence care; however, stated it was important for staff to answer call lights timely and provide the needed care. 3.Review of R8's Face Sheet, revealed the facility admitted the resident on 03/07/2025 with diagnoses to include Parkinsonism, acute osteomyelitis of the right ankle and foot, and muscle weakness. Review of R8's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/14/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. Observation of R8 on 07/24/2025 at 3:10 PM, revealed the resident was sitting up in the wheelchair in front of his bedside table and the call light was not in reach. The call light was wrapped around the bed rail which was furthest away from him. 4.Review of R9's Face Sheet, revealed the facility admitted the resident on 10/16/2019 with diagnoses to include unspecified sequelae cerebral infarction, chronic obstructive pulmonary disease, and aphasia following cerebral infarction. Review of R9's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/27/2025, revealed staff did not perform a Brief Interview for Mental Status (BIMS) as the resident was rarely or never understood. Observation of R9, on 07/22/2025 at 1:23 PM, revealed the call light was on the floor and inaccessible to the resident. 5.Review of R 30's Face Sheet, revealed the facility admitted the resident on 07/10/2017 with diagnoses to include epilepsy, heart failure, and unspecified dementia. Review of R30's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/14/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Observation of R30, on 07/24/2025 at 3:20 PM, revealed the resident's call light was tied to his bed and hanging in the floor. R 30 was sitting up in his wheelchair in the middle of his room away from the bed, and the call light was not in reach. 6.Review of R33's Face Sheet, revealed the facility admitted the resident on 07/11/2025 with diagnoses to include cerebral infarction, acute kidney failure, and encounter for palliative care. R 33's MDS Assessment was not completed due to the resident being a recent admission.Observation of R33, on 07/24/2025 at 3:09 PM, 3:30 PM, and 5:15 PM, revealed the resident was lying in bed and the call light was noted to be lying on the floor out of the resident's reach. 7. Review of R49's Face Sheet, revealed the facility admitted the resident on 07/17/2025 with diagnoses to include hyperlipidemia, anxiety disorder, and other specified soft tissue disorder. R49's MDS Assessment was not completed due to the resident being a recent admission. Observation of R49, on 07/24/2025 at 3:01 PM, revealed the resident's call light was noted lying on the floor as the resident was asleep in bed. The call light was out of reach of the resident. In an interview with State Registered Nurse Aide (SRNA) 3, on 07/25/2025 at 11:36 AM, she stated before leaving a resident's room staff was to make sure the call light was in reach. She further stated the call light should not be lying in the floor. In an interview with Licensed Practical Nurse (LPN 3), on 07/25/2025 at 2:37 PM, she stated staff should check for call light placement before leaving the room and make sure it was within reach of the resident. She stated a resident could have a fall or need some kind of assistance and would not be able to call staff for help if the call light was out of reach. In an interview with the Assistant Director of Nursing (ADON), on 07/25/2025 at 1:09 PM, she stated she constantly addressed issues with staff regarding the call lights. She stated call lights would be going off all the time while nursing staff was sitting at the desk and not answering, to the point she would have to go and answer them herself. She stated the facility needed to have in-services for the staff to educate them to answer the call lights immediately and to ensure the call lights were in reach of the resident before leaving the resident's room. Further, she stated she had high expectations for the care the residents at the facility received, and the facility needed to work on the call light issue. In an interview with the Director of Nursing (DON), on 07/25/2025 at 2:43 PM, she stated it was her expectation for all residents' call lights to be within reach of the resident. She stated the call lights should also be answered within a timely manner. She further stated staff had a lot of down time on the night shift so there should be no delay in answering the call lights on that shift. She further stated the facility was going to have to have heavy amounts of in-services to educate staff to answer call lights quickly and to ensure the call light was accessible to the resident. In an interview with the Administrator, on 07/25/2025 at 3:00 PM, he stated it was his expectation for the staff to provide compassionate care to the residents, according to their care plan. He stated it was the staffs' job to meet the needs of the residents. The Administrator further stated he thought call lights were brought up in resident council meeting. However, he stated he was not sure if any education had been presented to staff regarding the call light issue. He stated in the future there would need to be education, training and in-services to bring everyone up to standard regarding call lights. He further stated it was his expectation for call lights to be answered timely. The Administrator stated no staff should walk past a call light without acknowledging it, and if it was a non-clinical staff member who could not take care of the need, they should let the resident know they would be finding someone who could take care of them.

Based on observation, interview, and review of facility policy, staff failed to ensure a clean, comfortable, and home-like environment. Observations on 07/23/2025, 07/24/2025, and 07/24/2025, revealed the handrails along the hall corridor were filled with food wrappers, and crumbs. Also, there was a Styrofoam cup containing a liquid substance on the handrail by room [ROOM NUMBER].The findings include: Review of facility policy titled, Resident Rights, undated, revealed the resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely. Observation on 07/23/2025 at 1:40 PM, 07/24/2025 at 3:21 PM, and 07/24/2025 at 5:32 PM, revealed the handrails along the hall corridor were filled with food wrappers, and crumbs. Continued observation revealed there was a Styrofoam cup containing a liquid substance on the handrail by room [ROOM NUMBER]. In an interview with Housekeeper (HK)1 on 07/25/2025 at 1:49 PM, she stated her primary job responsibilities included maintaining a clean environment for the residents and staff. She stated the facility typically had four to five housekeeping staff members working per shift and sometimes a sixth housekeeper if needed. In further interview, she stated the extra person working in housekeeping on the evening shift would be the one responsible for cleaning the hallway corridors, handrails, and floors. During continued interview with HK1, on 07/25/2025 at 1:49 PM, she stated if she was to see something that needed immediate attention such as a spill on the floor, she would clean it up. She stated even when short staffed, the housekeepers could get the job done. However, she stated it just depended on which housekeepers were working on a particular day, if the job gets done. She stated failure to properly clean could cause cross contamination. HK1 stated if the cup on the handrail had spilled onto the floor, it could have created a fall hazard. Further, she stated the loose items on the handrail could have caused a potential choking hazard if mobile residents came by and put the items in their mouth. In an interview with the Housekeeping Supervisor, on 07/25/2025 at 1:55 PM, she stated it was her expectation for her housekeeping staff to make sure everything was neat and tidy. The Housekeeping Supervisor stated she had an extra housekeeper who was responsible for the halls, doors, lobby, glass, and activities area. She stated this week she did not have that extra person working. However, she stated when she did not have the extra housekeeper, she assigned those specific areas to other housekeepers who were to clean them once the rooms had been cleaned. During further interview with the Housekeeping Supervisor, on 07/25/2025 at 1:55 PM, she stated she tried to go through the facility and make sure she walked the halls and picked up any items that may have been left behind, but she also worked as a State Registered Nurse Aide (SRNA) on the floor. She stated she often would get pulled from her housekeeping duties to work in the capacity of a nurse aide. During further interview with the Housekeeping Supervisor, on 07/25/2025 at 1:55 PM, she stated she used to take a housekeeper's word on whether or not something was cleaned, but she learned things were getting missed so she started having them take the cleaning form with them and sign it once tasks were completed. She stated there could be negative outcomes if a resident picked up some of the items from the handrails and attempted to eat them. She further a resident could have sustained a fall from the liquid if it had spilled. In an interview with the Director of Nursing, on 07 /25/2025 at 2:43 PM, she stated it was her expectation for the facility to be clean and tidy. Further, she stated the facility should be a homelike environment for the residents. In an interview with the Administrator, on 07/25/2025 at 3:00 PM, he stated it was his expectation for the housekeeping staff to keep the common rooms, hallways and patient rooms clean in order to maintain a homelike environment. He stated he walked the facility periodically to ensure housekeeping was being maintained. The Administrator stated if he saw an area the housekeeping staff missed, he would find the Housekeeping Supervisor and discuss what needed to be cleaned. He stated the Housekeeping Supervisor also completed audits to ensure the housekeepers were completing work as assigned. The Administrator stated, yesterday, he picked up things from the floor to try and maintain a clean area. He further stated, all staff definitely needed an in-service related to keeping the facility clean and it would take a culture change in order to make this happen. The Administrator stated the facility needed to hold staff accountable for keeping the building clean and tidy, and he was not sure if that was done in the past.

Based on observation, interview, and review of facility policy, the facility failed to store drugs in a manner to preserve integrity.Observation of the medication room refrigerator, revealed 2 COVID-19 vaccine syringes, both expired and 1 of the syringes was shattered.Review of the facility's policy titled Medication Storage, reviewed 03/2025, revealed expired, contaminated, deteriorated medications, and medications in containers that are cracked, soiled, or without secure closures are to be immediately removed from stock and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. Observation of the medication storage room refrigerator, on 07/23/2025 at 2:55 PM, revealed a plastic bag containing two expired COVID-19 vaccine syringes with an expiration date of 04/24/2025, and one of the syringes was shattered. During an interview with Kentucky Medication Aide (KMA)1, on 07/23/2025 at 3:00 PM, she stated nurses were responsible for checking the medication carts and medication refrigerators for expired medications. She further stated pharmacy representatives usually came once per month and checked for expired medications and vaccines on the carts and in the refrigerators. During an interview with the Director of Nursing (DON), on 07/23/2025 at 3:20 PM, she stated she did not know why expired COVID-19 vaccine syringes were in the medication refrigerator. She stated pharmacy staff was at the facility yesterday and should have removed the expired vaccines. During an interview with the DON, on 07/25/2025 at 2:43 PM, she stated if expired medications including vaccinations were administered to a resident, the resident could have a reaction. She further stated having expired vaccinations in the medication refrigerator was an infection control issue. The DON stated it was her expectation for staff to check the medication room and medication carts and remove expired medications from the medication room and refrigerator stock, and medication carts. During an interview with the facility's Administrator, on 07/25/2025 at 3:21 PM, he stated it was his expectation for nursing staff to provide exceptional care to the residents and provide for every resident's needs. He stated he expected staff to properly store medications and make sure all medications were not expired.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff failed to maintain infection control practices during urostomy care for Resident (R)2; during wound care for R26; and during medication administration for R4. Additionally, the facility failed to ensure staff was fit tested for a N95 respirator mask required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. These failures had the potential to affect all residents that resided in the facility. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, dated 01/01/2024, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy further revealed, Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. 1. Review of R2's Admission Record revealed the facility admitted the resident on 04/15/2024. According to the Admission Record, the resident's medical history included diagnoses of quadriplegia and other artificial openings of urinary tract status. Review of R2's Comprehensive Care Plan included a focus area revised 05/07/2024, which revealed the resident had a self-care deficit and required assistance with activities of daily living. Interventions included dependent for toileting hygiene. Review of R2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/2024, revealed the facility assessed R2 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS further revealed the resident was dependent on staff for toileting and had a urostomy. During an observation of urostomy care, for R2, on 09/12/2024 at 8:51 AM, Registered Nurse (RN)13 laid down a clean barrier on the bedside table, prepared the needed supplies, and then washed her hands. She stepped outside the resident's door and donned a gown and gloves for enhanced barrier precautions. RN13 then removed the soiled urostomy bag from the resident's abdomen and dropped the soiled bag onto the floor instead of into a trash receptacle. Without changing gloves or sanitizing or washing her hands, RN13 opened the new drainage bag and attached it to the drainage tubing and laid the new urostomy bag and tubing on top of the resident's bedding, without a barrier underneath. RN13 cleansed the urostomy site with warm washcloths, placed the soiled washcloths into a trash bag on the floor, then reached over and picked up the soiled urostomy bag from off the floor and placed it in the trash. Urine was observed running down the side of the resident's abdomen and RN13 retrieved a drainage pad and tucked it under the resident's abdomen with the same soiled gloves. With the same soiled gloves, RN13 applied skin prep adhesive around the stoma site, peeled the backing from the new urostomy bag, and adhered it to the resident's abdomen. RN13 then gathered the soiled drainage pad, placed it in the trash, doffed her gown and gloves, placed them in the trash, and exited the room without washing her hands. At no time after donning her initial gown and gloves did RN13 change her gloves or sanitize or wash her hands between clean and dirty processes of changing the urostomy bag and providing urostomy care. During an interview, on 09/12/2024 at 11:20 AM, RN13 stated she should have changed her gloves and washed her hands after taking off the dirty urostomy bag and before placing the clean urostomy bag to the resident's stoma site. During an interview, on 09/12/2024 at 3:26 PM, the Director of Nursing (DON) stated it was her expectation for the nurses to follow the proper infection control techniques they had been taught and to know when to change gloves. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated it was his expectation for urostomy care to be performed in a clinically sound manner and for staff to adhere to best practices. 2. Review of R26's Admission Record revealed the facility admitted the resident on 10/25/2019. According to the Admission Record, the resident's medical history included diagnoses of peripheral vascular disease and chronic peripheral venous insufficiency. Review of R26's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/2024, revealed the facility assessed the resident as having a BIMS score of 13 out of 15, which indicated intact cognition. The MDS also revealed the resident had two (2) venous or arterial ulcers. Review of R26's Comprehensive Care Plan, revised on 11/01/2019, revealed a focus area stating the resident was at risk for cardiac problems due to diagnoses of peripheral vascular disease and venous insufficiency. During an observation of wound care for R26, on 09/12/2024 at 1:55 PM, Licensed Practical Nurse (LPN)7 opened wound care supplies in the hallway, on top of the treatment cart. LPN7 applied hand sanitizer to her hands, grabbed the wound care supplies, walked into R26's room and placed the supplies on a bedside table, without a clean barrier in place. LPN7 removed the soiled dressings from the resident's lower right leg, folded the dressings in half, and placed them on top of the resident's bed linens instead of in the trash. She then removed her soiled gloves and placed them on top of the bedside table next to the clean dressings. LPN7 re-gloved without sanitizing or washing her hands. LPN7 then cleansed the resident's right leg wound with a wound cleanser and gauze, poured collagen powder onto her right gloved hand and began patting it onto the wound bed, and sprayed the resident's leg with skin prep spray. LPN7 then removed her gloves, and without sanitizing or washing her hands, she re-gloved, cleaned the resident's left lower leg wound with wound cleanser and sprayed the resident's left leg with skin prep spray. When the wound care was complete, LPN7 gathered up the soiled dressings, empty dressing packaging and soiled gloves from on top of the bedside table, threw the items into the trash and removed her gloves. At no time during the wound care process did LPN7 sanitize or wash her hands between glove changes when going from dirty to clean processes. During an interview, on 09/12/2024 at 3:26 PM, the DON stated it was her expectation for the nurses to follow proper infection control technique in providing care for open wounds. Per interview, this would include placing clean supplies on a clean barrier, and washing hands or applying alcohol gel (hand sanitizer) between donning gloves. Further, staff should not contaminate clean items with dirty items during wound care, and should not open wound care supplies in the hallway. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated it was his expectation for wound care to be performed in a clinically sound manner and for staff to adhere to best practices. 3. During an observation of medication pass on the 200 Hall, on 09/10/2024 at 8:17 AM, Kentucky Medication Aide (KMA)12 donned gloves and began preparing medications. KMA12 touched multiple surfaces on/in the medication cart, poured medications into her gloved hand, then placed the medications into a medication cup and administered the medications to R4. During an interview, on 09/12/2024 at 3:26 PM, the DON stated it was her expectation for the nursing staff to maintain standard precautions for medication distribution. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated it was his expectation for the nurses to administer medications appropriately. 39438 4. During an interview on 09/11/2024 at 3:05 PM, State Registered Nurse Aide (SRNA)8 stated she started working at the facility at the beginning of March. She stated she had not been fit tested for an N95 (respirator) mask. SRNA8 further stated she last cared for a resident with Coronavirus Disease 2019 (COVID-19) about one (1) month ago. During an interview, on 09/11/2024 at 3:18 PM, SRNA6 stated she started working at the facility two (2) years ago. She stated when she was assigned to a resident that had COVID-19, she wore an N95 mask, gloves, and gown. SRNA6 further stated she had not been fit tested for an N95 mask. During an interview, on 09/11/2024 at 3:30 PM, LPN7 stated she had been employed at the facility for eight (8) years. She further stated it had been a few weeks since she had provided care to a resident with COVID-19. In further interview, LPN7 stated she wore a gown, gloves, and an N95 mask when caring for residents with COVID-19; however, she had not been fit tested for an N95 mask. During an interview, on 09/11/2024 at 4:00 PM, Registered Nurse (RN)19 stated she had provided care to residents with COVID-19 about a month ago. She further stated when providing care to residents with COVID-19, she wore a gown, gloves, and N95 mask; however, she stated she had not been fit tested to wear an N95 mask. During an interview, on 09/12/2024 at 11:13 AM, Kentucky Medication Aide (KMA)20 stated he had been working in the facility since July. He further stated he had not been fit tested to wear an N95 mask. During an interview, on 09/12/2024 at 11:47 AM, RN9 stated she conducted COVID-19 tests during the facility's outbreak. However, she stated she had not been fit tested to wear an N95 mask. During an interview, on 09/12/2024 at 12:29 PM, RN21 stated she had been employed at the facility for almost three (3) years. She further stated she tested on e (1) resident during the COVID-19 outbreak, but had never been fit tested to wear an N95 mask. A document titled, Covid Tracing For Staff, revealed staff who cared for residents during the COVID-19 outbreak. SRNA6, LPN7, SRNA8, and RN9 were included on the document. During an interview, on 09/12/2024 at 2:06 PM; and 09/12/2024 at 5:31 PM, the DON confirmed the staff listed on the Covid Tracing For Staff were assigned to residents that had been diagnosed with COVID-19 during the outbreak. In further interview, the DON stated the facility used N95 masks if they had positive cases of COVID-19 in the building; however, fit testing had not been completed. The DON stated the facility was not aware of what fit testing was and the facility did not have a policy related to fit testing. During an interview, on 09/12/2024 at 3:51 PM, the Administrator confirmed they did not do fit testing for the N95 masks at the facility.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure medications were obtained from the pharmacy in a timely manner for two (2) of three (3) sampled residents reviewed for pharmacy services, Resident (R)8 and R32. (Refer to F658) The findings include: Review of the facility policy titled, Administering Medications, revised on 11/15/2011, revealed, Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director. 1. Review of R32's Admission Record revealed the facility admitted the resident on 02/17/2020. According to the Admission Record, the resident's medical history included a diagnosis of atrial fibrillation. Review of R32's Comprehensive Care Plan, revealed a focus area revised 02/25/2020, stating the resident had a self-care deficit. Interventions directed staff to administer medications as ordered. Review of R32's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 07/08/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of 15, indicating severe cognitive impairment. Further review of the MDS, revealed the resident received an anticoagulant medication. Review of R32's Physician's Order sheet, revealed a current order initiated 03/06/2024, for Eliquis (anticoagulant medication) five (5) milligram (mg) tablet, give one (1) tablet by mouth once a day for atrial fibrillation. During observation of medication pass, on 09/10/2024 at 8:40 AM, Kentucky Medication Aide (KMA)12 was unable to locate R32's Eliquis tablet in either the medication cart or the medication room. 2. Review of R8's Admission Record revealed the facility admitted the resident on 08/02/2021. According to the Admission Record, the resident's medical history included a diagnosis of type 2 diabetes mellitus. Review of R8's Comprehensive Care Plan, revealed a focus area revised 02/25/2020, stating the resident was at risk for hyperglycemia and hypoglycemia related to a diagnosis of diabetes. Interventions directed staff to administer diabetic medications as ordered by the physician (initiated 08/18/2021). Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Additional review revealed the facility assessed the resident as having an active diagnosis of diabetes mellitus. A Physician's Order sheet for R8 revealed a current order dated 03/30/2024, for metformin hydrochloride (medication used to treat diabetes mellitus), 1,000 milligrams, give one (1) tablet by mouth every morning. During an observation of medication pass, on 09/10/2024 at 9:08 AM, KMA12 was unable to find R8's metformin tablet in either the medication cart or in the medication room. During an observation, on 09/11/2024 at 12:12 PM, Licensed Practical Nurse (LPN)7 checked the medication cart and stated R8's metformin tablets were, Still not in the cart, and R32's Eliquis tablets were, Not in the cart either. LPN7 stated she looked for the stickers that should have been pulled from both medication boxes and faxed to the pharmacy in order to refill the medications, but could not find them. LPN7 then located a Refill Reorder Form with the sticker for R8's metformin tablets dated as faxed to the pharmacy on 08/31/2024. LPN7 was not able to locate a Refill Reorder Form with R32's sticker for Eliquis 5 mg. LPN7 stated, If we were having trouble getting the medication from pharmacy, we should pick up the phone and call. During an interview, on 09/12/2024 at 10:47 AM, KMA12 stated the process for reordering medications was to pull the sticker from the medication box and put the sticker on a pharmacy sheet. KMA 12 stated at the end of her shift, she would give it to the nurse on duty to fax to the pharmacy. During a telephone interview, on 09/11/2024 at 3:39 PM, Pharmacist15 stated R8's 1,000 mg metformin tablets were sent to the facility on [DATE] in a count of 30 pills. Pharmacist15 further stated R8's 1,000 mg metformin tablets had been filled again that morning, 09/11/2024, and would be in the facility's delivery that night. Further, Pharmacist15 stated R32's 5 mg Eliquis tablets had last been filled on 08/19/2024 in a count of 14 pills. Pharmacist15 stated R32's 5 mg Eliquis tablets had been filled again that morning and would be in the facility's delivery that night. During a telephone interview, on 09/11/2024 at 4:04 PM, Pharmacist23, from the facility's dispensing pharmacy, stated 30 tablets of R8's 1,000 mg metformin had last been sent out on 07/22/2024, and That order would not be enough medication to last until 09/11/2024. It should have been ordered sooner. Pharmacist23 also stated, regarding R32's 5 mg Eliquis tablets, A 14-day supply was dispensed on 08/19/2024, again, we are 23 days past the date it was filled, and only 14 tablets were sent. They ran out of medication prior to receiving the next shipment, which is being sent to them tonight, 09/11/2024. Pharmacist23 further stated, Both of those medications are in the facility's emergency kit and should have been pulled from it; however, if they had been pulled, we would have a pull slip, and we do not. Pharmacist23 stated the facility was on the box system, so there was not an alert for them to reorder medication, and when the medication was running low the facility had to notify the pharmacy. During an interview, on 09/12/2024 at 3:26 PM, the Director of Nursing stated she expected nursing staff to notify the pharmacy when they were out of a medication and have the pharmacy send it as soon as possible. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated he expected staff to reorder medication timely, as they needed to, and to have a process to ensure the facility received the medication that was ordered.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed there were two (2) errors out of 27 opportunities, which resulted in a medication error rate of 7.41%. This affected two (2) of three (3) residents observed during medication administration, Resident (R)8 and and R32. Refer to F658 The findings include: A facility policy titled, Administering Medications, revised on 11/15/2011, revealed, Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director. The policy further revealed the Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR (Medication Administration Record) space provided for that particular drug. 1. Review of R32's Admission Record revealed the facility admitted the resident on 02/17/2020. Per the Admission Record, the resident's medical history included a diagnosis of atrial fibrillation. R32's current Physician's Order sheet for September 2024, contained an order initiated 03/06/2024 for Eliquis (anticoagulant medication used to prevent blood clots) 5 milligram (mg) tablet with instructions to give one (1) tablet by mouth once a day for atrial fibrillation. During an observation of medication pass, on 09/10/2024 at 8:40 AM, Kentucky Medication Aide (KMA)12 was unable to find Eliquis 5 mg in the medication cart for R32. KMA12 then looked in the medication room, but was not able to find the resident's Eliquis 5 mg tablets. R32's September 2024 Medication Administration Record (MAR), revealed staff initialed and circled the resident's 09/10/2024, 9:00 AM dose of Eliquis, indicating the medication was not administered. 2. Review of R8's Admission Record revealed the facility admitted the resident on 08/02/2021. Per the Admission Record, the resident's medical history included a diagnosis of type 2 diabetes mellitus. R8's current Physician's Order sheet for September 2024, contained an order initiated 03/30/2024 for metformin HCL (hydrochloride) (a medication that lowers blood sugar levels) 1,000 mg with instructions to give one (1) tablet by mouth every morning. During an observation of medication pass, on 09/10/2024 at 9:08 AM, KMA12 was unable to find metformin 1,000 mg in the medication cart. After KMA12 checked the medication room for back-up medication, metformin 1,000 mg tablets could not be found for R8. R8's September 2024 MAR, revealed staff initialed and circled the resident's 09/10/2024, 9:00 AM dose of metformin, indicating the medication was not administered. During an interview, on 09/12/2024 at 10:47 AM, KMA12 stated R32's Eliquis 5 mg tablets and R8's metformin 1000 mg tablets were not in the medication cart and she could not give them. During an interview, on 09/12/2024 at 3:26 PM, the Director of Nursing (DON) stated when the facility was out of a medication, she expected the nurses to contact the pharmacy and ask that they send the medication as soon as possible. She further stated, in the meantime, if the facility had to troubleshoot, the nurses should have called the doctor if needed. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated it was his expectation for medications to be given as ordered and to have a process to ensure the facility was receiving ordered medications.

Based on interview, record review, facility document review, and review of facility policy, the facility failed to report an allegation of abuse within the two (2) hour time frame for one (1) of three (3) residents reviewed for abuse prohibition, (Resident (R) 40. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 04/10/2023, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. According to the policy, Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also revealed, under Reporting/Response, the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies including law enforcement when applicable, immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R40's Admission Record revealed the facility admitted the resident on 07/20/2023 with diagnoses including Alzheimer's disease and anxiety. Review of R40's Comprehensive Care Plan included a focus area initiated 08/15/2023, which revealed the resident was at risk for increased behaviors, altered mood state, and altered psychosocial well-being related to diagnoses of anxiety and dementia. Interventions directed staff to be alert for expressions of mood indicators, behaviors, and/or altered psychosocial well-being (initiated 08/15/2023). Review of R40's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/10/2024, revealed the facility completed a Staff Assessment for Mental Status, which indicated the resident was severely impaired in cognitive skills for daily decision making. Review of the [State Agency] Long Term Care Facility - Self-Reported Incident Form Final Report/5 Day Follow-up, dated 09/03/2024, revealed an incident allegedly occurred in the dining room on 08/24/2024 at approximately 7:00 PM, and R49 who had a BIMS score of 15, indicating intact cognition, was a witness to the incident. The report revealed R49 was sitting at a table talking to R40 when R34 rolled up in a wheelchair. R34 started to kick R40's foot and told R40 to move to another table. According to the report, there were no staff in the dining room at the time of the alleged abuse. R49 advised R34 to stop kicking R40's foot; however, R34 stated R49 was not the boss of them and continued to kick R40's foot. Per the report, R49 moved R40 away from R34 so R34 would not be able to kick R40. According to the facility's report, Registered Nurse (RN)9 stated R49 reported the allegation of abuse to her on 08/24/2024 at approximately 7:00 PM. However, the report revealed the Administrator was not aware of the allegation of abuse until 08/26/2024 at approximately 9:15 AM, when an investigation of the allegation of abuse was initiated. (According to the facility's Initial Report, dated 08/26/2024, the facility submitted the Initial Report to the state agency on 08/26/2024 at 10:50 AM, two (2) days after the alleged incident occurred.) Interview with the Administrator, on 09/11/2024 at 9:20 AM, revealed RN9 did not notify him of the allegation of abuse until 08/26/2024. The Administrator stated once he was notified, he started an investigation and submitted a report to the state agency on 08/26/2024. According to the Administrator, the facility was out of compliance for reporting time for the allegation of resident-to-resident abuse. Interview with RN #9, on 09/12/2024 at 11:55 AM, revealed R49 reported R34 was kicking at R40's foot with an open toed shoe and R49 separated the residents. RN9 stated any allegation of abuse was expected to be reported immediately to administration. However, RN9 further stated she did not report this incident immediately to administration on 08/24/2024 because she did not consider R34 kicking at R40's feet to be abuse. During a follow-up interview, on 09/12/2024 at 4:31 PM, the Administrator stated staff was expected to report allegations of abuse immediately and he would report the allegation of abuse to the state agency within two (2) hours.

Based on interview, record review, and review of facility policy, the facility failed to initiate a new Level I Preadmission Screening and Resident Review (PASARR) for a resident who received new psychiatric diagnoses following admission. This affected one (1) of one (1) residents reviewed for PASARR requirements, (Resident (R)14. The findings include: An undated facility policy titled, Preadmission Assessment and Annual Resident Review (PASARR), revealed, The purpose of the Preadmission Assessment and Annual Resident Review Program (PASARR) policy and procedure is to develop guidelines for admission related to those individuals with mental illness and intellectual disabilities to ensure they receive the care and services needed in the most appropriate setting. R14's Pre-Admission Screening and Resident Review (PASARR) Nursing Facility Identification Screen (Level I), dated 07/15/2013, prior to R14's admission to the facility, revealed the resident did not have a major mental disorder, to include severe anxiety disorder, other psychotic disorders, or another mental disorder that may lead to a chronic disability. The Level I screening indicated the resident did not meet the criteria for mental illness or mental retardation. Review of R14's Admission Record revealed the facility admitted the resident on 07/16/2013. According to the Admission Record, the resident had a medical history that included diagnoses including psychosis due to a substance or known physiological condition (onset 08/07/2015), anxiety disorder (onset 10/22/2015), and major depressive disorder (onset 10/22/2015). Review of R14's Comprehensive Care Plan included a focus area initiated on 04/11/2014, which revealed the resident was non-complaint with care being provided as evidenced by a rejection of care and refusal of medications. Interventions directed staff to allow the resident to make as many choices as possible within limits (initiated 04/11/2014); to be alert to increased signs and symptoms of depression, and to promptly report to the physician symptoms such as crying, sadness, and verbalizing self-worth; and to notify the physician of unwillingness to accept care and/or medications (initiated 04/11/2014). Review of R14's Comprehensive Diagnostic Evaluation & Treatment Plan, dated 08/06/2015, revealed the Reason for Referral indicated delusional/anxiety. The record revealed the DSM - IV [Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition] Diagnoses indicated the resident had diagnoses of generalized anxiety disorder, depression, vascular dementia with disturbance of mood and behavior with delusions, and psychosis. Further review of R14's Comprehensive Care Plan included a focus area revised on 04/10/2023, which revealed the resident was at risk for increased behaviors, altered mood state, and altered psychosocial well-being related to a diagnosis of cerebrovascular accident (CVA-Stroke), resulting in brain damage with moderate confusion, increased agitation and attention seeking behaviors. Interventions directed staff to be alert for expressions of mood indicators, behaviors, and/or altered psychosocial well-being (initiated 03/26/2014); document all displayed mood indicators/behaviors and determine effectiveness of interventions (initiated 03/26/2014); seek a psychiatric consultation as ordered (initiated 03/26/2014); assess for the cause of the increased mood indicators/behaviors (initiated 03/26/2014); and tell the resident to stop the exhibited behavior while immediately distancing the recipient/resident to prevent harm from aggression (initiated 08/16/2015). Review of R14's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of 15 indicating moderate cognitive impairment. Per the MDS, the resident had active psychiatric diagnoses of anxiety, depression, and psychotic disorder. Further review of the MDS, revealed the resident was receiving antidepressant medication during the assessment timeframe. Review of R14's Diagnosis Report, dated 09/11/2024, revealed diagnoses including manic psychosis (onset 08/07/2015), recurrent major depressive disorder (onset 10/22/2015), and anxiety disorder (onset 10/22/2015). Further review of R14's medical record revealed no other PASARR had been completed since admission to the facility. Additionally, there was no evidence to indicate a referral was made to the appropriate state-designated authority after receiving new psychiatric diagnoses. During an interview, on 09/12/2024 at 3:07 PM, the Medical Records Director (MRD) stated she had worked at the facility since 2008. She further stated when she was alerted there was a new admission coming to the facility, she accessed the electronic system to fill out the initial application for a Level I screening. If the application was positive, the state designated mental health authority would call the facility and start the process for a Level II evaluation to be completed. The MRD stated if a resident received a new psychiatric diagnosis, she logged into the electronic system and updated the diagnosis to see if it triggered a positive Level I screening. She further stated, when R14 received new diagnoses in 2015, she should have updated the diagnoses in the electronic system and completed another Level I screening to see if it triggered as positive. During an interview, on 09/12/2024 at 3:26 PM, the Director of Nursing (DON) stated she did not know anything at all about the PASARR process. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated he expected the PASARR assessments to be completed as appropriate.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure services provided by the facility met professional standards of quality for one (1) of three (3) residents observed during medication pass, (Resident (R)8. R8's Physician's Order sheet for 09/2024, revealed a current order for metformin hydrochloride (HCL) 1,000 milligrams (mg) with instructions to give one (1) tablet by mouth every morning at 9:00 AM. The Physician's Order sheet further revealed a current order for metformin HCL 500 mg with instructions to give one (1) tablet at 5:00 PM. During an observation of medication administration on 09/10/2024 at 9:08 AM, Kentucky Medication Aide (KMA)12 was unable to locate R8's metformin hydrochloride (HCL) 1,000 milligram (mg) tablets. Staff interviews revealed R8's metformin HCL 1,000 mg tablets had been reordered on 08/31/2024, but had not been delivered. Staff interviews further revealed they had been administering two (2) 500 milligram (mg) tablets of metformin HCL instead of the ordered 1,000 mg tablet for the 9:00 AM dose. Staff had not notified the physician, the 1,000 mg tablets were unavailable or followed up with pharmacy. The findings include: Review of the facility policy titled, Administering Medications, revised on 11/15/2011, revealed Medications will be administered in a timely manner and as prescribed by the resident's Attending Physician or the facility's Medical Director. The policy indicated, . The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the Attending Physician's written/verbal orders. The policy further revealed . The individual administering the medication must ensure that the right medication, right dosage, right time and right method of administration are verified e.g. [exempli gratia, for example], review of drug label, physician's order, etc. [et cetera; and so forth] before the medication is administered. Review of R8's Admission Record revealed the facility admitted the resident on 08/02/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. Review of R8's Comprehensive Care Plan, revealed a focus area revised 02/25/2020, stating the resident was at risk for hyperglycemia and hypoglycemia related to a diagnosis of diabetes. Interventions directed staff to give diabetic medications as ordered by the physician (initiated 08/18/2021). Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as having an active diagnosis of diabetes mellitus. Review of R8's Physician's Order sheet for 09/2024, revealed a current order dated 03/30/2024 for metformin hydrochloride (HCL) (medication used to treat type 2 diabetes) 1,000 milligrams (mg) with instructions to give one (1) tablet by mouth every morning at 9:00 AM. The Physician's Order sheet further revealed a current order dated 03/30/2024 for metformin HCL 500 mg with instructions to give one (1) tablet at 5:00 PM. During an observation of medication administration on 09/10/2024 at 9:08 AM, for R8, KMA12 was unable to find metformin 1,000 mg tablets in the medication cart. After looking in the medication room for back-up medication, the metformin 1,000 mg tablets could not be found. R8's MAR for the timeframe from 09/01/2024 through 09/10/2024, revealed staff documented the resident received metformin 1,000 mg on 09/01/2024 through 09/09/2024 and indicated the medication was not given on 09/10/2024. During an interview, on 09/11/2024 at 11:34 AM, the Director of Nursing (DON) stated R8 received metformin 500 mg in the evening and staff should have doubled up the 500 mg medication instead of leaving the resident without any of the medication for the 9:00 AM dose. When asked if it was acceptable to double up on medication to get the correct milligrams, she stated, That is what I would have done. During an interview, on 09/11/2024 at 2:51 PM, the Social Services Director (SSD), who was also a KMA, stated R8's metformin had been reordered on 08/31/2024 and still had not been delivered. She stated the MAR had been signed several times indicating the medication was administered. The SSD further stated R8 had not missed a dose when she had administered medications because she had given the resident two (2) 500 mg tablets of metformin to make 1,000 mg for the 9:00 AM dose. During a subsequent interview, on 09/12/2024 at 10:28 AM, the SSD stated she had passed medications to R8 on 09/01/2024 and 09/08/2024. She stated R8 had been out of metformin 1,000 mg tablets for a few days, but she was not exactly sure how many days. She further stated the resident could have been out of the 1,000 mg tablets on 09/01/2024 because she had told the nurse to reorder them on that date and had administered the resident two (2) of the resident's evening 500 mg metformin tablets on 09/08/2024 for the 9:00 AM dose. The SSD stated she had not called the physician about doubling up on the metformin because she did not have permission to call the doctor. She stated she was not sure if the nurse had called the physician related to this. She further stated she felt doubling up smaller doses of a medication was acceptable as long as the resident received the correct amount of the medication. During an interview, on 09/12/2024 at 12:01 PM, Licensed Practical Nurse (LPN) 27 stated she had passed medication to R8 on 09/06/2024 and 09/07/2024. She stated R8 had been out of metformin 1,000 mg for a few weeks and although the facility had an overflow of medications, the metformin was not included. LPN27 stated she had been administering two (2) 500 mg metformin tablets in order for the resident to receive the correct dose of medication. However, she further stated it was not acceptable to double up smaller doses of a medication to equal the prescribed amount. LPN27 stated the physician should be notified immediately if a medication refill was needed or if a new prescription needed to be written, but she had not called the doctor in reference to R8 being out of the metformin 1,000 mg tablets. During a phone interview, on 09/11/2024 at 4:04 PM, Pharmacist 23, from the facility's dispensing pharmacy, stated it would not be appropriate for facility staff to use two (2) metformin 500 mg tablets when they ran out of the 1,000 mg tablets. He stated doing this would cause them to run out of the 500 mg tablets before it was due to be refilled. During a follow up interview, on 09/12/2024 at 3:26 PM, the Director of Nursing (DON) stated if the orders were for metformin 1,000 milligrams (mg), give one (1) tablet by mouth every morning at 9:00 AM, it would not be appropriate for staff to administer two (2) 500 mg tablets. She stated when staff identified a resident was out of a medication, they should contact the pharmacy to send the medication. In the meantime, they would need to call the doctor to get an order if needed, and document the phone call in the nurse's notes. During an interview, on 09/12/2024 at 4:07 PM, the Administrator stated it was his expectation for staff to administer medications as ordered and to reorder medications as needed.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for one (1) of one (1) sampled residents reviewed for ADLs, Resident (R)41. Although R41 had a contracture of the left hand, the facility failed to ensure R41's nails were trimmed. The findings include: Review of the facility's undated policy, titled Nail Care, revealed routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. The resident's plan of care will identify the frequency of nail care to be provided; the type of nail care to be provided; the person(s) responsible for providing nail care such as licensed nurse, nurse aide, podiatrist, or activity professional. Review of R41's Admission Record revealed the facility admitted the resident on 07/05/2023. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), hemiplegia and hemiparesis (weakness on one side of the body) affecting left non-dominant side, and contracture of muscle in the left hand. Review of R41's Comprehensive Care Plan, included a focus area initiated on 07/14/2023, revealing the resident was at risk for self-care deficit related to non-independence with ADLs, impaired mobility, weakness, and a diagnosis of cerebrovascular accident (CVA). Interventions directed staff to provide nail care per the facility policy. Review of R41's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. Further review revealed the facility assessed the resident as not having rejected care during the assessment period. Additional review revealed R41 required substantial/maximal staff assistance with personal hygiene. Review of R41's Kardex (a care plan that acts as a quick reference guide to the individual needs of residents), as of 09/12/2024, revealed no information related to nail care. Observation on 09/09/2024 at 11:26 AM, revealed R41 had long, jagged fingernails. R41's left hand was contracted. During a concurrent interview, R41 stated the fingernails on her left hand really need trimmed. Resident #41 stated she was concerned her fingernails would cause a wound on her contracted hand if they were not trimmed. Observation on 09/11/2024 at 2:45 PM, revealed R41's fingernails continued to be long and jagged. During a concurrent interview R41 stated, if staff did not trim her fingernails, the nails on her contracted hand would cut the skin. During interview on 09/12/2024 at 10:45 AM, State Registered Nurse Aide (SRNA)1 stated the SRNAs trimmed resident fingernails unless the resident was diabetic. SRNA1 further stated she was unsure if R41 was diabetic, and she would need to ask the nurse. Additionally, SRNA1 stated R41 was compliant with care and did not refuse care. During interview on 09/12/2024 at 12:28 PM, SRNA10 stated she trimmed resident fingernails whenever she saw that it needed to be done, or whenever the resident requested their nails be trimmed. SRNA10 stated she was unaware of R41 asking for her nails to be trimmed. She stated R41s family trimmed her nails. During interview on 09/12/2024 at 1:32 PM, Licensed Practical Nurse (LPN)5 was asked to check R41's nails. LPN5 checked R41's nails and stated the activity department trimmed the resident's nails. LPN5 then picked up R41s left hand and stated staff had to be real careful with the resident's contracted hand because the nails would dig into the skin. During interview on 09/12/2024 at 1:38 PM, LPN7 stated the nurses trimmed diabetic resident's fingernails once a week. LPN7 further stated the SRNAs were responsible for trimming the non-diabetic resident's nails upon request or when the resident's nails needed cut or filed. LPN7 stated the SRNAs usually trimmed nails when they gave showers, but the nurse was not sure if nail trimming was documented anywhere. LPN7 stated it was important for R41 to receive routine and as needed nail care promptly due to the resident's hand contracture. During interview on 09/12/2024 at 2:49 PM, the Social Services Director (SSD) stated the SRNAs performed nail care for residents who were not diabetic. The SSD stated nail care should be performed on the resident's shower days, not a scheduled day, or just when the SRNA noticed the nails were long. The SSD stated she was not sure if nail care was documented anywhere. During interview, on 09/12/2024 at 3:42 PM, Occupational Therapist (OT)24 stated R41 was not diabetic so anyone could trim her nails. During interview, on 09/12/2024 at 2:52 PM, the Director of Nursing (DON) stated nail care was the responsibility of the treatment nurse. The DON further stated the facility did not currently have a treatment nurse, and therefore the SRNAs or nurses were to perform nail care. The DON stated she was not aware of any schedule for nail care; but nails were to be trimmed as needed on shower days. In further interview, the DON stated it was her expectation residents' nails would be clean, filed and not jagged. During interview, on 09/12/2024 at 3:16 PM, the Administrator stated it was his expectation for resident nail care to be performed routinely, and nails should be cleaned, trimmed, and not jagged.

Based on interview, record review, facility document review, and review of facility policy, the facility failed to ensure pharmacy recommendations were acted upon timely for one (1) of five (5) sampled residents reviewed for unnecessary medications, Resident (R)10. The findings include: A facility policy titled, Medication Regimen Review, revised 06/02/2024, revealed, the consultant pharmacist will conduct MRRs (medication regimen reviews) if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record. The facility should alert the medical director where MRRs are not addressed by the attending physician in a timely manner. The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations. Review of R10's Admission Record revealed the facility admitted the resident on 02/03/2023 and readmitted the resident on 11/06/2023. According to the Admission Record, the resident's medical history included diagnoses of hypertension and chronic combined systolic and diastolic heart failure. A Consultation Report, electronically signed by Pharmacist15, on 06/18/2024, revealed R10 received atenolol 50 milligrams (mg) twice a day for hypertension with the recommendation to consider adjusting the dose of atenolol to 25 mg twice daily for hypertension. Further review revealed the physician had not signed the report. Another Consultation Report, electronically signed by Pharmacist15 on 06/18/2024, revealed R10 received Myrbetriq (mirabegron) (a medication to treat overactive bladder) 50 mg daily with a recommendation to reduce Myrbetriq to 25 mg once daily. Further review revealed the physician had not signed the report. Another Consultation Report, electronically signed by Pharmacist15 on 06/18/2024, revealed R10 received tetrahydrozoline eye drops (an ophthalmic decongestant), which should be limited to 72 hours to avoid worsening symptoms with the recommendation to discontinue the tetrahydrozoline eye drops. Further review revealed the physician had not signed the report. Resident10's Physician's Order, dated 06/2024, contained the following orders: atenolol 50 mg with instructions to give one (1) tablet by mouth two (2) times a day; Myrbetriq extended release 50 mg tablet with instructions to give one (1) tablet by mouth once a day; and tetrahydrozoline eye drops 0.05% with instructions to instill one (1) drop into each eye two (2) times a day. R10's Physician's Orders, dated 07/2024, 08/2024, and 09/2024 contained the same orders for atenolol, Myrbetriq, and tetrahydrozoline. There was no indication the pharmacist recommendations from 06/18/2024 had been reviewed by the physician. During an interview, on 09/11/2024 at 11:27 AM, the Director of Nursing (DON) stated after the pharmacist visited the facility, within that same week, she received an email that contained the recommendations. She stated the pharmacist sent the June recommendations on 06/18/2024 per the date on the recommendation report, and she was not the DON at the facility at that time. The DON confirmed the physician had not responded to the recommendations for R10. The DON further stated, if the physician had responded to the recommendations, the recommendation report would have been signed and in the resident's chart under orders. During an interview, on 09/12/2024 at 8:33 AM, Pharmacist15 stated she came to the facility at least once a month to do a comprehensive regimen review for each resident. She stated after she completed the pharmacy reviews, they were posted on their website for the facility to review. Pharmacist15 stated, as a courtesy, she also emailed the pharmacy reviews to the DON and the Administrator. She stated she reconciled on the next visit to see if the recommendations had been reviewed by the provider. Pharmacist15 stated she did not see a response for the recommendations in June for R10. She reported the recommendations on 06/18/2024, and sent the report to the former DON, the Administrator, and a regional staff member. Pharmacist15 stated if she saw a follow up was not completed, then she would reissue the recommendations. She stated she expected staff to follow up on the recommendations by her next visit, the following month. During an interview, on 09/12/2024 at 9:39 AM, the Medical Director stated if a pharmacist made a recommendation, staff must let the physician know timely. The Medical Director stated, timely would be whatever the policy and procedure indicated. The Medical Director further stated R10 went to the hospital and the recommendations may have fell through during that time. During an interview, on 09/12/2024 at 8:55 AM, the Administrator stated the DON was responsible for making sure the pharmacist recommendations were followed up on by the provider. The Administrator stated the recommendations were communicated to him and the DON via email. The Administrator further stated it was his expectation for there to be a response and/or a follow-up to the recommendations.

Based on interviews, and review of the facility's policy, it was determined the facility failed to maintain evidence of the result of all grievance documenting facility staff's investigation of the grievance and provide the resident information toward the resolution of the grievance. Interviews revealed staff failed to maintain documentation of grievances filed, to include the investigations, and results, for the past twelve (12) months, if residents had filed any grievances. The findings include: Review of the facility's policy titled, Filing Resident Grievances/Complaints, not dated, revealed upon receipt of a written/oral grievance and/or complaint, the Social Service Director or designee would investigate the allegations and submit a written report of such findings to the Administrator within one working day of receiving the grievance and/or complaint. Further review of the policy revealed a written summary of the report would also be provided to the resident, and a copy would be filed in the Social Service Office. During the survey entrance conference, on 09/19/22 at 9:10 AM, a request was made to the Director of Nursing (DON) for the facility's evidence of all grievances filed, their investigations, and the results, for the previous six (6) months. Interview with the Social Services Director (SSD), on 09/20/22 at 8:44 AM, revealed the facility had no documentation of grievances filed. She stated she had never kept any records. The SSD stated she had just resolved the grievances as they were brought to her attentions, but should have kept a log and recorded what was done to resolve issues. Additional interview with the DON, on 09/20/22 at 3:40 PM, revealed she expected that a log of all grievances be kept.

Based on interview, record review, and review of facility policy, it was determined the facility failed to thoroughly investigate unwitnessed falls with injuries for four (4) of four (4) sampled residents (Residents #1, #2, #3 and #4). Record review revealed falls were not thoroughly investigated for Residents #1, #2, #3, and #4. The findings include: Review of the facility's policy titled, Abuse Policy, dated 08/05/2022, revealed Investigation .to ensure that all reports of .injuries of unknown source .were promptly and thoroughly investigated. Reporting incidents of real and suspected .injury of an unknown source would be every staff member, visitor, family members responsibility. The individual conducting investigation would, at a minimum determine: (Who, What, Where, When, and Why) . Injuries of unknown source- an injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 1. Review of Resident #1's medical record revealed the facility readmitted the resident on 07/25/2022, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Cognitive Communication Deficit, Fracture of Right Humerus, and Altered Mental Status. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 05/04/2022, revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the MDS assessment, revealed the resident required supervision of one (1) staff member for bed mobility, transfers, walking in room, eating, toilet use, personal hygiene, and limited assistance of one staff member. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 07/14/2022, revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident was severely cognitively impaired. Further review of the MDS assessment, revealed the resident required extensive assistance of two (2) or more staff for transfers. Review of Resident #1's Comprehensive Care Plan, dated 02/25/2020 and reviewed on 03/05/2021, revealed the resident was at risk for falls due to impaired mobility, weakness, and use of ant-depressant medication and ant-anxiety medications. Interventions included staff to encourage resident to use call light for assistance, demonstrate use of call light and repeat as needed, Fall/Siderail/Device assessment completed on admission, quarterly, and PRN (as needed), keep call light and personal items within reach at all times, offer toileting upon rising, after each meal, at bedtime, and prn while awake, and routine checks to assure that the resident's safety and well-being were maintained. Review of the Unusual Occurrence Report, dated 06/25/2022, revealed staff heard a loud noise, went into Resident #1's room, and found him/her lying against door on his/her left side. Resident #1 stated he/she was going to the bathroom when the fall occurred and stated his/her shoulder was broken. Further review of the report revealed the fall was unwitnessed and the resident was on the floor by the closet, with his/her rolling walker in front of the closet. Further review of the document revealed no investigation had been completed. 2. Review of Resident #2's medical record revealed the facility readmitted the resident on 07/25/2022, with diagnoses which included Unsteadiness on Feet, Syncope and Collapse, and Dementia with Behavioral Disturbance. Review of Resident #2's Quarterly MDS assessment, dated 06/08/2022, revealed the facility assessed Resident #2 to have a Brief Interview of Mental Status (BIMS) score of six (6) out of fifteen (15) which indicated the resident was severely cognitively impaired. Further review of the assessment, revealed the resident required extensive assistance of two (2) staff members for assistance with bed mobility and extensive assistance of one (1) staff member for transfers, dressing, toilet use, and personal hygiene. Review of Resident #2's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2 to have a Brief Interview of Mental Status (BIMS) score of five (5) out of fifteen (15) which indicated the resident was severely cognitively impaired. Further review of the assessment, revealed the resident required extensive assistance of two (2) staff members for bed mobility and transfers. Review of Resident #2's Comprehensive Care Plan, dated 03/31/2022, revealed Resident #2 was at risk for falls due to history of falls, impaired mobility, weakness, and use of anti-psychotic medications. Interventions included staff to encourage resident to use call light for assistance, demonstrate use of call light and repeat as needed, encourage/assist resident to turn and reposition when in bed and up in chair, Fall/Siderail/Device assessment completed on admission, quarterly, and PRN, keep call light within reach at all times, keep pathways free of clutter at all times, keep personal items within reach at all times, offer toileting upon rising, after each meal, at bedtime, and prn while awake, routine checks to assure that the resident safety and well-being are maintained, and non-skid mat to bed, recliner, and toilet. Continued record review revealed Resident #2 had unwitnessed falls on 04/27/2022, 04/30/2022, 05/14/2022, 06/23/2022, and 08/29/2022. Review of the Unusual Occurrence Report, dated 08/29/2022, revealed Resident #2 was found on floor-beside the recliner, nurse assessed resident's left hip, right elbow, and facial swelling. The nurse called Emergency Medical Systems (EMS) and the resident was transported to a emergency room (ER). Further review revealed the incident was documented as unwitnessed. Interview with Licensed Practical Nurse (LPN) #2, stated she was passing medications on the short had when she opened Resident #2's door and found the resident on his/her knees with their head on floor in front of the recliner. LPN #2 stated she did an assessment of the resident and found he/she had a knot on the head. Continued interview with LPN #2, revealed the Nurse Practitioner (NP) was in building, and did an assessment of the Resident #2. The NP sent him/her to the ER for evaluation. LPN #2 stated the resident was found on floor, with a knot on the forehead and it was assumed the injury was caused by an unwitnessed fall. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 08/31/2021, with diagnoses which included Dementia, Altered Mental Status, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #3's Quarterly MDS assessment, dated 08/25/2022, revealed the facility assessed Resident #3 to have a Brief Interview of Mental Status (BIMS) score of ten (10) out of fifteen (15) which indicated the resident was moderately cognitively impaired. Further review of the assessment, revealed the resident required supervised assistance of one (1) person for all Activities of Daily Living (ADLs). Review of the Unusual Occurrence Report, dated 08/29/2022, revealed Resident #3 was found on the floor with walker at side. Resident stated, the room just started spinning. Further review of the document revealed the incident was unwitnessed. 4. Review of Resident #4's medical record revealed the facility admitted the resident on 09/28/2021, with diagnoses which included Difficulty in Walking, Muscle Weakness, and Cognitive Communication Deficit. Review of Resident #4's Annual MDS assessment, dated 07/06/2022, revealed a BIMS had not been completed and the staff assessment of mental status indicated Resident #4's cognitive skills were moderately impaired. Further review of the assessment, revealed the resident required extensive assistance of one (1) staff for all ADLs. Review of the Unusual Occurrence Report, dated 09/12/2022, revealed Resident #4 was noted to be sitting in chair at nurse's desk with goose egg to his/her left forehead, related to an apparent unwitnessed fall. Interview with the Director of Nursing (DON), on 09/20/2022 at 9:40 AM, revealed after reviewing the residents' Unusual Occurrence Reports, she had completed the investigations but did not document any of the investigations. She further stated she usually just goes around with a sticky pad to write down notes of interviews and observations conducted related to the incidents.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a fall with injury was reported to the State Survey Agency (SSA) for one (1) of four (4) sampled residents (Resident #1). Resident #1 had an unwitnessed fall on 06/25/2022, and sustained a fracture of his/her right humerus, requiring surgical repair. The findings include: Review of the facility's policy titled, Abuse Policy, dated 08/05/2022, revealed resident's had the right to be free from injuries of an unknown source (fractures, dislocations, or sprains) of questionable origin, or the source of the injury were not observed by any person or the source of the injury could not be explained by the resident. Continued review revealed the results of an investigation would be reported to the appropriate individuals and agencies: Family, Administrator, Doctors, Adult Protective Services (APS), Office of Inspection General (OIG), and Local Police Department. Staff would report any suspected or witnessed incident of abuse, including injuries of unknown origin and the Administrator or designee would immediately report to APS, OIG, and Local enforcement as appropriate. Injuries of unknown source- an injury should be classified as an injury of unknown source when both of the following conditions were met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Review of Resident #1's medical record revealed the facility readmitted the resident on 07/25/2022 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Cognitive Communication Deficit, Fracture of Right Humerus, and Altered Mental Status. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 05/04/2022, revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated the resident was severey cognitively impaired. Further review of the MDS assessment, revealed the resident required supervision of one (1) staff member for bed mobility, transfers, waling in room, eating, toilet use, personal hygiene, and limited assistance of one staff member. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 07/14/2022, revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident was severely cognitively impaired. Further review of the MDS assessment, revealed the resident required extensive assistance of two (2) or more staff for transfers. Review of the Unusual Occurrence Report, dated 06/25/2022, revealed staff heard a loud noise, went into Resident #1's room, and found him/her lying against door on his/her left side. Resident #1 stated he/she was going to the bathroom when the fall occurred and stated his/her shoulder was broken. Further review of the report revealed the fall was unwitnessed and the resident was on the floor by the closet, with his/her rolling walker in front of the closet. Further review of the document revealed no investigation had been completed. Interview with the Director of Nursing (DON), on 09/21/2022 at 9:46 AM, revealed the facility did not consider Resident #1's injury as an unknown source because they knew the resident had fallen. She further stated when Resident #1 was interviewed after the fall, he/she was able to tell staff what happened. The DON stated she would interview staff and write it on a sticky pad but could not produce any evidence that an investigation was completed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure it must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections one (1) of four (4) sampled residents (Resident #7). Observation on 09/20/2022, revealed the Wound Care Nurse (WCN) did not perform hand hygiene between glove changes while providing wound care to Resident #7. The findings include: Review of the facility's policy titled, Hand Hygiene, not dated, revealed all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .the use of gloves would not replace hand hygiene. If the task required gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of Resident #7's medical record revealed the facility readmitted Resident #7 on 10/12/2021, with diagnoses which included Rheumatoid Arthritis, Neuralgia and Neuritis, and Thrombocytopenia. Review of Resident #7's Physician's Orders, revealed an order to cleanse area with sterile normal saline, apply Santyl to wound (left inner ankle), and Adaptec dressing. Review of Resident #7's Wound Care Plan, revealed a left inner ankle unstageable wound with interventions which included, skin audit every week and as needed, encourage resident to turn/reposition, and keep foot up/off each other, boot to left foot, notify MD and family of the area and of any abnormal noted during healing, keep clean and dry as possible, monitor amount of drainage, color, and odor of the wound and notify MD as needed. Observation of Resident #7, on 09/20/2022 at 10:38 AM, revealed the WCN did not perform hand hygiene between glove changes while performing wound care to the resident's left ankle pressure ulcer. Interview with the WCN, on 09/20/2022 at 11:05 AM, revealed she should have performed hand hygiene between each glove change. She stated she realized she failed to wash her hands between glove changes when she had finished and walking out of the resident's room. Interview with the Director of Nursing (DON)/Infection Control Preventionist (ICP), on 09/20/2022 at 3:48 PM, revealed she expected nursing staff to wash their hands prior to donning gloves, between glove changes, and after the completion of task.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of two (2) residents (Resident #2 and #3) with indwelling urinary catheters in a selected sample of eight (8) residents received treatment and care in accordance with professional standards of practice related to indwelling urinary catheter care. Observations revealed staff did not ensure Residents #2's and #3' catheter tubing was anchored to the thigh per facility professional standards manual (Lippincott). In addition, Resident #2 was observed being propelled by staff down the hallway with the catheter tubing dragging the ground. The findings include: Review of the facility policy, Nursing Standards of Practice last revised 04//25/13, revealed services provided to our residents are performed in accordance with current acceptable standards of clinical practice. Our facility's Lippincott: Manual of Nursing Standards and Nursing Services Policy and Procedure manuals contain step-by-step guidance for each type of nursing care rendered. Staff is encouraged to reference such manual(s) when needed to assure that appropriate protocols are followed in accordance with established procedures. Review of the Lippincott Procedures for Indwelling urinary catheter insertion, male last revised 11/11/16 revealed to secure the catheter using a catheter securement device. If a securement device isn't available, tape catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow. Do not place the drainage bag/tubing on the floor. Review of the Urinary Catheter Insertion Evaluation Form revealed to secure the tubing to the medial thigh using securement device or tape. 1. Record review revealed the facility admitted Resident #2 on 12/01/05 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/2020, revealed a Brief Interview for Mental Status (BIMS) was not attempted due to the resident never/rarely understood. Further review found the resident was not able to be interviewed due to Severely Impaired Cognition. Observation on 09/23/2020 at 9:02 revealed State Registered Nurse Aide (SRNA) #1 propelled Resident #2 down hallway from shower room with catheter tubing dragging the ground. Observation of wound care for Resident #2, on 09/23/2020 at 9:49 AM revealed the resident's urinary catheter tubing was not secured to the residents' thigh per policy. 2. Record review revealed the facility admitted Resident #3 on 05/27/2020 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/17/2020 revealed the BIMS was not attempted due to the resident being rarely/never understood and the facility assessed the resident's cognition was moderately impaired and unable to be interviewed. Observation of Resident #3's wound care on 09/23/2020 at 10:18 AM revealed the resident's urinary tubing had no securement device to secure the urinary catheter tubing to the resident's thigh. Interview with SRNA #1 on 09/23/2020 at 1:30 PM revealed she was not aware she had been dragging the resident's catheter tubing on the floor. She stated she knew she was not supposed to because of the potential for infection and it would dirty the catheter tubing. She revealed the catheter tubing should be off the ground as well as the catheter bag; per facility policy . Interview with Wound Care nurse on 09/23/2020 at 10:40 AM, 1:40 PM and 2:10 PM revealed she observed Resident #2's catheter tubing being drug on the ground while the SRNA #1 propelled the resident down the hall. She stated the tubing and bag are to be off of the ground per policy. She stated she was not sure why Resident #2's catheter tubing was not secured. She further revealed Resident #3's tubing was secured after surveyor observation; however fifteen minutes later, it was observed the catheter securement had been pulled off by the resident. She stated she thought that had been tried in the past; however, there was no documented evidence in the resident's record or care plan. Interview with the Director of Nursing (DON) on 09/24/2020 at 11:10 AM revealed she expects all catheter bags and tubing to be secured off the ground and tubing to be secured to the residents' thigh per the facility policy and standards of practice. She stated if a resident does not tolerate the securement device, it should have been documented in the Comprehensive Care Plan and nurses notes that the resident refused.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of eight (8) sampled residents (Resident #7 and #8) has a right to personal privacy. Observations during wound care revealed staff failed to ensure the window blinds were closed to ensure privacy for Resident #7 and #8. The findings include: Review of the facility policy titled, Clean Dressing Change, dated 2019 revealed to screen for privacy. After the procedure, staff is to open door, blinds, or curtains if desired by resident. 1. Record review revealed the facility admitted Resident #7 on 09/27/16 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #7's cognition as intact with a Brief Interview For Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Observation of wound care to Resident #7 on 09/24/2020 at 9:50 AM revealed the Wound Care Nurse performed wound care to resident's buttocks with the window blinds open. The resident's bed was next to the window. Interview with Resident #7 on 09/24/2020 at 10:05 AM revealed the window blind is usually open when his/her dressing is changed. Resident #7 stated it would be better if it was closed. That's how they do things here, I don't think they care if my butt is in the air. 2. Record review revealed the facility readmitted Resident #8 on 12/05/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #8's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Observation of Resident #8's dressing change on 09/24/2020 at 10:18 AM revealed the wound care nurse failed to close the window blinds in the resident's room. The resident's buttocks was uncovered and open to the window. Interview with Resident #8 at 10:28 AM on 09/24/2020 revealed he/she was unaware the blinds were open; however he/she would rather the blinds be closed. Interview with Wound Care Nurse on 09/24/2020 at 10:55 AM revealed she should have given the residents privacy and closed the window blinds. She stated it was her responsibility to protect the resident's right to privacy. Interview with Director of Nursing (DON) on 09/24/2020 at 12:34 PM revealed she expected all staff to follow the facility policy and protect the resident's right to privacy and close blinds, curtains or doors; if needed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of eight (8) sampled residents' (Resident #2) right to a dignified existence Observation revealed Resident #2 was wheeled down hallway from shower with no dignity bag covering urinary catheter bag with urine in tubing and bag noted to have thick cloudy urine. The findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity not dated, revealed, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. Record review revealed the facility admitted Resident #2 on 12/01/05 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/2020, revealed a Brief Interview for Mental Status (BIMS) was not attempted due to the resident never/rarely understood. Further review found the resident was not able to be interviewed due to Severely Impaired Cognition. Observation on 09/23/2020 at 9:02 AM revealed State Registered Nurse Aide (SRNA) #1 was pushing Resident #2 down the hallway in wheelchair and the resident's indwelling urinary catheter bag and tubing was not covered and contained urine that was cloudy and thick. The Wound Care Nurse also observed the resident. Interview with SRNA #1 on 09/23/2020 at 1:30 PM revealed she should have had a dignity bag on the resident's catheter bag. She stated it is on the resident's Comprehensive Care Plan to have a dignity bag covering the bag; however she failed to place one on it. Interview with Wound Care Nurse on 09/23/2020 at 1:30 PM revealed SRNA #1 should have had a dignity bag over the urinary catheter bag and the tubing concealed. Interview with the Director of Nursing (DON) on 09/24/2020 at 12:34 AM revealed she expected all residents who had a urinary catheter bag to have a dignity bag covering the bag. She stated she expected all nursing staff to make sure the residents had a dignity bag covering the catheter bags.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure staff followed the facility's infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for four (4) of eight (8) sampled residents (Resident #2, #3, #5, and #6). Observations of wound care revealed staff failed to use proper handwashing techniques, sanitize scissors, clean overbed tables, or use impervious barriers. The findings include: Review of the facility policy titled, Hand Hygiene, dated 2020 revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled, Clean Dressing Change dated 2019 revealed, it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Wash hands and put on clean gloves. Remove soiled existing dressing. Remove gloves, Wash hands and put on clean gloves. Cleanse the wound as ordered. Remove gloves and wash hands. Put on clean gloves. Put on dressing. Discard disposable items and gloves and wash hands. 1. Record review revealed the facility admitted Resident #2 on 12/01/05 with [DIAGNOSES REDACTED]. Observation of wound care on 09/23/2020 at 9:02 AM revealed the Wound Care nurse removed her scissors from her pocket without cleaning them and proceeded to cut the clean dressing to fit wound. She did not clean the overbed table prior to laying the dressings on the table. She also removed her dirty gloves several times during the dressing change without washing/sanitizing hands between glove changes. 2. Record review revealed the facility admitted Resident #3 on 05/27/2020 with [DIAGNOSES REDACTED]. Observation of dressing change of sacral wounds on 09/23/2020 at 9:39 AM revealed the Wound Care nurse did not clean the overbed table prior to placing a towel down and placing the dressing change on the towel. She also failed to wash/sanitize her hands between glove changes. 3. Record review revealed the facility admitted Resident #5 on 10/14/16 with [DIAGNOSES REDACTED]. Observation of wound care for Resident #3's left heel on 09/23/2020 at 10:00 AM revealed the Wound Care nurse did not clean her scissors she removed from her scrub pocket prior to using on dressing. She also did not wash/sanitize her hands between gloving. 4. Record review revealed the facility admitted Resident #6 on 08/11/17 with [DIAGNOSES REDACTED]. Observation of wound care for Resident #6's sacrum on 09/24/2020 at 9:38 AM revealed the Wound Care nurse did not wash/sanitize her hands between glove changes. Interview with the Wound Care Nurse on 09/24/2020 at 10:55 AM revealed she should have followed the Hand Hygiene facility policy and wound care policy and cleansed her hands between glove changes. She stated she also should have cleaned her scissors each time prior to cutting dressings after removing from her pocket and cleaned the overbed table per facility policy. Interview with the Director of Nursing (DON) on 09/24/2020 at 11:10 AM revealed she expected all staff to follow the Hand Hygiene Policy and wash hands prior to and after removing gloves per facility policy. She stated she also expected staff to clean the overbed tables prior to placing a barrier and to clean scissors prior to using on a clean dressing.

Based on interview, record review, and facility policy review, it was determined the facility failed to maintain medical records that are complete and accurately documented related to the residents' response to treatments and/or services for six (6) of eight (8) sampled residents (Resident #2, #3, #5, #6, #7, and #8). Interviews revealed when recording whether a resident was turned and repositioned, State Registered Nurse Aides (SRNA's) were answering yes that residents were being turned and repositioned; however, the residents were refusing to be turned. The findings include: Interview on 09/23/2020 at 2:10 PM with the Administrator revealed there was no facility documentation policy. 1. Record review revealed the facility admitted Resident #2 on 12/01/05 with [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #3 on 05/27/2020 with [DIAGNOSES REDACTED]. 3. Record review revealed the facility admitted Resident #5 on 10/14/16 with [DIAGNOSES REDACTED]. 4. Record review revealed the facility admitted Resident #6 on 08/11/17 with [DIAGNOSES REDACTED]. 5. Record review revealed the facility admitted Resident #7 on 09/27/16 with [DIAGNOSES REDACTED]. 6. Record review revealed the facility readmitted Resident #8 on 12/05/19 with [DIAGNOSES REDACTED]. Review of Resident #2, #3, #5, #6, #7, and #8's SRNA care records revealed each of the residents were being turned and repositioned every two hours daily; however, interviews on 09/23/2020 with SRNA #2 at 2:17 PM, SRNA #3 at 2:35 PM, and SRNA #1 at 2:51 PM revealed the SRNA's had been documenting that the residents were turned and repositioned every two hours daily even though Resident #2, #3, #5, #6, #7, and #8's would refuse to be turned and repositioned. Further review of the SRNA Care Records revealed there was a box to record resident refusal; however, the SRNA's were not using the refusal prompt. Interview with the Director of Nursing on 09/24/2020 at 11:10 AM revealed she expected staff to document accurately.

Based on interview, record review, and review of the facility's policy and procedure and Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14 Patient Care Orders, last revised 10/2010, it was determined the facility failed to provide services to meet professional standards of quality of care for one (1) of four (4) sampled residents (Resident #1) related to following the physician's orders [REDACTED]. Resident #1 was readmitted to the facility on [DATE] at approximately 5:20 PM with a physician's orders [REDACTED]. Licensed staff failed to follow the physician's orders [REDACTED]. At 6:10 PM, a female called the facility and notified staff that an elderly person was walking down the road. The nurse exited the front of the building and saw Resident #1 walking down the road and approached the resident and was able to escort him/her back to the facility. Resident #1 had exited the front doors of the facility and walked 0.4 miles from the facility on a two (2) lane road with a speed limit of forty-five (45) miles per hour without the staff's knowledge. The facility's failure to follow the physician's orders [REDACTED]. Immediate Jeopardy was identified on 04/01/14 and was determined to exist on 03/22/14. The facility was notified of the Immediate Jeopardy on 04/01/14. An acceptable Allegation of Compliance (AoC) was received on 04/08/14 alleging the removal of Immediate Jeopardy on 04/05/14. The State Survey Agency validated, on 04/10/14, the Immediate Jeopardy was removed on 04/05/14, as alleged. The Scope and Severity was lowered to a "D" at 482.20 Resident Assessment, F-281 and F282; and 485.25 Quality of Care, F-323 while the facility develops and implements the Plan of Correction (PoC) and the facility's Performance Improvement Committee monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Physician order [REDACTED]. Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14 Patient Care Orders, revised 10/2010, revealed Registered Nurses and Licensed Practical Nurses were responsible for the administration of medication or treatment as authorized by a Physician, Physician Assistant, or Advanced Practice Registered Nurse. Record review revealed the facility readmitted Resident #1 on 03/22/14 with [DIAGNOSES REDACTED]. Review of the Admission physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1, on 03/29/14 at 7:30 PM, revealed Resident #1 was returned to the facility by ambulance on 03/22/14 at 5:20 PM. The LPN stated she signed the resident back in and looked in on him/her to let him/her know she would be back to perform an assessment. The LPN revealed she did not place the Secure Care bracelet or notify any other direct care staff that Resident #1 was back in the building. LPN #1 stated she should have notified LPN #2 that the resident was back in the building and the Secure Care bracelet needed to be applied to his/her left ankle per physician's orders [REDACTED]. Interview with LPN #2 (Medication Nurse, who had the bracelets in the medication cart), on 03/30/14 at 2:14 PM, revealed she was not notified Resident #1 was going to be returning to the facility or that he/she had arrived. LPN #2 stated the Secure Care bracelets were kept in the [DEVICE]/medication cart and the Charge Nurse would have to come get a bracelet from her or designate her to place the bracelet on the resident when a physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 03/28/14 at 11:13 AM, revealed her practice has been to follow the resident to the room during readmission and if a Secure Care bracelet was ordered by the physician, she would place it on the resident on arrival to the room. The ADON stated she would have expected the Charge Nurse to place the Secure Care bracelet on arrival or delegate someone to be with the resident one on one until the Secure Care bracelet was placed. Interview with the Director of Nursing (DON), on 03/28/14 at 3:33 PM, revealed he would have expected the Charge Nurse to have prepared for the admission when she received report by getting the supplies together and notifying the direct care staff of the readmission so they could get prepared for Resident #1's arrival. Interview with the Administrator, on 03/31/14 at 2:24 PM, revealed she expected the Charge Nurse or a designee to go to the room when the resident was readmitted to observe the transfer, implement the plan of care, assess the resident, initiate physician's orders [REDACTED]. Interview with the Medical Director, on 03/31/14 at 3:24 PM, revealed she expected residents with a physicians's order for a Secure Care bracelet to have the bracelet applied as soon as they entered the building. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/22/14, once Resident #1 was back in the building and in his/her room, the Charge Nurse assigned a nurse aide to stay with him/her until she returned with the Secure Care bracelet for him/her. The bracelet was replaced on Resident #1 by the Charge Nurse, on 03/22/14. The Charge Nurse completed a body audit/assessment on Resident #1 once he/she was back in the building with no injuries noted on 03/22/14. On 03/22/14, the Charge Nurse completed an Unusual Occurrence report for Resident #1. The Charge Nurse initiated a head count, on 03/22/14, to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road. The Charge Nurse documented the events of the incident in Resident #1's Chart, on 03/22/14. On 03/22/14, the Charge Nurse, Treatment Nurse, Certified Medication Aide (CMT), State Registered Nurse Aide (SRNA), and Ward Clerk that were working at the time of the incident were either questioned or wrote a statement about whether they saw Resident #1 exit the building or if they had any interaction with him/her by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staffing Coordinator. Resident #1's care plan and Elopement Assessment were updated by the ADON, on 03/22/14. The Administrator notified the Office of Inspector General (OIG), Department for Community Based Services (DCBS), and the local Police about the incident, on 03/22/14. The ADON audited the care plans, and elopement risk assessments of all residents wearing a Secure Care bracelet to ensure they had a physician order [REDACTED]. An Elopement Assessment audit was completed for all residents by the ADON, on 03/22/14, to ensure all Elopement Assessments were up to date. All exit doors were checked for proper functioning by Administrator, on 03/22/14. All residents' Secure Care anklets were checked for proper functioning by the Staffing Coordinator, on 03/22/14 The DON counseled the Charge Nurse for failing to keep the resident safe upon return from the hospital, on 03/22/14. A task audit was completed in Point Click Care (electronic medical records) by the Administrator and ADON, on 03/22/14, to ensure Secure Care check tasks were in place for all residents at risk for elopement. The Administrator, DON, and ADON had direct input into the revision of the Resident Discharge or Transfer section of the Secure Care policy, on 03/22/14. The revision pertained to changing the location of where to put the bracelet once it was removed from a resident. The Administrator typed the revisions and replaced the old Secure Care policy in the P & P manual with the new copy. Per the DON's and ADON's input, the new copy now includes the following revisions: "If the resident is sent to the hospital, discharged or leaves for a home visit, the Charge Nurse MUST cut the bracelet strap off the resident prior to the resident leaving. Affix the bracelet on the rings in the resident's medical chart. When the resident returns, the Charge Nurse should replace the bracelet immediately. The Nurses' Notes should state that the bracelet was removed and another Note stating when it was placed back on the resident." All nursing staff and Administrative staff were in-serviced by phone on the revised Secure Care Policy by the ADON, DON, and Staffing Coordinator, on 03/22/14, to include: the Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, Leave of Absence (LOA) or discharged , and document in the Nurse's Notes that it was removed and fastened to the rings inside the resident's chart. Also it is the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. The DON notified the Medical Director, on 03/22/14, of the incident; Resident #1's condition once back in the building; the counseling of the Charge Nurse for failing to follow physicians orders; the revisions made to the Secure Care policy; the notification of the Power of Attorney (POA), physician, Office of Inspector General (OIG), Department for Community Based Services (DCBS), and local police; the checking of the physician orders; updates to elopement assessments and care plans; checking the exit doors and the resident's bracelets for proper functioning; review of revisions to the CQI tool N-29 "New Admission & Hospital Return Review"; nursing orientation updates; staff in-service training; and audits of Point Click Care tasks. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. The information included pertaining to the Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When functioning in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. The Care plans were reviewed and updated, on 04/04/14, by licensed staff and Department Directors for all residents who were not assessed to be at risk for elopement to ensure that physician orders [REDACTED]. Licensed Nurses, Certified Medication Aides (CMA), State Registered Nurse Aides(SRNA), Ward Clerks, Activity Director, Activity Assistant, Social Service Director, Maintenance, Dietary Manager, Office Manager, and Medical Records Coordinator were called, on 03/22/14, and informed about the details surrounding the elopement and the nurse's failure to follow the physician orders [REDACTED]. The staff was in-serviced, on 03/22/14, by phone by the DON, ADON, and Staffing Coordinator on the revisions made to the Secure Care policy to include: The Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, LOA or discharged and document in the Nurse's Notes that it was removed and fastened to the ring inside the resident's chart. Also the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. All PRN staff, staff on Federal Medical Leave Act (FMLA), and any potential agency staff will be educated on the Secure Care policy prior to working again by the DON, ADON, or Staffing Coordinator. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. Information included pertaining to the Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When acting in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. CQI tool N-29 "New Admission & Hospital Return Review" was reviewed, on 03/22/14, by the Administrator, DON, and ADON. Together, we decided to add the following four (4) questions to monitor after reviewing with QA team and the Medical Director: i. Was a Secure Care bracelet removed from the resident and affixed to his/her chart at discharge? ii. Is there documentation that the bracelet was removed and where it is located? iii. Was the Secure Care bracelet put back on the resident upon return from the hospital, LOA? iv. Is there documentation that the bracelet was put back on the resident when he/she returned to the facility? The CQI tool N-29 "New Admission & Hospital Return Review" will be completed weekly for four (4) weeks, monthly for four (4) months, then per CQI schedule by the DON or ADON. ADON completed CQI N-29 "New admission & Hospital Return Review"for Resident #1, on 03/22/14. CQI N-29 was completed, on 04/04/14, by the DON on all residents who have been discharged , LOA or hospitalized and those who have returned to the facility since 03/22/14 with 100% accuracy. **The State Agency validated the corrective action taken by the facility as follows: Review of Nurse's Notes, dated 03/22/14 at 6:30 PM, validated Resident #1 returned to the facility, complete body audit/assessment completed, SRNA assigned to monitor Resident #1 one to one until Secure Care bracelet replaced, and Secure Care bracelet applied by the Charge Nurse. The Charge Nurse initiated a head count to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road and documentation of all notifications and events related to the incident were documented. Review of Resident #1's "Elopement Assessment" and "Elopement/Wandering" care plan validated, on 03/22/14, those documents were updated by ADON. Review of Residents' #2-#20 physicians' orders, elopement assessments and care plans revealed the residents had orders for the Secure Care bracelets and the residents were assessed and care planned for elopement. Observation of Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18, #19 and #20 revealed the Secure Care bracelets were in place on each resident. Resident #13 and Resident #16 were in the hospital and observation revealed their Secure Care bracelets were in the ring of their charts. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that the ADON also audited all residents charts to ensure the "Elopement Risk Assessment" was up to date and she had checked for proper functioning of all exits with the Secure Care system, on 03/22/14. She stated a task audit in Point Click Care (electronic medical records) was performed to ensure the Secure Care tasks were in place for all residents with Secure Care bracelets, on 03/22/14. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, validated she had checked for proper functioning of all residents' Secure Care bracelets. Review of the counseling form revealed the DON counseled the Charge Nurse for not keeping Resident #1 safe on return from the hospital, on 03/22/14. Review of inservice records, dated 03/22/14, revealed all nursing staff and Administrative staff that could be contacted were in-serviced in person or inserviced by phone on the revisions in the Secure Care policy by the ADON, DON, and Staffing Coordinator. Those that could not be contacted on 03/22/14 were inserviced before they were allowed to return to work either by phone or in person when they arrived for work on their next scheduled day. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, revealed she had used the call list to ensure all staff was in-serviced on the Secure Care policy revision before they returned to work. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that care plans were reviewed and updated by licensed staff and Department Directors, on 04/04/14, to ensure that residents were not at risk of elopement, forty-one (41) residents, were having their physicians orders followed. Interviews with RN #4 and #5, LPN #5, #6, and #7, and SRNA #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 on 04/10/14 at 11:00 AM, 11:04 AM, 11:08 AM, 11:12 AM, 11:16 AM, 11:20 AM, 11:24 AM, 11:31 AM, 11:36 AM, 11:39 AM, 11:42 AM, 11:46 AM, 11:50 AM, 11:55 AM, 12:02 PM, and 12:06 PM respectively, revealed they received an inservice on the changes to the Secure Care policy in person and by phone starting on 03/22/14 and all of the staff had been inserviced before they returned to work on their next scheduled day. All interviews revealed the inservice was related to the Charge Nurse being responsible to ensure the Secure Care bracelet was placed immediately on admission and readmission to the facility, the Secure Care bracelet was removed just before the resident goes out of the facility, documentation of the removal of the bracelet, how the bracelet was stored in the resident's chart until the resident returned to the facility, placement of the Secure Care bracelet, function of the bracelet, expiration date of the bracelet, and location of Secure Care supplies. Review of the CQI tool N-29, "New Admission & Hospital Return Review", dated 03/22/14, compared to CQI tool N-29, undated, validated the changes made on the CQI tool N-29. Review of the CQI tool N-29 and interview with the Administrator, on 04/10/14, revealed the ADON completed the CQI tool N-29 form on Resident #1, on 03/22/14, and on all residents who have been out of facility or hospitalized from [DATE] through 04/03/14 with 100% accuracy. The monitoring was going to continue weekly for a total of 4 weeks, monthly for a total of 4 months, then per CQI schedule by the DON or ADON.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to provide adequate supervision and monitoring for one (1) of four (4) sampled residents (Resident #1). The facility failed to follow their policy and procedures related to providing supervision and monitoring to ensure resident's safety. The facility assessed and care planned Resident #1 as an elopement risk requiring supervision to include a Secure Care bracelet. Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE] at approximately 5:20 PM with a physician's orders [REDACTED]. Staff failed to apply the Secure Care bracelet according to the care plan and physician's orders [REDACTED]. At approximately 6:10 PM, a female called the facility and notified staff she saw an elderly person walking on the road near the facility. The nurse exited the front of the building and saw Resident #1 walking down the road and approached the resident and was able to escort him/her back to the facility. Resident #1 had exited the front doors of the facility and walked 0.4 miles from the facility on a two (2) lane road with a speed limit of forty-five (45) miles per hour without the staffs knowledge. The facility's failure to provide supervision and assistive devices to prevent an elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/01/14 and was determined to exist on 03/22/14. The facility was notified of the Immediate Jeopardy on 04/01/14. An acceptable Allegation of Compliance (AoC) was received on 04/08/14 alleging the removal of Immediate Jeopardy on 04/05/14. The State Survey Agency validated, on 04/10/14, the Immediate Jeopardy was removed on 04/05/14, as alleged. The Scope and Severity was lowered to a "D" at 482.20 Resident Assessment, F-281 and F282 and 485.25 Quality of Care, F-323 while the facility develops and implements the Plan of Correction (PoC) and the facility's Performance Improvement Committee monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Elopement Nursing Facility policy and procedure, last revised 12/02/13, revealed the "Nursing personnel must report and investigate all reports of missing resident. Residents are comprehensively assessed for wandering/elopement risk in order to minimize the potential for eloping from the facility". The definition of "elopement" is "when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so". If a resident is identified as a potential wanderer he/she will be issued a Secure Care bracelet, as appropriate. The Charge Nurse is responsible obtaining the physician's orders [REDACTED]. Review of the facility's "Job Description and Performance Standards" for "Charge Nurse" Briggs Corporation, (not dated), revealed the Charge Nurse shall "Follow facility admission procedures and communicate resident admission to other departments, physicians and ancillary service providers". Review of the facility's "Admission Assessment and Follow-Up: Role of Nurse" policy and procedure, last revised December 2012, revealed Step 13 of the Nurse's Role is to "Notify other disciplines and departments of the resident's admission. Record review revealed the facility admitted Resident #1 on 03/06/14 with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment, dated 03/06/14, revealed the facility assessed Resident #1 as an elopement risk because the resident had expressed a desire to go home and exhibited signs that would indicate he/she would act on that desire to go home and leave the facility unattended. Review of the Comprehensive Care Plan for Elopement/Wandering, dated 03/06/14, revealed interventions to obtain an order for [REDACTED]. as needed. Review of Nurse's Notes and Physician order [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1, on 03/29/14 at 7:30 PM, revealed Resident #1 was returned to the facility by ambulance about 5:20 PM. She stated she signed the resident back in and looked in on him/her to let him/her know she would be back to perform an assessment. The LPN revealed she did not place the Secure Care bracelet on the resident or notify any other direct care staff that the resident was back in the building. LPN #1 revealed at approximately 6:10 PM she received a call from a female stating she had seen an elderly person in a blue shirt and gray pants walking on the road near the facility. LPN #1 revealed she called available staff to the front of the building and called out for a head count. LPN #1 stated she exited the front of the building and could see a person walking up the street to the right of the building so she called to another staff to get a car and go in that direction and she went to the resident. LPN #1 stated when they reached the resident, the resident stated he/she was going home and she asked him/her to come back to the facility so they could assist him/her. The LPN revealed when they arrived back to the facility she completed a body audit and vital signs, and there were no injuries noted. She stated she placed the resident on one to one observation until the Secure Care bracelet could be applied, then she notified the Director or Nursing (DON). Interview with Resident #1, on 03/27/14 at 11:15 AM, revealed he/she remembered leaving the building and was walking home. Interview with State Registered Nurse Aide (SRNA) #3, on 03/26/14 at 3:15 PM, revealed she had seen Resident #1 while passing trays, she stated she was not aware the resident had returned. The SRNA stated she brought the tray to the resident and prepared the meal tray. The SRNA revealed it was her first day working alone and she was not familiar with the resident and did not know the resident eloped until after the incident. Interview with SRNA #2, on 03/26/14 at 2:56 PM, revealed she had seen Resident #1 walking down the hallway while she was picking up meal trays and heard the elopement called out while helping another resident to the bathroom. The SRNA stated she was not aware Resident #1 was the one that had eloped until after he/she was back in the building. She stated she had never worked with the resident and did not know the resident was an elopement risk. Interview with SRNA #1, on 03/28/14 at 2:26 PM, revealed she was not notified Resident #1 was going to be returning to the facility or that he/she had arrived. She stated she was in the Restorative dining room and did not see the resident when he/she returned. Interview with Ward Clerk #1, on 03/31/14 at 12:56 PM, revealed she was in the main dining room when the resident was returned to the building and out of sight of the resident's room to have seen him return. She stated she was not aware Resident #1 was returning from the hospital or notified when he/she returned. She revealed normally she was paged if she was not at the desk so she could verify the placement and functioning of the Secure Care bracelet. Interview with LPN #2 (Medication Nurse), on 03/30/14 at 2:14 PM, revealed she was not notified that Resident #1 was going to be returning to the facility or that he/she had arrived. LPN #2 stated the Secure Care bracelets were kept in the medication cart and the Charge Nurse would have to come get a bracelet from her or designate her to place the bracelet when the resident had a physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 03/28/14 at 11:13 AM, revealed her practice has been to follow the resident to the room during a readmission and if the Secure Care bracelet was ordered by the physician, she would place it on the resident when they arrived at the room. The ADON stated she would have expected the Charge Nurse to place the Secure Care bracelet on arrival or delegate someone to be with the resident one on one until the Secure Care bracelet was placed. Interview with the Director of Nursing (DON), on 03/28/14 at 3:33 PM, revealed he would have expected the Charge Nurse to have prepared for the admission when she received report by getting the needed supplies together and notifying the direct care staff of the readmission so the staff could get prepared for Resident #1's arrival. Interview with the Administrator, on 03/31/14 at 2:24 PM, revealed she expected the Charge Nurse or a designee to go to the room when the resident was readmitted to observe the transfer, implement the plan of care, assess the resident, initiate physician's orders [REDACTED]. Interview with Medical director, on 03/31/14 at 3:24 PM, revealed she expected residents with a physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/22/14, once Resident #1 was back in the building and in his/her room, the Charge Nurse assigned a nurse aide to stay with him/her until she returned with the Secure Care bracelet for him/her. The bracelet was replaced on Resident #1 by the Charge Nurse, on 03/22/14. The Charge Nurse completed a body audit/assessment on Resident #1 once he/she was back in the building with no injuries noted on 03/22/14. On 03/22/14, the Charge Nurse completed an Unusual Occurrence report for Resident #1. The Charge Nurse initiated a head count, on 03/22/14, to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road. The Charge Nurse documented the events of the incident in Resident #1's Chart, on 03/22/14. On 03/22/14, the Charge Nurse, Treatment Nurse, Certified Medication Aide (CMT), State Registered Nurse Aide (SRNA), and Ward Clerk that were working at the time of the incident were either questioned or wrote a statement about whether they saw Resident #1 exit the building or if they had any interaction with him/her by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staffing Coordinator. Resident #1's care plan and Elopement Assessment were updated by the ADON, on 03/22/14. The Administrator notified the Office of Inspector General (OIG), Department for Community Based Services (DCBS), and the local Police about the incident, on 03/22/14. The ADON audited the care plans, and elopement risk assessments of all residents wearing a Secure Care bracelet to ensure they had a physician order [REDACTED]. An Elopement Assessment audit was completed for all residents by the ADON, on 03/22/14, to ensure all Elopement Assessments were up to date. All exit doors were checked for proper functioning by Administrator, on 03/22/14. All residents' Secure Care anklets were checked for proper functioning by the Staffing Coordinator, on 03/22/14 The DON counseled the Charge Nurse for failing to keep the resident safe upon return from the hospital, on 03/22/14. A task audit was completed in Point Click Care (electronic medical records) by the Administrator and ADON, on 03/22/14, to ensure Secure Care check tasks were in place for all residents at risk for elopement. The Administrator, DON, and ADON had direct input into the revision of the Resident Discharge or Transfer section of the Secure Care policy, on 03/22/14. The revision pertained to changing the location of where to put the bracelet once it was removed from a resident. The Administrator typed the revisions and replaced the old Secure Care policy in the P & P manual with the new copy. Per the DON's and ADON's input, the new copy now includes the following revisions: "If the resident is sent to the hospital, discharged or leaves for a home visit, the Charge Nurse MUST cut the bracelet strap off the resident prior to the resident leaving. Affix the bracelet on the rings in the resident's medical chart. When the resident returns, the Charge Nurse should replace the bracelet immediately. The Nurses' Notes should state that the bracelet was removed and another Note stating when it was placed back on the resident." All nursing staff and Administrative staff were in-serviced by phone on the revised Secure Care Policy by the ADON, DON, and Staffing Coordinator, on 03/22/14, to include: the Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, Leave of Absence (LOA) or discharged , and document in the Nurse's Notes that it was removed and fastened to the rings inside the resident's chart. Also it is the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. The DON notified the Medical Director, on 03/22/14, of the incident; Resident #1's condition once back in the building; the counseling of the Charge Nurse for failing to follow physicians orders; the revisions made to the Secure Care policy; the notification of the Power of Attorney (POA), physician, Office of Inspector General (OIG), Department for Community Based Services (DCBS), and local police; the checking of the physician orders; updates to elopement assessments and care plans; checking the exit doors and the resident's bracelets for proper functioning; review of revisions to the CQI tool N-29 "New Admission & Hospital Return Review"; nursing orientation updates; staff in-service training; and audits of Point Click Care tasks. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. The information included pertaining to the Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When functioning in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. The Care plans were reviewed and updated, on 04/04/14, by licensed staff and Department Directors for all residents who are not assessed to be at risk for elopement to ensure that physician orders [REDACTED]. Licensed nurses, Certified Medication Aides (CMA), State Registered Nurse Aides(SRNA), Ward Clerks, Activity Director, Activity Assistant, Social Service Director, Maintenance, Dietary Manager, Office Manager, and Medical Records Coordinator were called, on 03/22/14, and informed about the details surrounding the elopement and the nurse's failure to follow the physician orders [REDACTED]. The staff was in-serviced, on 03/22/14, by phone by the DON, ADON, and Staffing Coordinator on the revisions made to the Secure Care policy to include: The Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, LOA or discharged and document in the Nurse's Notes that it was removed and fastened to the ring inside the resident's chart. Also the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. All PRN staff, staff on FMLA, and any potential agency staff will be educated on the Secure Care policy prior to working again by the DON, ADON, or Staffing Coordinator. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. Information included pertaining to Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When acting in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. CQI tool N-29 "New Admission & Hospital Return Review" was reviewed, on 03/22/14, by the Administrator, DON, and ADON. Together, we decided to add the following four (4) questions to monitor after reviewing with QA team and Medical Director: i. Was a Secure Care bracelet removed from the resident and affixed to his/her chart at discharge? ii. Is there documentation that the bracelet was removed and where it is located? iii. Was the Secure Care bracelet put back on the resident upon return from the hospital, LOA? iv. Is there documentation that the bracelet was put back on the resident when he/she returned to the facility? The CQI tool N-29 "New Admission & Hospital Return Review" will be completed weekly for four (4) weeks, monthly for four (4) months, then per CQI schedule by the DON or ADON. ADON completed CQI N-29 "New admission & Hospital Return Review"for Resident #1, on 03/22/14. CQI N-29 was completed, on 04/04/14, by the DON on all residents who have been discharged , LOA or hospitalized and those who have returned to the facility since 03/22/14 with 100% accuracy. **The State Agency validated the corrective action taken by the facility as follows: Review of Nurse's Notes, dated 03/22/14 at 6:30 PM, validated Resident #1 returned to the facility, complete body audit/assessment completed, SRNA assigned to monitor Resident #1 one to one until Secure Care bracelet replaced, and Secure Care bracelet applied by the Charge Nurse. The Charge Nurse initiated a head count to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road and documentation of all notifications and events related to the incident were documented. Review of Resident #1's "Elopement Assessment" and "Elopement/Wandering" care plan validated, on 03/22/14, those documents were updated by ADON. Review of Resident's #2-#20 physicians' orders, elopement assessments and care plans revealed the residents had orders for the Secure Care bracelets and the residents were assessed and care planned for elopement. Observation of Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18, #19 and #20 revealed the Secure Care bracelet was in place on each resident. Resident #13 and Resident #16 were in the hospital and observation revealed their Secure Care bracelets were in the ring of their charts. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that the ADON also audited all residents charts to ensure the "Elopement Risk Assessment" was up to date and she had checked for proper functioning of all exits with the Secure Care system, on 03/22/14. She stated a task audit in Point Click Care (electronic medical records) was performed to ensure the Secure Care tasks were in place for all residents with Secure Care bracelets, on 03/22/14. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, validated she had checked for proper functioning of all residents' Secure Care bracelets. Review of the counseling form revealed the DON counseled the Charge Nurse for not keeping Resident #1 safe on return from the hospital, on 03/22/14. Review of inservice records, dated 03/22/14, revealed all nursing staff and Administrative staff that could be contacted were in-serviced in person or inserviced by phone on the revisions in the Secure Care policy by the ADON, DON, and Staffing Coordinator. Those that could not be contacted on 03/22/14 were inserviced before they were allowed to return to work either by phone or in person when they arrived for work on their next scheduled day. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, revealed she had used the call list to ensure all staff was in-serviced on the Secure Care policy revision before they returned to work. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that care plans were reviewed and updated by licensed staff and Department Directors, on 04/04/14, to ensure that residents that were not at risk of elopement, forty-one (41) residents, were having their physicians orders followed. Interviews with RN #4 and #5, LPN #5, #6, and #7, and SRNA #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14, on 04/10/14 at 11:00 AM, 11:04 AM, 11:08 AM, 11:12 AM, 11:16 AM, 11:20 AM, 11:24 AM, 11:31 AM, 11:36 AM, 11:39 AM, 11:42 AM, 11:46 AM, 11:50 AM, 11:55 AM, 12:02 PM, and 12:06 PM respectively, revealed they received an inservice on the changes to the Secure Care policy in person and by phone starting on 03/22/14 and all of the staff had been inserviced before they returned to work on their next scheduled day. All interviews revealed the inservice was related to the Charge Nurse being responsible to ensure the Secure Care bracelet was placed immediately on admission and readmission to the facility, the Secure Care bracelet was removed just before the resident goes out of the facility, documentation of the removal of the bracelet, how the bracelet was stored in the resident's chart until the resident returned to the facility, placement of the Secure Care bracelet, function of the bracelet, expiration date of the bracelet, and location of Secure Care supplies. Review of the CQI tool N-29, "New Admission & Hospital Return Review", dated 03/22/14, compared to CQI tool N-29, undated, validated the changes made on the CQI tool N-29. Review of the CQI tool N-29 and interview with the Administrator, on 04/10/14, revealed the ADON completed the CQI tool N-29 form on Resident #1, on 03/22/14, and on all residents who have been out of facility or hospitalized from [DATE] through 04/03/14 with 100% accuracy. The monitoring was going to continue weekly for a total of 4 weeks, monthly for a total of 4 months, then per CQI schedule by the DON or ADON.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to provide a Secure Care bracelet in accordance to the written plan of care, for one (1) of four (4) sampled residents (Resident #1). On 03/06/14, the facility assessed and care planned Resident #1 as an elopement risk requiring supervision to include a Secure Care bracelet. Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE] at approximately 5:20 PM. Staff failed to apply the Secure Care bracelet according to the care plan when the resident returned to the facility. At approximately 6:10 PM, a female called the facility and notified staff she saw an elderly person walking on the road near the facility. Resident #1 had exited the front doors of the facility and walked 0.4 miles from the facility on a two (2) lane road with a speed limit of forty-five (45) miles per hour without the staff knowledge. The facility's failure to provide care according to each resident's written plan of care related to a Secure Care bracelet has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/01/14 and was determined to exist on 03/22/14. The facility was notified of the Immediate Jeopardy on 04/01/14. An acceptable Allegation of Compliance (AoC) was received on 04/08/14 alleging the removal of Immediate Jeopardy on 04/05/14. The State Survey Agency validated, on 04/10/14, the Immediate Jeopardy was removed on 04/05/14, as alleged. The Scope and Severity was lowered to a "D" at 482.20 Resident Assessment, F-281 and 485.25 Quality of Care, F-323 while the facility develops and implements the Plan of Correction (PoC) and the facility's Performance Improvement Committee monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Elopement Nursing Facility policy and procedure, last revised 12/02/13, if a resident is identified as a potential wanderer he/she will be issued a Secure Care bracelet, as appropriate. Record review revealed the facility admitted Resident #1 on 03/06/14 with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment, dated 03/06/14, revealed the facility assessed Resident #1 as an elopement risk because the resident had expressed a desire to go home and exhibited signs that would indicate he/she would act on that desire to go home and leave the facility unattended. Review of the Comprehensive Care Plan for Elopement/Wandering, dated 03/06/14, revealed interventions to obtain an order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1, on 03/29/14 at 7:30 PM, revealed Resident #1 was returned to the facility by ambulance about 5:20 PM. She stated she signed the resident back in and looked in on him/her to let him/her know she would be back to perform an assessment. LPN #1 revealed she did not place the Secure Care bracelet on the resident, as per care plan, because she was trying to talk to another resident's physician and complete the paperwork to send the other resident to the hospital when Resident #1 returned to the facility. She revealed she should have told LPN #2 Resident #1 had returned so LPN #2 could have applied the Secure Care bracelet. LPN #1 revealed at approximately 6:10 PM she received a call from a female stating she had seen an elderly person in a blue shirt and gray pants walking on the road near the facility. LPN #1 stated when they reached the resident, the resident stated he/she was going home and she asked him/her to come back to the facility so they could assist him/her. Interview with Resident #1, on 03/27/14 at 11:15 AM, revealed he/she remembered leaving the building and was walking home. Interview with the Director of Nursing (DON), on 03/28/14 at 3:33 PM, revealed he would have expected the Charge Nurse to ensure the plan of care was in place before the resident left in the room. Interview with the Administrator, on 03/31/14 at 2:24 PM, revealed she expected the Charge Nurse or a designee to go to the room when the resident was readmitted to observe the transfer, implement the plan of care, assess the resident, initiate physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/22/14, once Resident #1 was back in the building and in his/her room, the Charge Nurse assigned a nurse aide to stay with him/her until she returned with the Secure Care bracelet for him/her. The bracelet was replaced on Resident #1 by the Charge Nurse, on 03/22/14. The Charge Nurse completed a body audit/assessment on Resident #1 once he/she was back in the building with no injuries noted on 03/22/14. On 03/22/14, the Charge Nurse completed an Unusual Occurrence report for Resident #1. The Charge Nurse initiated a head count, on 03/22/14, to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road. The Charge Nurse documented the events of the incident in Resident #1's Chart, on 03/22/14. On 03/22/14, the Charge Nurse, Treatment Nurse, Certified Medication Aide (CMT), State Registered Nurse Aide (SRNA), and Ward Clerk that were working at the time of the incident were either questioned or wrote a statement about whether they saw Resident #1 exit the building or if they had any interaction with him/her by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staffing Coordinator. Resident #1's care plan and Elopement Assessment were updated by the ADON, on 03/22/14. The Administrator notified the Office of Inspector General (OIG), Department for Community Based Services (DCBS), and the local Police about the incident, on 03/22/14. The ADON audited the care plans, and elopement risk assessments of all residents wearing a Secure Care bracelet to ensure they had a physician order [REDACTED]. An Elopement Assessment audit was completed for all residents by the ADON, on 03/22/14, to ensure all Elopement Assessments were up to date. All exit doors were checked for proper functioning by Administrator, on 03/22/14. All residents' Secure Care anklets were checked for proper functioning by the Staffing Coordinator, on 03/22/14 The DON counseled the Charge Nurse for failing to keep the resident safe upon return from the hospital, on 03/22/14. A task audit was completed in Point Click Care (electronic medical records) by the Administrator and ADON, on 03/22/14, to ensure Secure Care check tasks were in place for all residents at risk for elopement. The Administrator, DON, and ADON had direct input into the revision of the Resident Discharge or Transfer section of the Secure Care policy, on 03/22/14. The revision pertained to changing the location of where to put the bracelet once it was removed from a resident. The Administrator typed the revisions and replaced the old Secure Care policy in the P & P manual with the new copy. Per the DON's and ADON's input, the new copy now includes the following revisions: "If the resident is sent to the hospital, discharged or leaves for a home visit, the Charge Nurse MUST cut the bracelet strap off the resident prior to the resident leaving. Affix the bracelet on the rings in the resident's medical chart. When the resident returns, the Charge Nurse should replace the bracelet immediately. The Nurses' Notes should state that the bracelet was removed and another Note stating when it was placed back on the resident." All nursing staff and Administrative staff were in-serviced by phone on the revised Secure Care Policy by the ADON, DON, and Staffing Coordinator, on 03/22/14, to include: the Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, Leave of Absence (LOA) or discharged , and document in the Nurse's Notes that it was removed and fastened to the rings inside the resident's chart. Also it is the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. The DON notified the Medical Director, on 03/22/14, of the incident; Resident #1's condition once back in the building; the counseling of the Charge Nurse for failing to follow physicians orders; the revisions made to the Secure Care policy; the notification of the Power of Attorney (POA), physician, Office of Inspector General (OIG), Department for Community Based Services (DCBS), and local police; the checking of the physician orders; updates to elopement assessments and care plans; checking the exit doors and the resident's bracelets for proper functioning; review of revisions to the CQI tool N-29 "New Admission & Hospital Return Review"; nursing orientation updates; staff in-service training; and audits of Point Click Care tasks. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. The information included pertaining to the Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When functioning in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. The Care plans were reviewed and updated, on 04/04/14, by licensed staff and Department Directors for all residents who are not assessed to be at risk for elopement to ensure that physician orders [REDACTED]. Licensed nurses, Certified Medication Aides (CMA), State Registered Nurse Aides(SRNA), Ward Clerks, Activity Director, Activity Assistant, Social Service Director, Maintenance, Dietary Manager, Office Manager, and Medical Records Coordinator were called, on 03/22/14, and informed about the details surrounding the elopement and the nurse's failure to follow the physician orders [REDACTED]. The staff was in-serviced, on 03/22/14, by phone by the DON, ADON, and Staffing Coordinator on the revisions made to the Secure Care policy to include: The Charge Nurse's responsibility to remove the bracelet when the resident leaves the facility for the hospital, LOA or discharged and document in the Nurse's Notes that it was removed and fastened to the ring inside the resident's chart. Also the Charge Nurse's responsibility to apply the Secure Care bracelet upon admission and readmission and document in the Nurse's Notes that it was reapplied and checked for proper functioning. All PRN staff, staff on FMLA, and any potential agency staff will be educated on the Secure Care policy prior to working again by the DON, ADON, or Staffing Coordinator. The Administrator and DON reviewed the current Licensed Nurses Orientation form and revised it to include detailed training information pertaining to the Secure Care program and other issues, on 03/22/14. All new hire licensed staff will receive orientation on the revised Licensed Nurses Orientation by the DON. Information included pertaining to Secure Care program is: i. Having resident's room, equipment and all care needs ready prior to a new admission or readmission. ii. New Nursing Policy & Procedure Manuals. iii. Removing and replacing a Secure Care bracelet when resident leaves the facility for LOA, hospitalization or discharge and document that the bracelet was removed and attached to the resident's medical chart. v. Location of the Secure Care supplies. vi. Upon return from LOA, hospital, assigning staff one on one until Secure Care bracelet is replaced. Documenting that the bracelet was replaced on resident for proper functioning, placement and expiration date. vii. When acting in the Charge Nurse position, inform staff of admission or readmission to ensure resident's room and care needs are ready. CQI tool N-29 "New Admission & Hospital Return Review" was reviewed, on 03/22/14, by the Administrator, DON, and ADON. Together, we decided to add the following four (4) questions to monitor after reviewing with QA team and Medical Director: i. Was a Secure Care bracelet removed from the resident and affixed to his/her chart at discharge? ii. Is there documentation that the bracelet was removed and where it is located? iii. Was the Secure Care bracelet put back on the resident upon return from the hospital, LOA? iv. Is there documentation that the bracelet was put back on the resident when he/she returned to the facility? The CQI tool N-29 "New Admission & Hospital Return Review" will be completed weekly for four (4) weeks, monthly for four (4) months, then per CQI schedule by the DON or ADON. ADON completed CQI N-29 "New admission & Hospital Return Review"for Resident #1, on 03/22/14. CQI N-29 was completed, on 04/04/14, by the DON on all residents who have been discharged , LOA or hospitalized and those who have returned to the facility since 03/22/14 with 100% accuracy. **The State Agency validated the corrective action taken by the facility as follows: Review of Nurse's Notes, dated 03/22/14 at 6:30 PM, validated Resident #1 returned to the facility, complete body audit/assessment completed, SRNA assigned to monitor Resident #1 one to one until Secure Care bracelet replaced, and Secure Care bracelet applied by the Charge Nurse. The Charge Nurse initiated a head count to ensure the safety of all other residents in the building after receiving the phone call from the unidentified female about a person walking up the road and documentation of all notifications and events related to the incident were documented. Review of Resident #1's "Elopement Assessment" and "Elopement/Wandering" care plan validated, on 03/22/14, those documents were updated by ADON. Review of Resident's #2-#20 physicians' orders, elopement assessments and care plans revealed the residents had orders for the Secure Care bracelets and the residents were assessed and care planned for elopement. Observation of Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18, #19 and #20 revealed the Secure Care bracelet was in place on each resident. Resident #13 and Resident #16 were in the hospital and observation revealed their Secure Care bracelets were in the ring of their charts. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that the ADON also audited all residents charts to ensure the "Elopement Risk Assessment" was up to date and she had checked for proper functioning of all exits with the Secure Care system, on 03/22/14. She stated a task audit in Point Click Care (electronic medical records) was performed to ensure the Secure Care tasks were in place for all residents with Secure Care bracelets, on 03/22/14. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, validated she had checked for proper functioning of all residents' Secure Care bracelets. Review of the counseling form revealed the DON counseled the Charge Nurse for not keeping Resident #1 safe on return from the hospital, on 03/22/14. Review of inservice records, dated 03/22/14, revealed all nursing staff and Administrative staff that could be contacted were in-serviced in person or inserviced by phone on the revisions in the Secure Care policy by the ADON, DON, and Staffing Coordinator. Those that could not be contacted on 03/22/14 were inserviced before they were allowed to return to work either by phone or in person when they arrived for work on their next scheduled day. Interview with the Staffing Coordinator, on 04/10/14 at 12:11 PM, revealed she had used the call list to ensure all staff was in-serviced on the Secure Care policy revision before they returned to work. Interview with the Administrator, on 04/10/14 at 11:00 AM, verified that care plans were reviewed and updated by licensed staff and Department Directors, on 04/04/14, to ensure that residents that were not at risk of elopement, forty-one (41) residents, were having their physicians orders followed. Interviews with RN #4 and #5, LPN #5, #6, and #7, and SRNA #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14, on 04/10/14 at 11:00 AM, 11:04 AM, 11:08 AM, 11:12 AM, 11:16 AM, 11:20 AM, 11:24 AM, 11:31 AM, 11:36 AM, 11:39 AM, 11:42 AM, 11:46 AM, 11:50 AM, 11:55 AM, 12:02 PM, and 12:06 PM respectively, revealed they received an inservice on the changes to the Secure Care policy in person and by phone starting on 03/22/14 and all of the staff had been inserviced before they returned to work on their next scheduled day. All interviews revealed the inservice was related to the Charge Nurse being responsible to ensure the Secure Care bracelet was placed immediately on admission and readmission to the facility, the Secure Care bracelet was removed just before the resident goes out of the facility, documentation of the removal of the bracelet, how the bracelet was stored in the resident's chart until the resident returned to the facility, placement of the Secure Care bracelet, function of the bracelet, expiration date of the bracelet, and location of Secure Care supplies. Review of the CQI tool N-29, "New Admission & Hospital Return Review", dated 03/22/14, compared to CQI tool N-29, undated, validated the changes made on the CQI tool N-29. Review of the CQI tool N-29 and interview with the Administrator, on 04/10/14, revealed the ADON completed the CQI tool N-29 form on Resident #1, on 03/22/14, and on all residents who have been out of facility or hospitalized from [DATE] through 04/03/14 with 100% accuracy. The monitoring was going to continue weekly for a total of 4 weeks, monthly for a total of 4 months, then per CQI schedule by the DON or ADON.

Based on observation, interview, record review and review of the facility policy it was determined the facility failed to have an effective system in place to ensure one (1) resident (#4), in the selected sample of thirteen (13) residents, received the proper care and treatment related to oxygen (O2) therapy. Resident #4 was readmitted to the facility from the hospital on [DATE]. The resident was experiencing difficulty breathing on 04/15/13 and orders were received for O2 via mask, titrate from 2-4 liters per minute to maintain O2 saturation (sat.) over 90%. Resident #4 was observed on 04/24/13 at 12:20 PM exhibiting difficulty breathing. The surveyor asked the facility staff to intervene, and the resident's O2 sat was assessed at 81% (normal 95-100 %). Observation of the oxygen cylinder regulator revealed it indicated the cylinder was empty. Staff interviews revealed there was no system in place to ensure there was adequate O2 in the O2 cylinders. The facility was notified of the Immediate Jeopardy on 04/26/13. This facility's failure to have a system to ensure residents received adequate oxygen has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/26/13 and determined to exist on 04/24/13. The facility was made aware of the Immediate Jeopardy on 04/26/13. An acceptable Allegation of Compliance (AoC) was received on 04/29/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 04/28/13, as alleged. The scope and severity was lowered to a "D" while the facility developed and implemented a Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the facility's policy and procedure entitled, "Oxygen Administration", last revised 03/2004, revealed staff should check the mask, tank, humidifying jar, etc., to be sure they were in good working order and were securely fastened. A record review revealed Resident #4 was re-admitted to the facility on [DATE] at 2:30 PM from the hospital with a [DIAGNOSES REDACTED]. A review of the Nurse's Notes, dated 04/15/13 at 4:00 PM, revealed the resident was noted to have increased respirations with decreased oxygen saturations. The Physician was called and an order was obtained for oxygen via mask, may titrate from 2-4 L/minute to maintain saturation of over 90%. Observation on 04/24/13 at 12:20 PM revealed Resident #4 was in the dining room in a wheelchair with a nasal cannula in his/her nose and O2 tubing connected to an O2 cylinder. The resident was exhibiting difficulty breathing. The staff were requested to intervene by the surveyor; and the resident's O2 sat was assessed at 81% (normal 90-100%). Observation of the O2 cylinder revealed the cylinder regulator indicated the cylinder was empty. Licensed Practical Nurse (LPN) #2 changed the empty O2 cylinder for a new O2 cylinder that indicated full on the regulator and set the regulator to deliver O2 at 4/Liters per minute. Further observation revealed Resident #4's O2 saturation improved to 89% at 12:25 PM and additionally improved to 92% at 12:27 PM on the 4/Liters of O2. Interview with LPN #2, on 04/24/13 at 12:27 PM, revealed the Certified Nurse Aides (CNA) were to make sure O2 cylinders were adequately full when they transferred residents from the O2 concentrators in the residents' rooms to the portable O2 cylinders placed on the residents' wheelchairs. An interview with CNA #20 (who transferred the resident to the O2 cylinder and transported the resident to the dining room), on 04/24/13 at 12:45 PM, revealed she did not adjust Resident #4's O2 when she assisted him/her to transfer and that she did not see anyone set it. She additionally stated she did not know if the resident's O2 was turned on or off. An interview with CNA #8, on 04/24/13 at 12:30 PM and 5:50 PM, revealed normally the CNAs would transfer a resident from an O2 concentrator to a portable cylinder and would ask the Nurse to make sure it was right. CNA #8 stated that Nurses did not come to check the O2 cylinders every time they transferred a resident to a portable tank. The CNA revealed she didn't think the O2 regulator on Resident #4's O2 cylinder displayed empty but could not say what the regulator indicated. CNA #8 stated she had no idea how long O2 would last in an oxygen cylinder at any setting. An interview with the Director of Nursing (DON), on 04/24/13 at 2:00 PM, revealed the O2 cylinders were utilized for residents when going to activities or transported to different areas in the facility. The DON stated Nurses were responsible for setting the O2 to the appropriate setting. Per interview, staff were not required to track through documentation how much O2 was in the O2 cylinder. An interview with the Administrator, on 04/24/13 at 2:10 PM and 04/26/13 at 1:45 PM, revealed the CNAs can apply oxygen but can not change the regulator or initiate any new O2 administration. The Licensed Nurse was ultimately responsible to ensure there was adequate oxygen in the cylinders. **The facility implemented the following actions to remove the Immediate Jeopardy: *On 04/24/13, the Administrator began investigating and interviewing any Nurse/CNA identified to have been involved/associated with Resident #4 on 04/24/13. *On 04/24/13, the Administrator counseled two CNAs identified on duty and on the floor 04/24/13 providing care to Resident #4. *On 04/24/13, the DON completed an audit on all current residents prescribed oxygen to ensure the oxygen tank in use was not empty. *On 04/24/13, the policy titled "Oxygen, Application and Changing of Equipment and Supplies" was reviewed and revised by the Corporate Compliance Director. The revisions included the Licensed Nurse will verify tank fill level before meals to ensure adequate oxygen administration per Physician order. *On 04/24/13, an in-service for all Licensed Nurses and CNAs was initiated and conducted by the DON, ADON and Corporate Compliance Director on the revised policy "Oxygen, Application and Changing of Equipment and Supplies". The in-service was completed 04/27/13. *On 04/26/13, CQI form "Oxygen Audit" was developed and implemented by the Administrator. *On 04/26/13, the DON and ADON were in-serviced by the Administrator on the implementation, scheduling and reporting of the new CQI form "Oxygen Audit". *The DON and ADON completed a chart audit for residents using the "Oxygen Audit" form on 04/26/13. *The CQI form "Oxygen Audit" was completed on 04/26/13 and will be completed weekly x 4, monthly x 2 and quarterly thereafter by the DON on a random resident sample of six. The DON will report the results of the audit to the Administrator. The Administrator will report audit results to the QA committee to confirm that all oxygen is ordered, documented and care planned correctly. *The DON completed the "Oxygen Audit" on 04/27/13. *A Quality Assurance Meeting was held on 04/27/13 with the facility Medical Director to discuss issues identified during the OIG complaint survey. The State Survey Agency validated the corrective action taken by the facility as follows: Record review and interviews with LPN #2, #4, and #5 and CNAs #5, #8, and #13 revealed they had received inservicing related to the policy "Oxygen, Application and Changing of Equipment and Supplies" by the DON, ADON and Corporate Compliance Director on the revised . The in-service was completed 04/27/13. The new CQI form "Oxygen Audit" was verified and interviews with the DON and ADON von 04/30/13 beginning at 3:40 PM verified they had received inservicing by the Administrator on the implementation of the new CQI form "Oxygen Audit". Chart reviews and interviews with the DON and ADON on 04/30/13 beginning at 3:40 PM revealed the DON and ADON had completed a chart audit for residents using the "Oxygen Audit" form and was completed 04/27/13. A QA meeting was verified held on 04/27/13 with the Medical Director in attendance and oxygen administration and plan of action implemented was discussed.

Based on observation, interview and record review, it was determined the facility failed to have an effective system to ensure one (1) resident (#4), in the selected sample of thirteen (13) residents, was provided the necessary care and services to maintain the highest practicable physical, mental and physical well-being. The facility failed to ensure Licensed Nursing staff provided a thorough assessment and followed the facility's "Change in Condition", policy and procedure related to Physician notification once informed by the Certified Nurse Aides (CNA) of a possible significant change in condition. (Refer to F157) On [DATE], CNAs observed Resident #4 to be drenched in sweat and exhibiting labored breathing. The day and second shift Nurses were made aware sometime around the 3:00 PM shift change that Resident #4 was exhibiting these symptoms. There was no documented evidence the Nurses assessed the resident. At approximately 5:20 PM, the CNAs notified the Director of Nursing (DON) when the Nurses failed to respond to Resident #4's reported change of condition. Resident #4 was transferred to the emergency room at 5:50 PM and admitted with the [DIAGNOSES REDACTED]. The facility's failure to conduct a timely thorough assessment of Resident #4 has caused, or is likely to cause, serious injury, harm, impairment or death to a resident. The Immediate Jeopardy with Substandard Quality of Care was identified on [DATE] and identified to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A record review revealed Resident #4's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the acute hospital stay Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility had assessed Resident #4 with severe cognitive impairment, unable to make needs known, non ambulatory and was dependent on staff for all activities of daily living. A interview with CNA #13, on [DATE] at 10:20 AM, revealed on [DATE] she had provided care for Resident #4 and the resident seemed normal until sometime around the 3:00 PM at Nursing shift change. CNA #13 stated her and CNA #8 were assisting Resident #4 to transfer from the bed to the wheelchair when they noticed Resident #4 did not look right as the resident's face and neck seemed swollen and was "drenched in sweat" requiring CNA #13 to change the resident's clothing. CNA #8 notified the Nurse and the Nurse had told the CNAs to put oxygen on the resident but they did not because that was not something CNAs could do. The Nurse did not come to the resident's room and the CNAs moved Resident #4 to the Nursing station. The Director of Nursing came by and CNA #13 asked him to look at Resident #4 and told him Resident #4's change of condition had already been reported to one of the Nurses. An interview with CNA #8, on [DATE] at 10:40 AM revealed she assisted CNA #13 with transferring Resident #4 from the bed to the wheelchair around the 3:00 PM shift change for licensed Nurses. CNA #8 stated Resident #4 was breathing heavier than normal and was drenched in sweat and not speaking as he/she normally did. Resident #4 was normally always cold. The CNAs moved Resident #4 to the Nursing station and the resident remained there long enough for CNA #8 and CNA #13 to assist in transferring two or three more residents. CNA #8 stated they were told to move Resident #4 to the Nursing station so that vitals signs could be obtained by the Nurse but the Nurse did not obtain the vital signs. CNA #8 stated it made her mad when the Nurses didn't do anything and she obtained the resident's vital signs because she was worried about the resident. An interview with CNA/RA (Restorative Aide) #3, on [DATE] at 3:05 PM, revealed on [DATE] sometime after the licensed staff shift change at 3:00 PM, she observed Resident #4 was having trouble breathing, did not look right and was soaking wet with sweat. CNA #3 stated CNA #8 and CNA #13 were assisting Resident #4 to transfer from the bed to the wheelchair. CNA #3 stated she knew something was wrong with Resident #4 and Resident #4 was taken to the nursing station and LPN #2 told CNA #8 to put oxygen on Resident #4. An interview with LPN #2, on [DATE] at 3:05 PM, revealed on [DATE] after the 3:00 PM shift change one of the CNAs (did not recall which CNA) reported Resident #4 was not feeling well. She stated she told that CNA she would get the second shift LPN (LPN #5) to look at the resident. LPN #2 stated she did not obtain vital signs or conduct an assessment because she was preparing to leave for the day. The LPN also stated she informed LPN #5 that Resident #4 had been moaning and groaning all day and that was usual for the resident. LPN #2 stated she had seen Resident #4 after the CNA reported he/she wasn't feeling well but that "He/she didn't look any different". An interview with LPN #5, on [DATE] at 4:26 PM, revealed she usually arrived for second shift around 2:50 PM. The LPN stated on [DATE], she received report from the day shift Nurse, LPN #2 sometime around 3:00 PM to 3:30 PM. She revealed there was no mention of Resident #4 during the shift report. The LPN stated after report she had gone to another resident's (Resident #3) room to perform a full skin assessment at about 3:30 PM. LPN #5 stated, during the assessment, CNA #3 entered the resident's room and informed her that Resident #4 was sweating. LPN #5 revealed she completed the skin assessment which took about ten additional minutes. LPN #5 then went to the nursing office to document the completed skin assessment and at that time LPN #2 told her Resident #4 was stable and to just watch him/her. LPN #5 then went to the Administrator's office for an undetermined period of time and when she returned the DON had Resident #4 in the nursing station and had oxygen on him/her. The LPN stated the DON told her Resident #4's O2 sat. was 84% with O2 and to notify the Physician. LPN #5 revealed she obtained vital signs herself before notifying the Physician and recalled the O2 sat was low, the pulse was high, the blood pressure was low and the temperature was elevated. LPN #5 stated she documented the vital signs in the resident's record, called the Physician, left a message, the Physician returned the call right away and gave orders to send Resident #4 to the emergency room . LPN #5 stated she should have stopped and assessed Resident #4 when the CNA had came to her during the skin assessment of the other resident. She stated she would normally do so and said Resident #4 could have died . An interview with the Director of Nursing (DON), on [DATE] at 1:15 PM and on [DATE] at 9:00 AM, revealed on [DATE] CNA #13 had notified him during the time the day shift Nurses were still in the facility and the second shift Nurses were on the floor that something was not right with Resident #4 and she had notified LPN #2. The DON said Resident #4 was very short of breath but had good lung sounds and was using accessory muscles and he told LPN #5 to send the resident out. On [DATE] at 9:00 AM the DON stated he did not realize there had been such a time span from when the CNAs had reported to the Nurse something was wrong with Resident #4 and the time CNA #13 had asked him to look at the resident. The DON expected the Nurse to assess immediately if there was report of a change of condition in any resident. An interview with Resident #4's Physician, on [DATE] at 8:00 AM and [DATE] at 10:00 AM, revealed she had been unaware of the delay in notifying her of Resident #4's change of condition on [DATE] and would have expected the Nurse to notify her immediately. The Physician stated she was concerned that she was not notified timely. The Physician stated Resident #4 required treatment of [REDACTED]. The Physician described the common symptoms of [MEDICAL CONDITION] Embolism was sweating profusely, clammy skin, shortness of breath and was very frightening for patients. She additionally stated blood clots do not dissolve right away and take time, however, the treatment would have been the same no matter when she was notified. The Physician stated Resident #4 was fortunate as blood clots in the lung can be fatal and there was a potential it could have been fatal for Resident #4. A review of the Nurse's Note written by Licensed Practical Nurse (LPN) #5, dated [DATE] at 5:20 PM, revealed a call was placed to the Physician in regards to the resident's low oxygen (O2) saturation (sat.)of 84% (normal: 95%-100%) on room air, Temperature 100.9 degrees (normal 98.6 degrees), pulse 100 (normal ,[DATE]) , Respirations 24 (normal ,[DATE]), blood pressure (B/P) ,[DATE] (normal ,[DATE]). The resident was using his/her accessory muscles to breath and his/her skin was cool and clammy. A new order was received to send the resident to the emergency room . A call was placed to the family at 5:25 PM and they were made aware of the new order and the family agreed. At 5:50 PM, the ambulance arrived for transport and the report was called to the emergency room . A review of Resident #4's emergency room Record, dated [DATE], revealed the resident was diagnosed with [REDACTED]. An interview with the emergency room Physician, on [DATE] at 11:05 AM, revealed shortness of breath and chest pain were common signs of [MEDICAL CONDITION] Embolism. The onset of symptoms could be sudden and presence of underlying disease could cause the symptoms to vary. The Physician revealed he would expect staff to respond immediately to any resident displaying shortness of breath and report to the Physician. The Physician revealed the condition could cause death. The treatment would be the same for [MEDICAL CONDITION] Embolism if it was two hours, four hours or six hours after onset. The Physician revealed treatment intervention ideally should be sooner than later to improve the chances of a good outcome. **The facility implemented the following actions to remove the Immediate Jeopardy: *On [DATE], the Administrator investigated and interviewed any Licensed Nurse/CNA identified to have been involved/associated with Resident #4 on [DATE] prior to 5:20 PM. The Administrator counseled two Nurses identified on duty and on the floor on [DATE] and caring for Resident #4. *The Policy for Change in Resident's Condition or Status was reviewed and was determined to be a sufficient policy of when to assess and what should be reported to the Physician. *Inservicing on the policy "Resident Change in Condition or Status" for all Licensed Nurses was initiated and completed by the DON on [DATE]. All new employees will be inserviced prior to completion of orientation. *The Charting and Documentation Policy was reviewed and revised [DATE] by the Corporate Compliance Director. All Licensed Nurses had completed inservicing on the revised policy by [DATE]. *CQI tool N-26, Notification of Change in Resident Condition, that audits the resident medical record for required documentation according to the current Nursing Standards of Practice, was reviewed and revised [DATE]. Inservicing was completed by the Corporate Compliance Director on [DATE] with the Administrator, DON, ADON, PRN (as needed) Administrative Nurses on the revised CQI tool N-26, Notification of Change in Resident Condition. *The policy titled "Nursing Services Policy and Procedure Manuel" was removed and a new policy titled "Nursing Standards of Practice Policy" was implemented and included references and guidelines the facility would follow in regards to current Nursing Standards of Practice to include: Lippincott: Manual of Nursing Standards, the Kentucky Board of Nursing Standards of Practice, and Nursing Services Policy and Procedure Manual. All Nurses were inserviced by the ADON and DON on the Nursing Standards of Practice Policy, placement of these reference materials in the Nurse's Station and when and how to assess a resident for a change of condition. All new employees will be inserviced prior to completion of orientation. *The CQI tool N-26 was completed on [DATE] on all residents under the supervision of the DON to identify any other resident with the potential to be affected by the failure to notify a Physician of a change in condition. * The N26 Notification of Change in Resident Condition will be completed weekly x 4, monthly x 2, and quarterly thereafter by the DON on a random resident sample of six. The DON will report the results of the audit to the Administrator. The Administrator will report audit results to the QA committee and confirm that all notifications were made correctly. *On [DATE], the ADON randomly interviewed CNAs who had worked the 3:00 PM to 11 PM shift to make sure resident change in conditions have been addressed in a timely manner. The ADON will randomly interview at least three CNAs on alternating shifts to make sure resident change in conditions have been addressed in a timely manner. Any concerns will be addressed immediately, by the ADON. These interviews will be completed weekly x 4, then monthly x 2, and quarterly thereafter by the ADON. *A QA meeting was held on [DATE] with the facility Medical Director to discuss issues identified with residents having significant change in clinical status, Physician notification of that change and the plan of action implemented. The State Survey Agency validated the corrective action taken by the facility as follows: Interviews conducted on [DATE] beginning at 3:20 PM with the Administrator, LPN #2, #4, and #5 and CNA #5, #8 and #13 revealed the Administrator had investigated and interviewed Licensed Nurses and CNAs identified to have been involved with Resident #4 on [DATE]. Interviews with Licensed Nurses #2, #4, and #5 on [DATE] beginning at 3:40 PM revealed they had received inservicing related to the The Policy for Change in Resident's Condition or Status and had been provided by the DON. The revised policy "Charting and Documentation" was verified revised by the Corporate Compliance Director and sign off documentation and interviews on [DATE] beginning at 3:40 PM with LPNs #2, #4, and #5 verified inservicing had been completed by [DATE]. The CQI tool N-26, Notification of Change in Resident Condition for audits of the resident medical record for required documentation was verified revised [DATE] and interviews with the Administrator, DON, ADON, LPN #2, LPN #4, and LPN #5 on [DATE] beginning at 3:40 PM revealed the revised CQI tool N-26 verified inservicing had been completed by the Corporate Compliance Director. The newly revised Nursing Standards of Practice Policy which included references and guidelines the facility will follow in regards to current Nursing Standards of Practice including Lippincott: Manual of Nursing Standards, Kentucky Board of Nursing Standards of Practice and Nursing Services Policy and Procedure Manual were all verified available at the nursing station. Review of sign off documentation and interviews with LPNs #2, #4, and #5 on [DATE] beginning at 3:40 PM revealed inservicing had been completed by the ADON and DON. Interview with the DON on [DATE] at 3:40 PM revealed he had completed the CQI tool N-26 on all residents on [DATE] and would be completing the tool weekly x 4, monthly x 2, and quarterly thereafter on a random sample of six residents.

Based on observation, interview, record review, and review of facility's policy and procedure it was determined the facility failed to have an effective system to ensure the Comprehensive Care Plan was revised for one (1) residents (#4), in the selected sample of thirteen (13) residents. Resident #4 was readmitted to the facility from the hospital on [DATE]. The resident was experiencing difficulty breathing on 04/15/13 and orders were received for O2 via mask, titrate from 2-4 liters per minute to maintain O2 saturation (sat.) over 90%. However, the facility failed to revise the care plan to include oxygen therapy. On 04/24/13 at 12:20 PM, Resident #4 was observed exhibiting difficulty breathing, and after surveyor intervention, staff assessed the resident's O2 sat at 81% (normal 95-100 %). Observation of the oxygen cylinder regulator revealed it indicated the cylinder was empty. Staff interviews revealed there was no system in place to ensure there was adequate O2 in the O2 cylinders. The facility was notified of the Immediate Jeopardy on 04/26/13. (Refer to F328) This facility's failure to have a system to ensure residents care plans were revised has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/26/13 and determined to exist on 04/24/13. The facility was made aware of the Immediate Jeopardy on 04/26/13. An acceptable Allegation of Compliance (AoC) was received on 04/29/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 04/28/13, as alleged. The scope and severity was lowered to a "D" while the facility developed and implemented a Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the facility's policy titled, Care Plan - Comprehensive, no date, revealed the facility should develop an individualized comprehensive care plan that includes measurable objectives to meet the resident's medical and nursing needs. Maintaining a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each care plan will be designed to identify problem areas, risk factors, goals and department responsible for each element of care. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed/updated quarterly. A record review revealed Resident #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Notes, dated 04/15/13 at 4:00 PM, revealed Licensed Practical Nurse (LPN) #2 called the Physician's answering service related to Resident #4 having increased respirations and decreased oxygen saturation. Further review of the nursing notes, revealed the Physician returned the call at 4:25 PM and gave an order for [REDACTED]. A review of a physician's orders [REDACTED]. Further record review revealed Resident #4's care plan was not revised to address the resident's decreased ability to breathe and O2 therapy and to provide interventions for staff. Observation on 04/24/13 at 12:20 PM revealed Resident #4 was exhibiting difficulty breathing. After surveyor intervention, staff assessed the resident's O2 sat at 81% (normal 90-100%). Further observation revealed the O2 cylinder was empty. Interview with LPN #2, on 04/24/13 at 12:27 PM, revealed the Certified Nurse Aides (CNA) were responsible to check the O2 cylinders when they transferred residents from the O2 concentrators in the residents' rooms to the portable O2 cylinders placed on the residents' wheelchairs. However, interview on 04/24/13 at 12:45 PM with CNA #20 who transferred the resident to the O2 cylinder and transported the resident to the dining room, revealed she did not check the resident's oxygen. An interview with CNA #8, on 04/24/13 at 12:30 PM and 5:50 PM, revealed CNA #8 did not think the O2 regulator on Resident #4's O2 cylinder displayed empty but could not say how much oxygen was in the cylinder. An interview with the Administrator, on 04/24/13 at 2:10 PM and 04/26/13 at 1:45 PM revealed the Nurse was responsible to obtain the physician's orders [REDACTED]. The MDS Coordinator was to verify the physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: *On 04/24/13, the Administrator began investigating and interviewing any Nurse/CNA identified to have been involved/associated with Resident #4 on 04/24/13. *On 04/24/13, the Administrator counseled two CNAs identified on duty and on the floor 04/24/13 providing care to Resident #4. *On 04/24/13, the DON completed an audit on all current residents prescribed oxygen to ensure the oxygen tank in use was not empty. *On 04/24/13, the policy titled "Oxygen, Application and Changing of Equipment and Supplies" was reviewed and revised by the Corporate Compliance Director. The revisions included the Licensed Nurse will verify tank fill level before meals to ensure adequate oxygen administration per Physician order. *On 04/24/13, an in-service for all Licensed Nurses and CNAs was initiated and conducted by the DON, ADON and Corporate Compliance Director on the revised policy "Oxygen, Application and Changing of Equipment and Supplies". The in-service was completed 04/27/13. * On 04/26/13 the Corporate Compliance Director provided inservice to the MDS Coordinator related to Interim and Comprehensive Care Plan policy and procedures. *On 04/26/13, CQI form "Oxygen Audit" was developed and implemented by the Administrator. *On 04/26/13, the DON and ADON were in-serviced by the Administrator on the implementation, scheduling and reporting of the new CQI form "Oxygen Audit". *The DON and ADON completed a chart audit for residents using the "Oxygen Audit" form on 04/26/13. *The CQI form "Oxygen Audit" was completed on 04/26/13 and will be completed weekly x 4, monthly x 2 and quarterly thereafter by the DON on a random resident sample of six. The DON will report the results of the audit to the Administrator. The Administrator will report audit results to the QA committee to confirm that all oxygen is ordered, documented and care planned correctly. *The DON completed the "Oxygen Audit" on 04/27/13. *A Quality Assurance Meeting was held on 04/27/13 with the facility Medical Director to discuss issues identified during the OIG complaint survey. The State Survey Agency validated the corrective action taken by the facility as follows: Record review and interviews with LPN #2, #4, and #5 and CNAs #5, #8, and #13 revealed they had received inservicing related to the policy "Oxygen, Application and Changing of Equipment and Supplies" by the DON, ADON and Corporate Compliance Director on the revised . The in-service was completed 04/27/13. On 04/30/13 the Oxygen Application and Changing of Equipment and Supplies was verified revised and interview on 04/30/13 with the MDS Coordinator verified she had been provided inservicing related to the policy by the Corporate Compliance Director. The new CQI form "Oxygen Audit" was verified and interviews with the DON and ADON von 04/30/13 beginning at 3:40 PM verified they had received inservicing by the Administrator on the implementation of the new CQI form "Oxygen Audit". Chart reviews and interviews with the DON and ADON on 04/30/13 beginning at 3:40 PM revealed the DON and ADON had completed a chart audit for residents using the "Oxygen Audit" form and was completed 04/27/13. A QA meeting was verified held on 04/27/13 with the Medical Director in attendance and oxygen administration and plan of action implemented was discussed.

Based on interview, record review and facility policy review it was determined the facility failed to have an effective system to ensure the Physician was notified timely of a significant change in condition for one resident (#4), in the selected sample of thirteen (13) residents. On [DATE], Resident #4 was observed by Certified Nursing Assistants (CNAs) to be drenched in sweat and exhibiting labored breathing. The CNAs notified the day shift and second shift Licensed Nurses. Record review and interview revealed the Nurses failed to notify the Physician, per the facility's policy, when they became aware of the resident's change of condition sometime around the 3:00 PM shift change. At approximately 5:20 PM, (2 and ,[DATE] hours after the change in condition was identified) the CNAs notified the Director of Nursing (DON) when the Nurses failed to respond to Resident #4's reported change of condition. Resident #4 was transferred to the emergency room at 5:50 PM and admitted with the [DIAGNOSES REDACTED]. (Refer to F309) The facility's failure to notify the resident's Physician of a significant change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the facility's policy and procedure, titled "Change in Resident's Condition", dated [DATE], revealed the Nurse Supervisor/Charge Nurse should notify the resident's attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition and/or when there was a need to alter the resident's medical treatment significantly. A record review revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the acute hospital stay Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility had assessed Resident #4 with severe cognitive impairment, unable to make needs known, non ambulatory and was dependent on staff for all activities of daily living. An interview with CNA #13 on [DATE] at 10:20 AM and CNA #8, on [DATE] at 10:40 AM, revealed on [DATE] they were assisting Resident #4 from the bed to the wheelchair sometime around the 3:00 PM shift change for licensed Nurses and noticed the resident's face and neck seemed swollen and he/she was "drenched in sweat". CNA #8 stated Resident #4 was breathing heavier than normal, was drenched in sweat, and was not talking as the resident usually repeated simple words repeatedly. Per interview, they notified the Nurse (could not remember which Nurse) and the Nurse told them to put oxygen on the resident but they did not place the oxygen on the resident because the facility's procedure was a Nurse had to it. An interview conducted with Licensed Practical Nurse (LPN) #4, on [DATE] at 11:50 AM, revealed on [DATE], CNAs (not certain which ones) brought Resident #4 to the nursing station sometime after the 3:00 PM shift change. The CNAs reported to her that Resident #4 was sweating and his/her face was red. She stated she told LPN #2 and clocked out for the day at 4:30 PM. An interview conducted with LPN #2, on [DATE] at 3:35 PM, revealed it was after the 3:00 PM shift change on [DATE] when one of the CNAs (did not recall who) said Resident #4 was not feeling well. She stated she told the CNA she would get the second shift LPN (#5) to look at the resident and she informed LPN #5 in report that Resident #4 had been moaning and groaning all day and that was unusual for him/her. However, interview with LPN #5, on [DATE] at 4:26 PM, revealed she received report from the day shift Nurse (LPN #2), sometime around 3:00 PM to 3:30 PM, and there was no mention of Resident #4 during the shift report. Per interview, around 3:30 PM, CNA #3 informed her Resident #4 was sweating, but approximately ten minutes later, LPN #2 told her Resident #4 was stable and to just watch him/her. LPN #5 then went to the Administrator's office for an undetermined period of time and when she returned to the unit, the Director of Nursing (DON) had Resident #4 in the nursing station and had oxygen on him/her. The DON told LPN #5 that Resident #4's oxygen saturation was 84% with oxygen on and to go ahead and call the Physician. Per interview, LPN #5 stated she should have stopped and assessed Resident #4 when the CNA told her about the change in condition and notified the Physician. She stated she would normally do so and said Resident #4 could have died . An interview with the DON, on [DATE] at 9:00 AM, revealed the Nurse should assess the resident immediately if there was a reported change of condition in any resident and should also notify the Physician. Review of the clinical record revealed no documented evidence the Physician was notified of Resident #4's change in condition until [DATE] at 5:20 PM. A review of the Nurse's note written by LPN #5, dated [DATE] at 5:20 PM, revealed a call was placed to the Physician in regards to the resident's low oxygen (O2) saturation (sat.) of 84% (normal: 95%-100%) on room air, temperature 100.9 degrees (normal 98.6 degrees), pulse 100 (normal ,[DATE]) , respirations 24 (normal ,[DATE]), and blood pressure (B/P) ,[DATE] (normal ,[DATE]). The resident was using his/her accessory muscles to breath and his/her skin was cool and clammy. A new order was received to send the resident to the emergency room and at 5:50 PM, the ambulance arrived for transport and the report was called to the emergency room . A review of Resident #4's emergency room Record, dated [DATE], revealed the hospital diagnosed the resident with [MEDICAL CONDITION] and Bilateral [MEDICAL CONDITION] Emboli and the resident's O2 sat was 81%. An interview with Resident #4's Physician, on [DATE] at 8:00 AM and on [DATE] at 10:00 AM, revealed she was unaware of the delay in notifying her of Resident #4's change of condition on [DATE] and would have expected the Nurse to notify her immediately and was concerned that she was not notified timely. The resident was diagnosed with [REDACTED]. Per interview, the Physician described the common symptoms of [MEDICAL CONDITION] Embolism as sweating profusely, clammy skin, shortness of breath and it was very frightening for patients. **The facility implemented the following actions to remove the Immediate Jeopardy: *On [DATE], the Administrator investigated and interviewed any Licensed Nurse/CNA identified to have been involved/associated with Resident #4 on [DATE] prior to 5:20 PM. The Administrator counseled two Nurses identified on duty and on the floor on [DATE] and caring for Resident #4. *The policy for Change in Resident's Condition or Status was reviewed and was determined to be a sufficient policy of when to assess and what should be reported to the Physician. *Inservicing on the Change in Resident Condition or Status policy for all Licensed Nurses was initiated and completed by the DON on [DATE]. All new employees will be inserviced prior to completion of orientation. *The Charting and Documentation Policy was reviewed and revised [DATE] by the Corporate Compliance Director. All Licensed Nurses had completed inservicing on the revised policy by [DATE]. *CQI tool N-26, Notification of Change in Resident Condition, that audits the resident medical record for required documentation according to the current Nursing Standards of Practice, was reviewed and revised [DATE]. Inservicing was completed by the Corporate Compliance Director on [DATE] with the Administrator, DON, ADON, prn Administrative Nurses on the revised CQI tool N-26, Notification of Change in Resident Condition. *The policy titled Nursing Services Policy and Procedure Manuel was removed and a new policy titled Nursing Standards of Practice Policy was implemented and included references and guidelines the facility would follow in regards to current Nursing Standards of Practice to include: Lippincott: Manual of Nursing Standards, Kentucky Board of Nursing Standards of Practice and Nursing Services Policy and Procedure Manual. All Nurses were inserviced by the ADON and DON on the Nursing Standards of Practice Policy, placement of these reference materials in the Nurse's Station and when and how to assess a resident for a change of condition. All new employees will be inserviced prior to completion of orientation. *The CQI tool N-26 was completed on [DATE] on all residents under the supervision of the DON to identify any other resident with the potential to be affected by the failure to notify a Physician of a change in condition. * The N26 Notification of Change in Resident Condition will be completed weekly x 4, monthly x 2, and quarterly thereafter by the DON on a random resident sample of six. The DON will report the results of the audit to the Administrator. the Administrator will report audit results to the QA committee and confirm that all notifications were made correctly. *On [DATE], the ADON randomly interviewed CNAs who had worked the 3:00 PM to 11 PM shift to make sure resident change in conditions have been addressed in a timely manner. The ADON will randomly interview at least three CNAs alternating shifts to make sure resident change in conditions have been addressed in a timely manner. Any concerns will be addressed immediately, by the ADON. These interviews will be completed weekly x 4, then monthly x 2, and quarterly thereafter by the ADON. *A QA meeting was held [DATE] with the facility Medical Director to discuss issues identified with residents having significant change in clinical status, Physician notification of that change and the plan of action implemented. The State Survey Agency validated the corrective action taken by the facility as follows: On [DATE], on site verification included interviews with CNAs #5, #8 and #13 on [DATE] beginning at 3:20 PM that confirmed the Administrator had interviewed them related to Resident #4 on [DATE] related to the resident's status on [DATE]. Interviews conducted with LPN #2, #4 and #5 on [DATE] beginning at 3:40 PM revealed they had received inservicing and counseling related to the events on [DATE]. In addition, the LPNs revealed they had received inservicing related to the policy "Change in Resident Condition" by the DON. The facility's previous and revised policy "Charting and Documentation" was reviewed and determined to have been revised on [DATE]. Inservicing for the Licensed Nurses was confirmed completed on the revised policy on [DATE] as per sign in sheet. Interviews conducted on [DATE] beginning at 3:40 PM revealed LPNs #2, #4 and #5 revealed they had received that inservicing by the Corporate Compliance Nurse. The CQI N-26 tool revisions were reviewed and verified. Inservicing to the Administrator, DON, ADON, Administrative Nurses was verified per sign off sheets and interviews conducted with the Administrator, DON and ADON on [DATE] beginning at 3:20 PM confirmed they had received that inservicing per the Corporate Compliance Director. The new Nursing Standards of Practice policy was reviewed and observation verified the Lippincott Manual of Nursing Standards, Kentucky Board of Nursing Standards of Practice and Nursing Services Policy and Procedure Manual were available for reference at the nursing station. The CQI N-26 tool was verified completed on all residents and scheduled for a random sample weekly x 4, monthly x 2, and quarterly thereafter.

Based on interview, record review, review of and the 2011 Lippincott, Williams and Wilkins Nursing Drug Handbook, and facility policy and procedures review it was determined the facility failed to have an effective system in place to ensure residents on [MEDICATION NAME] (anticoagulant/blood thinner) therapy received laboratory testing, to ensure monitoring of therapeutic levels and appropriate dosage of [MEDICATION NAME] was maintained. This failure affected eight (Residents #6, #8, #13, #14, #15, #16, #17 and #18) of nine residents on [MEDICATION NAME] therapy, in the selected sample of nineteen residents. The facility failed to ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) (tests used to make necessary medication adjustments in [MEDICATION NAME] dosage to keep blood levels within the therapeutic range) were scheduled and obtained per the physician's orders [REDACTED]. Resident #18 received 8.0 milligrams (mg) of [MEDICATION NAME] every day. A PT/INR was completed at the facility on 08/18/11 with results of a PT of 27.2 seconds and an INR of 2.5 (normal range PT 12.3-14.1 seconds and INR 2.0-3.5). Resident #18's physician ordered a repeat PT/INR be completed in one month (due on 09/18/11). However, the PT/INR was not obtained until 10/11/11, twenty-three days late, with high results of a PT of 56.2 seconds and an INR of 6.5. Resident #18's [MEDICATION NAME] was held for three days and restarted at a decreased dose of 6.0 mg per day. Residents #6, #8, #13, #14, #15, #16, and #17 PT/INR levels were not obtained timely based on the physician's orders [REDACTED]. The facility's failure to ensure adequate monitoring of [MEDICATION NAME] levels, caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on 09/18/11. An acceptable Allegation of Compliance (AoC) was received on 10/19/11. Immediate Jeopardy was verified removed on 10/18/11, as alleged in the AoC, prior to exit. The findings include: A review of the 2011 Lippincott, Williams and Wilkins Nursing Drug Handbook revealed a black box warning that "[MEDICATION NAME] can cause major or fatal bleeding which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients." A review of the facility's Lab Policy, dated 06/25/09, revealed upon the receipt of a lab order from the physician, the lab order should be transferred to the lab book at the nurse's station and the order should be faxed to pharmacy. An interview with the former ADON, on 10/13/11 at 2:35 PM, revealed she was employed at the facility from 08/01/11 through 08/26/11. She stated she was in charge of the lab audits; however, she did not complete the audits for August 2011. Per interview, part of the audit process was to also schedule the laboratory tests for the upcoming month. Therefore, when the audit was not completed for August 2011, the labs were not scheduled for September 2011. An interview with the Director of Nursing (DON), on 10/15/11 at 10:00 AM, revealed it was the licensed Nurse's responsibility to transfer telephone/fax and admission orders [REDACTED]. Further interview revealed it was the Assistant Director of Nurse's (ADON) responsibility to conduct laboratory audits at the end of every month to ensure all scheduled routine labs were completed. He stated the ADON resigned at the end of August 2011, and the lab audit was not completed. He confirmed he should have completed the audit after the ADON resigned. Additionally, he revealed he was not aware a part of completing the audit was to schedule the next month's labs. The failure to complete the August 2011 audit, which included the scheduling of routine PT/INR labs for September 2011, resulted in missed [MEDICATION NAME] levels in August and September 2011. An interview with the Administrator, on 10/15/11 at 11:30 AM, revealed it was the licensed nurses' responsibility to transfer telephone/fax and admission orders [REDACTED]. Further interview revealed the monthly lab audit should be conducted by the DON in the ADON's absence. She stated she was aware the August and September 2011 lab audits were not completed; however, she was not aware one of the purposes of the lab audit was to schedule the routine labs for the next month. 1. A record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of a laboratory report, dated 08/18/11, revealed the resident's PT was 27.2 seconds (normal: 12.3 - 14.1) and the INR was 2.5 (normal: 2.0-3.5). The physician documented on the lab report not to change the [MEDICATION NAME] dose, but to repeat the PT/INR in one month (due on 09/18/11). Further review of the Laboratory Book and Resident #18's record revealed the facility did not obtain the PT/INR until 10/11/11, twenty-three (23) days late. The 10/11/11 results revealed a PT of 56.2 seconds (normal 12.3-14.1) and the INR was 6.5 (normal: 2.0-3.5) and indicated these were critical levels. The physician was notified and orders were received to withhold the [MEDICATION NAME] for three days and restart the [MEDICATION NAME] at a decreased dose of 6 mg qd. 2. A record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly. A review of the laboratory report, dated 07/28/11, revealed the resident's PT was 27.4 seconds (normal: 12.3 - 14.1) and the INR was 2.6 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to not change the [MEDICATION NAME] dose and to check the INR monthly. A review of the Laboratory Book and Resident #14's record revealed the facility did not obtain the monthly PT/INR on 08/28/11. The lab was drawn on 09/30/11, thirty-three (33) days late, with a PT of 14.2 and an INR of 1.1, which indicated the INR was low. The physician ordered to increase the [MEDICATION NAME] dose from 3 mg po to 4 mg po qd. 3. A record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly and as needed (prn). A review of the laboratory report, dated 07/06/11, revealed the resident's PT was 14.6 seconds (normal: 12.3 - 14.1) and the INR was 3.1 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to not the change the [MEDICATION NAME] dose. A review of the Laboratory Book and Resident #15's record revealed the facility did not obtain the monthly PT/INR on 08/06/11. The lab was drawn on 09/19/11, forty-four (44) days late, with a PT of 19.7 and an INR of 1.7, which indicated the INR was low. Further review of the lab report revealed the physician documented to increase the [MEDICATION NAME] dose from 5 mg to 6.5 mg po qd. An interview with the physician, for Residents #14, #15 and #18, on 10/14/11 at 1:10 PM, revealed he expected the PT/INRs to be drawn in accordance with physician's orders [REDACTED]. He was not aware labs were missed in August and September. 4. A record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly and prn. A review of a laboratory report, dated 07/11/11, revealed the resident's PT was 34.6 seconds (normal: 12.3 - 14.1) and the INR was 3.2 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to increase the [MEDICATION NAME] dose to alternating 3 mg and 3.5 mg po every other day (qod), and to repeat the PT/INR in three days on 07/14/11. A review of a Laboratory Book and Resident #6's record revealed the facility failed to obtain the PT/INR until 10/11/11, eighty-nine (89) days late. The 10/11/11 results revealed a PT of 20.7 seconds and the INR was 1.8, which were low levels. The physician was notified and an order was given to increase [MEDICATION NAME] to 3.5 mg po qd. 5. A record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered weekly. A review of the laboratory report, dated 09/07/11, revealed the resident's PT was 34.5 seconds (normal 12.3 - 14.1) and the INR was 3.5 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to decrease the [MEDICATION NAME] from 2 mg to 1 mg po qd and to recheck the PT/INR on Monday, 09/12/11. A review of the Laboratory Book and Resident #13's record revealed the facility did not obtain the PT/INR on 09/12/11, or weekly on 09/19/11 and 09/26/11. The PT/INR was obtained 09/29/11 during a hospitalization , with the PT at 17.4 (normal: 12.3 - 14.1) and the INR at 1.58 (normal: 2.0-3.5). An interview with the Advanced Registered Nurse Practitioner, for Residents #6 and #13, on 10/11/11 at 4:06 PM, revealed the [MEDICATION NAME] dosage was based on the results of the PT/INR. 6. A record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly. A review of a laboratory report, dated 07/14/11, revealed the resident's PT was 31.7 seconds (normal 12.3 - 14.1) and the INR was 2.9 (normal: 2.0-3.5). The physician documented no change to the [MEDICATION NAME] dose. A review of the Laboratory Book and Resident #8's record revealed the facility did not obtain the monthly PT/INR for August and September 2011. The next PT/INR was drawn at the local hospital, on 09/24/11, during an emergency room evaluation. The resident's PT was 21.1 and the INR was 2.04, which were low levels. 7. A record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly and prn. A review of the laboratory report, dated 09/28/11, revealed the resident's PT was 28.3 (normal: 12.3 - 14.1) and the INR was 2.7 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to not change the [MEDICATION NAME] dose and repeat the lab in one week, on 10/05/11. A review of the Laboratory Book and Resident #16's record revealed the facility did not obtain the PT/INR ordered for 10/05/11. The lab was drawn on 10/12/11, seven (7) days late, with results of the PT of 14.1 and an INR of 1.1, which indicated the INR was low. The physician documented to increase [MEDICATION NAME] from 5 mg to 7 mg po qd. 8. A record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A PT/INR was ordered monthly. A review of the laboratory report, dated 07/01/11, revealed the resident's PT was 19.3 seconds (normal: 12.3 - 14.1) and the INR was 1.6 (normal: 2.0-3.5). Further review of the lab report revealed the physician documented to not change the [MEDICATION NAME] dose. The facility did not obtain the next monthly PT/INR until 08/26/11, twenty-five (25) days late. Results revealed a PT of 14.1 and an INR of 1.1, which indicated the INR was low. Further review of the lab report revealed the physician documented to increase the [MEDICATION NAME] dose to 10 mg po qd and to check the PT/INR in one week, on 09/03/11. The facility did not obtain the PT/INR until 10/07/11, thirty-four (34) days late, with results of a PT of 14.6 and an INR of 1.1. An interview with the physician, for Residents #8, #16 and #17, on 10/11/11 at 4:27 PM, revealed the PT/INR had the potential to decrease and increase, thus creating a possibility the [MEDICATION NAME] dose would change. An acceptable Allegation of Compliance was received on 10/19/11 and detailed the following: On 10/10/11, the facility conducted a lab audit and identified the facility had failed to schedule and obtain Resident #13's, #8's, #18's, #15's, #17's, #16's, #14's and #6's PT/INR tests. The PT/INR for each resident was obtained immediately and physicians' were notified of the results. A chart lab audit was conducted on 10/17/11 on all current residents receiving Anticoagulants to ensure PT/INR lab tests were current and completed per physician's orders [REDACTED]. The lab policy was revised on 10/16/11, to add clarification of employee responsibilities to ensure a consistent system for obtaining a laboratory test order to transcription and overall tracking of the laboratory process. On 10/17/11, the DON was inserviced on the revised facility Lab Policy by the Corporate Compliance Director. On 10/17/11, Licensed Nurses were inserviced by the DON or designee on the revised lab policy. On 10/16/11 a CQI tool, Laboratory Monitoring and Follow Up was revised and implemented. On 10/17/11, the Laboratory Monitoring and Follow Up was completed by the Administrator. The DON or designee will complete the Laboratory Monitoring and Follow Up weekly for four weeks, twice monthly for one month, then monthly thereafter. Verification of the removal of Immediate Jeopardy was completed as follows: A review of Resident #6, #8, #13, #14, #15, #16, #17, and #18, revealed PT/INR tests were obtained immediately and physician's were notified of the results. An audit was completed on 10/17/11 on all current residents receiving anticoagulants. A review of the Lab Book revealed PT/INRs were scheduled for residents on anticoagulation therapy. A review of the chart lab audit, completed on 10/17/11, revealed all current residents receiving anticoagulants were reviewed to ensure PT/INR tests were current and completed per physician's orders [REDACTED]. A review of the lab tracking policy revised on 10/16/11, revealed instructions for scheduling labs, follow-up with labs, and lab tracking. The policy stated the ADON or designees would monitor to ensure lab draws and results were received and followed up appropriately, and any issues would be addressed promptly. A review of the inservice records revealed the DON was inserviced on 10/17/11 by the Corporate Compliance Director regarding the revised facility Lab Policy. Licensed Nurses were inserviced 10/17/11 regarding the revised lab policy, laboratory test protocol, physician order [REDACTED]. An interview with the Director of Nursing, on 10/20/11 at 11:50 AM, revealed he received inservicing from the Administrator and Corporate Consultant Director regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab results. Interviews with two Licensed Practical Nurses, on 10/20/11 at 11:20 AM and 11:30 AM, revealed they received inservicing regarding the revised lab policy and the laboratory test protocol. An interview with the Administrator, on 10/20/11 at approximately 12:00 PM, revealed she was inserviced on the lab protocol. She was re-educated regarding her duties to ensure lab audits were completed in a timely manner. A review of records revealed a CQI tool, N-20, was revised on 10/16/11. The N-20 CQI tool was completed by the Administrator on 10/17/11, to ensure laboratory orders were completed as per physician's orders [REDACTED]. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective 10/18/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities.

Based on interview, record review, and review of facility policy and procedure it was determined the facility failed to be effectively/efficiently administered in a manner that maintained the highest physical well-being for eight (#6, #8, #13, #14, #15, #16, #17 and #18), of nineteen sampled residents. The facility failed to have an effective system to ensure policy and procedures were implemented related to the completion of physician ordered laboratory tests to monitor [MEDICATION NAME] therapy. The facility also failed to ensure Quality Assurance audits for laboratory tests were completed monthly. (Refer to F329 and F520) Resident #18 received 8.0 milligrams (mg) of [MEDICATION NAME] every day. A [MEDICATION NAME] (PT) and International Normalized Ratio (INR) test was completed at the facility on 08/18/11 with results of a PT of 27.2 seconds and an INR of 2.5 (normal range PT 12.3-14.1 seconds and INR 2.0-3.5). Resident #18's physician ordered a repeat PT/INR be completed in one month (due on 09/18/11). However, the PT/INR was not obtained until 10/11/11, twenty-three days late, with critical results of a PT of 56.2 seconds and an INR of 6.5. The physician was notified and the resident's [MEDICATION NAME] was held for three days and restarted at a decreased dose of 6.0 mg per day. The Administrator's failure to administer the facility in a manner that enabled it to use its resources to ensure policy and procedures were implemented to ensure the monitoring of [MEDICATION NAME] therapy was completed per physician's orders [REDACTED]. Immediate Jeopardy was determined to exist on 09/18/11. An acceptable Allegation of Compliance (AoC) was received on 10/19/11. Immediate Jeopardy was verified removed on 10/18/11, as alleged in the AoC, prior to exit. The findings include: A review of the facility's Lab Policy, dated 06/25/09, revealed upon the receipt of a lab order from the physician, the lab order should be transferred to the lab book at the nurse's station and the order should be faxed to pharmacy. A review of the facility's policy, "Quality Assurance and Improvement," undated, revealed, "This is the monitoring and evaluation of the quality and appropriateness of resident care and services with a focus on continuous improvement. Data is collected about appearance of care and services of care (through the use of indicators) and are monitored and assessed regularly to determine whether desired outcomes are reached." An interview with the Assistant Director of Nursing's (ADON), on 10/13/11 at 2:35 PM, revealed she was responsible to audit the laboratory tests on a monthly basis. She also revealed part of the lab audit included scheduling the labs to be completed for the next month. Per interview, she did not complete the lab audit for August 2011. An interview with the Director of Nursing (DON), on 10/15/11 at 10:00 AM, revealed it was the ADON's responsibility to conduct laboratory audits at the end of every month to ensure all scheduled labs were completed. He stated the ADON resigned at the end of August 2011 and the lab audit was not completed for August 2011. He revealed it was his responsibility to complete the audit after the ADON resigned; however, this was not completed for either August or September 2011. Per interview he was not aware scheduling the lab tests for the upcoming month was part of the lab audit. Therefore, the laboratory tests were not scheduled for September 2011. An interview with the Administrator, on 10/15/11 at 11:30 AM, revealed the laboratory orders were written in the lab book to ensure the labs were drawn. Further interview revealed a monthly lab audit should be conducted by the ADON, or by the DON in the ADON's absence, to ensure the labs were being completed as ordered. She was aware the lab audit had not been completed for August and September 2011, but was not aware scheduling the lab tests was part of the audit process. Record review of Residents #6, #8, #13, #14, #15, #16, #17, and #18, revealed the facility failed to ensure these residents, who were on [MEDICATION NAME] therapy, received laboratory testing per physician's orders [REDACTED]. The facility failed to obtain Resident #18's [MEDICATION NAME] level on 09/18/11, resulting in a critical PT/INR level on 10/11/11 of 56.2/6.5. An acceptable Allegation of Compliance was received on 10/19/11 and detailed the following: On 10/16/11, the Administrator was counseled on and re-educated by the Corporate Officer on failing to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. A Corporate Review of the Lab Audit was completed on 10/17/11 by the Corporate Officer. A review of the Lab Audit will be conducted monthly by the Corporate Officer. Verification of the removal of Immediate Jeopardy was completed as follows: A review of the counseling form, dated 10/16/11, and interview with the Administrator, revealed she was counseled on 10/16/11 related to using her resources effectively and efficiently to attain or maintain each resident's highest practicable physical, mental and psychosocial well being. She stated she was trained on using the resources and ensuring staff assigned to conduct certain duties were completing those duties. A review of the Review of the Lab Audit completed by the Corporate Officer revealed it was conducted on 10/17/11 and all Labs were completed and the physician's was notified with new orders received and carried out. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective 10/18/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities.

Based on interview, record review, and facility policy and procedure review it was determined the facility failed to implement the Quality Assurance Committee's plan of action to ensure labs were drawn according to physician's orders [REDACTED]. The facility's failure resulted in eight (#6, #8, #13, #14, #15, #16, #17 and #18) of nine residents on [MEDICATION NAME] not having PT/INR levels drawn, in the selected sample of nineteen. Resident #18's PT/INR was not completed on 09/18/11, per the physician's orders [REDACTED]. (Refer to F329 and F490) The facility's failure to implement the Quality Assurance Committees Action Plan related to laboratory audits, caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on 09/18/11. An acceptable Allegation of Compliance (AoC) was received on 10/19/11. Immediate Jeopardy was verified removed on 10/18/11, as alleged in the AoC, prior to exit. The findings include: A review of the facility's policy, "Quality Assurance and Improvement," undated, revealed, "This is the monitoring and evaluation of the quality and appropriateness of resident care and services with a focus on continuous improvement. Data is collected about appearance of care and services of care (through the use of indicators) and are monitored and assessed regularly to determine whether desired outcomes are reached." An interview with the Assistant Director of Nursing's (ADON), on 10/13/11 at 2:35 PM, revealed she was responsible to audit the laboratory tests and part of the lab audit included scheduling the labs to be completed for the next month. Per interview, she did not complete the lab audit for August 2011. An interview with the Director of Nursing (DON), on 10/15/11 at 10:00 AM, revealed it was the Assistant Director of Nursing's (ADON) responsibility to conduct laboratory audits at the end of every month to ensure all scheduled labs were completed. He stated the ADON resigned at the end of August 2011 and the lab audit was not completed. He revealed it was his responsibility to complete the audit. However, he was not aware a part of completing the audit was to schedule the next month labs. An interview with the Administrator, on 10/15/11 at 11:30 AM, revealed the DON should conduct the lab audit in the ADON's absence. She stated the lab audit should identify any missed labs the previous month, but she was not aware that one of the purposes of the lab audit was to schedule the routine labs for the next month. An interview with the Medical Director, on 10/15/11 at 10:45 AM, revealed she was made aware of only one of her resident's missing a PT/INR. She stated she was not made aware residents' routine labs were not scheduled for September or any missed labs in August. She revealed she expected the facility to notify her that labs were omitted, due to the lab audit not being completed at the end of August. She stated she was at the facility two to three times a week. Record review of Residents #6, #8, #13, #14, #15, #16, #17, and #18, revealed the facility failed to ensure laboratory monitoring for [MEDICATION NAME] therapy was completed per the physician's orders [REDACTED]. An acceptable Allegation of Compliance was received on 10/20/11 and detailed the following: On 10/17/11, a complete Lab Audit was completed on all current residents receiving Anticoagulants to ensure lab tests were current and completed per physician's orders [REDACTED]. The DON was inserviced on 10/12/11 and again on 10/17/11 on the protocol for conducting a lab audit. On 10/16/11, a CQI tool, Laboratory Monitoring and Follow Up, was revised and implemented. On 10/17/11, Laboratory Monitoring and Follow Up was completed by the Administrator on current residents receiving Anticoagulants. The Laboratory Monitoring and Follow Up will be completed by the DON or designee weekly for four weeks, twice monthly for one month, then monthly thereafter. A CQI tool, Corporate Review of Lab Audits, was completed 10/17/11 by the Corporate Officer on residents receiving anticoagulation therapy. Corporate Review of Lab Audits will be completed monthly by the Corporate Officer. A Quality Assurance Meeting was held on 10/17/11 with the facility's Medical Director to discuss issues identified, during the abbreviated survey, with residents on anticoagulants and the plan of action implemented. Verification of the removal of Immediate Jeopardy was completed as follows: A review of the chart lab audit, revealed a completion date of 10/17/11, reviewing all current residents receiving anticoagulants to ensure PT/INR tests were current and completed per physician's orders [REDACTED]. A review of inservice records revealed the Director of Nursing was inserviced 10/12/11 and 10/17/11 regarding the revised lab policy, lab audits and tracking, physician orders, N-20 laboratory monitoring, and C-2 corporate review of laboratory monitoring. An interview with the Director of Nursing revealed he received inservicing from the Administrator and Corporate Consultant Director regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab results. A review of records revealed a CQI tool, N-20, was revised on 10/16/11. The N-20 CQI tool was completed by the Administrator on 10/17/11 to ensure laboratory orders were completed per physician's orders [REDACTED]. A review of the lab audit, was completed 10/17/11 by the Corporate Compliance Officer, on residents receiving anticoagulation therapy. As of 10/20/11, the first monthly CQI audit was not due. A review of the Quality Assurance Minutes, dated 10/17/11, revealed a meeting was held to make the Medical Director aware of the issues identified with residents on anticoagulants and a plan of action was implemented. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective 10/18/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities.